1
|
Capuano E, Regazzoni F, Maines M, Fornara S, Locatelli V, Catanzariti D, Stella S, Nobile F, Greco MD, Vergara C. Personalized computational electro-mechanics simulations to optimize cardiac resynchronization therapy. Biomech Model Mechanobiol 2024:10.1007/s10237-024-01878-8. [PMID: 39192164 DOI: 10.1007/s10237-024-01878-8] [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: 02/09/2024] [Accepted: 07/12/2024] [Indexed: 08/29/2024]
Abstract
In this study, we present a computational framework designed to evaluate virtual scenarios of cardiac resynchronization therapy (CRT) and compare their effectiveness based on relevant clinical biomarkers. Our approach involves electro-mechanical numerical simulations personalized, for patients with left bundle branch block, by means of a calibration obtained using data from Electro-Anatomical Mapping System (EAMS) measures acquired by cardiologists during the CRT procedure, as well as ventricular pressures and volumes, both obtained pre-implantation. We validate the calibration by using EAMS data coming from right pacing conditions. Three patients with fibrosis and three without are considered to explore various conditions. Our virtual scenarios consist of personalized numerical experiments, incorporating different positions of the left electrode along reconstructed epicardial veins; different locations of the right electrode; different ventriculo-ventricular delays. The aim is to offer a comprehensive tool capable of optimizing CRT efficiency for individual patients. We provide preliminary answers on optimal electrode placement and delay, by computing some relevant biomarkers such as d P / d t max , ejection fraction, stroke work. From our numerical experiments, we found that the latest activated segment during sinus rhythm is an effective choice for the non-fibrotic cases for the location of the left electrode. Also, our results showed that the activation of the right electrode before the left one seems to improve the CRT performance for the non-fibrotic cases. Last, we found that the CRT performance seems to improve by positioning the right electrode halfway between the base and the apex. This work is on the line of computational works for the study of CRT and introduces new features in the field, such as the presence of the epicardial veins and the movement of the right electrode. All these studies from the different research groups can in future synergistically flow together in the development of a tool which clinicians could use during the procedure to have quantitative information about the patient's propagation in different scenarios.
Collapse
Affiliation(s)
- Emilia Capuano
- MOX, Dipartimento di Mathematica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Francesco Regazzoni
- MOX, Dipartimento di Mathematica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Massimiliano Maines
- Cardiology department, S.M. del Carmine Hospital, APSS, Corso Verona, 4, Rovereto, 38068, Trento, Italy
| | - Silvia Fornara
- LABS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Vanessa Locatelli
- LABS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Domenico Catanzariti
- Cardiology department, S.M. del Carmine Hospital, APSS, Corso Verona, 4, Rovereto, 38068, Trento, Italy
| | - Simone Stella
- MOX, Dipartimento di Mathematica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Fabio Nobile
- Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Station 8, Av. Piccard, CH-1015, Lausanne, Switzerland
| | - Maurizio Del Greco
- Cardiology department, S.M. del Carmine Hospital, APSS, Corso Verona, 4, Rovereto, 38068, Trento, Italy
| | - Christian Vergara
- LABS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy.
| |
Collapse
|
2
|
Pathmanathan P, Aycock K, Badal A, Bighamian R, Bodner J, Craven BA, Niederer S. Credibility assessment of in silico clinical trials for medical devices. PLoS Comput Biol 2024; 20:e1012289. [PMID: 39116026 PMCID: PMC11309390 DOI: 10.1371/journal.pcbi.1012289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 07/01/2024] [Indexed: 08/10/2024] Open
Abstract
In silico clinical trials (ISCTs) are an emerging method in modeling and simulation where medical interventions are evaluated using computational models of patients. ISCTs have the potential to provide cost-effective, time-efficient, and ethically favorable alternatives for evaluating the safety and effectiveness of medical devices. However, ensuring the credibility of ISCT results is a significant challenge. This paper aims to identify unique considerations for assessing the credibility of ISCTs and proposes an ISCT credibility assessment workflow based on recently published model assessment frameworks. First, we review various ISCTs described in the literature, carefully selected to showcase the range of methodological options available. These studies cover a wide variety of devices, reasons for conducting ISCTs, patient model generation approaches including subject-specific versus 'synthetic' virtual patients, complexity levels of devices and patient models, incorporation of clinician or clinical outcome models, and methods for integrating ISCT results with real-world clinical trials. We next discuss how verification, validation, and uncertainty quantification apply to ISCTs, considering the range of ISCT approaches identified. Based on our analysis, we then present a hierarchical workflow for assessing ISCT credibility, using a general credibility assessment framework recently published by the FDA's Center for Devices and Radiological Health. Overall, this work aims to promote standardization in ISCTs and contribute to the wider adoption and acceptance of ISCTs as a reliable tool for evaluating medical devices.
Collapse
Affiliation(s)
- Pras Pathmanathan
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Kenneth Aycock
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Andreu Badal
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Ramin Bighamian
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Jeff Bodner
- Medtronic, PLC., Minneapolis, Minnesota, United States of America
| | - Brent A. Craven
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, United States of America
| | - Steven Niederer
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- The Alan Turing Institute, London, United Kingdom
| |
Collapse
|
3
|
Chen Z, Ma X, Wu S, Gao Y, Song Y, Lu M, Dai Y, Zhang S, Hua W, Gold MR, Zhao S, Chen K. A Comparison of the Association of Septal Scar Burden on Responses to LBBAP-CRT and BVP-CRT. JACC Clin Electrophysiol 2024; 10:1439-1451. [PMID: 38727661 DOI: 10.1016/j.jacep.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 07/26/2024]
Abstract
BACKGROUND Left bundle branch area pacing (LBBAP) is an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). However, despite the presence of left bundle branch block, whether cardiac substrate may influence the effect between the 2 strategies is unclear. OBJECTIVES This study aims to assess the association of septal scar on reverse remodeling and clinical outcomes of LBBAP compared with BVP. METHODS We analyzed patients with nonischemic cardiomyopathy who had CRT indications undergoing preprocedure cardiac magnetic resonance examination. Changes in left ventricular ejection fraction (LVEF) and echocardiographic response (ER) (≥5% absolute LVEF increase) were assessed at 6 months. The clinical outcome was the composite of all-cause mortality, heart failure hospitalization, or major ventricular arrhythmia. RESULTS There were 147 patients included (51 LBBAP and 96 BVP). Among patients with low septal scar burden (below median 5.7%, range: 0% to 5.3%), LVEF improvement was higher in the LBBAP than the BVP group (17.5% ± 10.9% vs 12.3% ± 11.8%; P = 0.037), with more than 3-fold increased odds of ER (OR: 4.35; P = 0.033). In high sepal scar subgroups (≥5.7%, range: 5.7%-65.9%), BVP trended towards higher LVEF improvement (9.2% ± 9.4% vs 6.4% ± 12.4%; P = 0.085). Interaction between septal scar burden and pacing strategy was significant for ER (P = 0.002) and LVEF improvement (P = 0.011) after propensity score adjustment. During median follow-up of 33.7 (Q1-Q3: 19.8-42.1) months, the composite clinical outcome occurred in 34.7% (n = 51) of patients. The high-burden subgroups had worse clinical outcomes independent of CRT method. CONCLUSIONS Remodeling response to LBBAP and BVP among nonischemic cardiomyopathy patients is modified by septal scar burden. High septal scar burden was associated with poor clinical prognosis independent of CRT methods.
Collapse
Affiