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Keene D, Kaza N, Srinivasan D, Ali N, Tanner M, Foley P, Chandrasekaran B, Moore P, Adhya S, Qureshi N, Muthumala A, Lane R, Rinaldi A, Agarwal S, Leyva F, Behar J, Bassi S, Ng A, Scott P, Prasad R, Swinburn J, Tomson J, Sethi A, Shah J, Lim PB, Kyriacou A, Thomas D, Chuen J, Kamdar R, Kanagaratnam P, Mariveles M, Johnson N, Falaschetti E, Howard JP, Arnold A, Cleland JGF, Francis DP, Whinnett Z, Shun-Shin M. Predictors of the efficacy of His bundle pacing in patients with a prolonged PR interval: A stratified analysis of the HOPE-HF randomized controlled trial. Eur J Heart Fail 2024. [PMID: 39023285 DOI: 10.1002/ejhf.3367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 06/02/2024] [Accepted: 06/19/2024] [Indexed: 07/20/2024] Open
Abstract
AIMS The randomized, double-blind, placebo-controlled HOPE-HF trial assessed the benefit of atrio-ventricular (AV) delay optimization delivered using His bundle pacing. It recruited patients with left ventricular ejection fraction ≤40%, PR interval ≥200 ms, and baseline QRS ≤140 ms or right bundle branch block. Overall, there was no significant increase in peak oxygen uptake (VO2max) but there was significant improvement in heart failure specific quality of life. In this pre-specified secondary analysis, we evaluated the impact of baseline PR interval, echocardiographic E-A fusion, and the magnitude of acute high-precision haemodynamic response to pacing, on outcomes. METHODS AND RESULTS All 167 randomized participants underwent measurement of PR interval, acute haemodynamic response at optimized AV delay, and assessment of presence of E-A fusion. We tested the impact of these baseline parameters using a Bayesian ordinal model on VO2max, quality of life and activity measures. There was strong evidence of a beneficial interaction between the baseline acute haemodynamic response and the blinded benefit of pacing for VO2 (Pr 99.9%), Minnesota Living With Heart Failure (MLWHF) (Pr 99.8%), MLWHF physical limitation score (Pr 98.9%), EQ-5D visual analogue scale (Pr 99.6%), and exercise time (Pr 99.4%). The baseline PR interval and the presence of baseline E-A fusion did not have this reliable ability to predict the clinical benefit of pacing over placebo across multiple endpoints. CONCLUSIONS In the HOPE-HF trial, the acute haemodynamic response to pacing reliably identified patients who obtained clinical benefit. Patients with a long PR interval (≥200 ms) and left ventricular impairment who obtained acute haemodynamic improvement with AV-optimized His bundle pacing were likely to obtain clinical benefit, consistent across multiple endpoints. Importantly, this gradation can be reliably tested for before randomization, but does require high-precision AV-optimized haemodynamic assessment to be performed.
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Affiliation(s)
- Daniel Keene
- National Heart and Lung Institute, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Nandita Kaza
- National Heart and Lung Institute, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Nadine Ali
- National Heart and Lung Institute, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - Mark Tanner
- West Sussex Hospitals NHS Trust, West Sussex, UK
| | - Paul Foley
- Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | | | - Philip Moore
- West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK
- Barts Health NHS Trust, London, UK
| | | | | | - Amal Muthumala
- Barts Health NHS Trust, London, UK
- North Middlesex University Hospital, London, UK
| | - Rebecca Lane
- Royal Brompton and Harefield NHS Trust, London, UK
| | - Aldo Rinaldi
- Guy's and St. Thomas's NHS Foundation Trust, London, UK
| | - Sharad Agarwal
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | | | - Sukh Bassi
- Sherwood Forest Hospitals NHS Foundation Trust, Mansfield, UK
| | - Andre Ng
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | | | - Jon Swinburn
- Royal Berkshire NHS Foundation Trust, Reading, UK
| | | | - Amarjit Sethi
- London North West University Healthcare NHS Trust, London, UK
| | - Jaymin Shah
- London North West University Healthcare NHS Trust, London, UK
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Andreas Kyriacou
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dewi Thomas
- Morriston Hospital Regional Cardiac Centre, Swansea, UK
| | - Jenny Chuen
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | | | | | - Nicholas Johnson
- Imperial College Trials Unit, Imperial College London, London, UK
| | | | - James P Howard
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ahran Arnold
- National Heart and Lung Institute, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
| | - John G F Cleland
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Zachary Whinnett
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Matthew Shun-Shin
- National Heart and Lung Institute, Imperial College London, London, UK
- Imperial College Healthcare NHS Trust, London, UK
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2
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Curila K, Poviser L, Stros P, Jurak P, Whinnett Z, Jastrzebski M, Waldauf P, Smisek R, Viscor I, Hozman M, Osmancik P, Kryze L, Kautzner J. LVSP and LBBP Result in Similar or Improved LV Synchrony and Hemodynamics Compared to BVP. JACC Clin Electrophysiol 2024:S2405-500X(24)00348-7. [PMID: 38829298 DOI: 10.1016/j.jacep.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/25/2024] [Accepted: 04/27/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND The effect of left ventricular septal myocardial pacing (LVSP) and left bundle branch pacing (LBBP) on ventricular synchrony and left ventricular (LV) hemodynamic status is poorly understood. OBJECTIVES The aim of this study was to investigate the impact of LVSP and LBBP vs biventricular pacing (BVP) on ventricular electrical synchrony and hemodynamic status in cardiac resynchronization therapy patients. METHODS In cardiac resynchronization therapy candidates with LV conduction disease, ventricular synchrony was assessed by measuring QRS duration (QRSd) and using ultra-high-frequency electrocardiography. LV electrical dyssynchrony was assessed as the difference between the first activation in leads V1 to V8 to the last from leads V4 to V8. LV hemodynamic status was estimated using invasive systolic blood pressure measurement during multiple transitions between LBBP, LVSP, and BVP. RESULTS A total of 35 patients with a mean LV ejection fraction of 29% and a mean QRSd of 168 ± 24 ms were included. Thirteen had ischemic cardiomyopathy. QRSd during BVP, LVSP, and LBBP was the same, but LBBP provided shorter LV electrical dyssynchrony than BVP (-10 ms; 95% CI: -16 to -4 ms; P = 0.001); the difference between LVSP and BVP was not significant (-5 ms; 95% CI: -12 to 1 ms; P = 0.10). LBBP was associated with higher systolic blood pressure than BVP (4%; 95% CI: 2% to 5%; P < 0.001), whereas LVSP was not (1%; 95% CI: 0% to 2%; P = 0.10). Hemodynamic differences during LBBP and LVSP vs BVP were more pronounced in nonischemic than ischemic patients. CONCLUSIONS Ultra-high-frequency electrocardiography allowed the documentation of differences in LV synchrony between LBBP, LVSP, and BVP, which were not observed by measuring QRSd. LVSP provided the same LV synchrony and hemodynamic status as BVP, while LBBP was better than BVP in both.
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Affiliation(s)
- Karol Curila
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic.
| | - Lukas Poviser
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Stros
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Pavel Jurak
- Institute of Scientific Instruments, Czech Academy of Sciences, Brno, Czech Republic
| | - Zachary Whinnett
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Petr Waldauf
- Department of Anesthesia and Intensive Care, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Radovan Smisek
- Institute of Scientific Instruments, Czech Academy of Sciences, Brno, Czech Republic
| | - Ivo Viscor
- Institute of Scientific Instruments, Czech Academy of Sciences, Brno, Czech Republic
| | - Marek Hozman
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Pavel Osmancik
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Lukas Kryze
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Josef Kautzner
- Institute of Clinical and Experimental Medicine, Prague, Czech Republic
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Vijayaraman P, Chelu MG, Curila K, Dandamudi G, Herweg B, Mori S, Jastrzebski M, Sharma PS, Shivkumar K, Tung R, Upadhyay G, Vernooy K, Welter-Frost A, Whinnett Z, Zanon F, Ellenbogen KA. Cardiac Conduction System Pacing: A Comprehensive Update. JACC Clin Electrophysiol 2023; 9:2358-2387. [PMID: 37589646 DOI: 10.1016/j.jacep.2023.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/10/2023] [Accepted: 06/02/2023] [Indexed: 08/18/2023]
Abstract
The field of cardiac pacing has changed rapidly in the last several years. Since the initial description of His bundle pacing targeting the conduction system, recent advances in pacing the left bundle branch and its fascicles have evolved. The field and investigators' knowledge of conduction system pacing including relevant anatomy and physiology has advanced significantly. The aim of this review is to provide a comprehensive update on recent advances in conduction system pacing.
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Affiliation(s)
- Pugazhendhi Vijayaraman
- Geisinger Heart Institute, Geisinger Commonwealth School of Medicine, Wilkes-Barre, Pennsylvania, USA.
| | - Mihal G Chelu
- Division of Cardiology, Baylor College of Medicine and Baylor St. Luke's Medical Center and Texas Heart Institute, Houston, Texas, USA
| | - Karol Curila
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Gopi Dandamudi
- Virginia Mason Franciscan Health, Seattle, Washington, USA
| | - Bengt Herweg
- University of South Florida Morsani College of Medicine, Department of Cardiovascular Sciences, Tampa, Florida, USA
| | - Shumpei Mori
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Parikshit S Sharma
- Department of Cardiology, Rush University School of Medicine, Chicago, Illinois, USA
| | - Kalyanam Shivkumar
- University of California Los Angeles (UCLA) Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Roderick Tung
- Division of Cardiology, University of Arizona College of Medicine-Phoenix, Banner-University Medical Center, Phoenix, Arizona, USA
| | - Gaurav Upadhyay
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Kevin Vernooy
- Center for Arrhythmia Care, Heart and Vascular Center, University of Chicago, Chicago, Illinois, USA
| | - Allan Welter-Frost
- Cleveland Clinic Indian River Hospital, Heart Vascular and Thoracic Institute, Vero Beach, Florida, USA
| | - Zachary Whinnett
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | - Kenneth A Ellenbogen
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
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Miyazawa AA, Francis DP, Whinnett ZI. Basic Principles of Hemodynamics in Pacing. Card Electrophysiol Clin 2022; 14:133-140. [PMID: 35715072 DOI: 10.1016/j.ccep.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Pacing therapy aims to improve overall cardiac function by normalizing cardiac electrical activation. Although hemodynamic measurements allow the impact of cardiac pacing on cardiac function to be quantified, the protocol is crucial to minimize the effect of noise and achieve greater precision. Multiple steps can be undertaken to optimize accuracy of hemodynamic measurements. These include comparing with a reference state, using an average of a set number of beats, making repeated measurements, ensuring all beats are included, and pacing at faster heart rates. These measurements can aid comparison between different pacing modalities and guide optimal programming.
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Affiliation(s)
- Alejandra A Miyazawa
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK.
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Sterliński M, Zakrzewska-Koperska J, Maciąg A, Sokal A, Osca-Asensi J, Wang L, Spyropoulou V, Maus B, Lemme F, Okafor O, Stegemann B, Cornelussen R, Leyva F. Acute Hemodynamic Effects of Simultaneous and Sequential Multi-Point Pacing in Heart Failure Patients With an Expected Higher Rate of Sub-response to Cardiac Resynchronization Therapy: Results of Multicenter SYNSEQ Study. Front Cardiovasc Med 2022; 9:901267. [PMID: 35647062 PMCID: PMC9133424 DOI: 10.3389/fcvm.2022.901267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/19/2022] [Indexed: 12/04/2022] Open
Abstract
The aim of the SYNSEQ (Left Ventricular Synchronous vs. Sequential MultiSpot Pacing for CRT) study was to evaluate the acute hemodynamic response (AHR) of simultaneous (3P-MPP syn) or sequential (3P-MPP seq) multi-3-point-left-ventricular (LV) pacing vs. single point pacing (SPP) in a group of patients at risk of a suboptimal response to cardiac resynchronization therapy (CRT). Twenty five patients with myocardial scar or QRS ≤ 150 or the absence of LBBB (age: 66 ± 12 years, QRS: 159 ± 12 ms, NYHA class II/III, LVEF ≤ 35%) underwent acute hemodynamic assessment by LV + dP/dtmax with a variety of LV pacing configurations at an optimized AV delay. The change in LV + dP/dt max (%ΔLV + dP/dt max) with 3P-MPP syn (15.6%, 95% CI: 8.8%-22.5%) was neither statistically significantly different to 3P-MPP seq (11.8%, 95% CI: 7.6-16.0%) nor to SPP basal (11.5%, 95% CI:7.1-15.9%) or SPP mid (12.2%, 95% CI:7.9-16.5%), but higher than SPP apical (10.6%, 95% CI:5.3-15.9%, p = 0.03). AHR (defined as a %ΔLV + dP/dt max ≥ 10%) varied between pacing configurations: 36% (9/25) for SPP apical, 44% (11/25) for SPP basal, 54% (13/24) for SPP mid, 56% (14/25) for 3P-MPP syn and 48% (11/23) for 3P-MPP seq.Fifteen patients (15/25, 60%) had an AHR in at least one pacing configuration. AHR was observed in 10/13 (77%) patients with a LBBB but only in 5/12 (42%) patients with a non-LBBB (p = 0.11). To conclude, simultaneous or sequential multipoint pacing compared to single point pacing did not improve the acute hemodynamic effect in a suboptimal CRT response population.
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Affiliation(s)
- Maciej Sterliński
- First Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Joanna Zakrzewska-Koperska
- First Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
- *Correspondence: Joanna Zakrzewska-Koperska
| | - Aleksander Maciąg
- Second Department of Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Adam Sokal
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center of Heart Disease, Zabrze, Poland
| | - Joaquin Osca-Asensi
- Cardiology Department, University and Polytechnic Hospital la Fe, Valencia, Spain
| | - Lingwei Wang
- Section of Arrhythmias, Department of Cardiology, Clinical Sciences, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - Baerbel Maus
- Bakken Research Center, Medtronic plc, Maastricht, Netherlands
| | - Francesca Lemme
- Bakken Research Center, Medtronic plc, Maastricht, Netherlands
| | - Osita Okafor
- Queen Elisabeth Hospital, Birmingham University, Birmingham, United Kingdom
| | - Berthold Stegemann
- Aston Medical School, Aston Medical Research Institute, Aston University, Birmingham, United Kingdom
| | | | - Francisco Leyva
- Aston Medical School, Aston Medical Research Institute, Aston University, Birmingham, United Kingdom
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Keene D, Miyazawa AA, Johal M, Arnold AD, Ali N, Saqi KA, March K, Burden L, Francis DP, Whinnett ZI, Shun‐Shin MJ. Optimizing atrio-ventricular delay in pacemakers using potentially implantable physiological biomarkers. Pacing Clin Electrophysiol 2022; 45:461-470. [PMID: 34967945 PMCID: PMC9305784 DOI: 10.1111/pace.14434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/25/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemodynamically optimal atrioventricular (AV) delay can be derived by echocardiography or beat-by-beat blood pressure (BP) measurements, but analysis is labor intensive. Laser Doppler perfusion monitoring measures blood flow and can be incorporated into future implantable cardiac devices. We assess whether laser Doppler can be used instead of BP to optimize AV delay. METHODS Fifty eight patients underwent 94 AV delay optimizations with biventricular or His-bundle pacing using laser Doppler and simultaneous noninvasive beat-by-beat BP. Optimal AV delay was defined using a curve of hemodynamic response to switching from AAI (reference state) to DDD (test state) at several AV delays (40-320 ms), with automatic quality control checking precision of the optimum. Five subsequent patients underwent an extended protocol to test the impact of greater numbers of alternations on optimization quality. RESULTS 55/94 optimizations passed quality control resulting in an optimal AV delay on laser Doppler similar to that derived by BP (median absolute deviation 12 ms). An extended protocol with increasing number of replicates consistently improved quality and reduced disagreement between laser Doppler and BP optima. With only five replicates, no optimization passed quality control, and the median absolute deviation would be 29 ms. These improved progressively until at 50 replicates, all optimizations passed quality control and the median absolute deviation was only 13 ms. CONCLUSIONS Laser Doppler perfusion produces hemodynamic optima equivalent to BP. Quality control can be automatic. Adding more replicates, consistently improves quality. Future implantable devices could use such methods to dynamically and reliably optimize AV delays.
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Affiliation(s)
- Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Alejandra A Miyazawa
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Monika Johal
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Nadine Ali
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Khulat A Saqi
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK
| | - Katherine March
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK
| | - Leah Burden
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Matthew J Shun‐Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
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Vijayaraman P, Nayak HM, Ellenbogen KA. Left Ventricular Septal Versus Left Bundle Branch Pacing: A New Beginning in Cardiac Resynchronization Therapy? J Am Coll Cardiol 2020; 75:360-362. [PMID: 32000946 DOI: 10.1016/j.jacc.2019.11.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 11/28/2022]
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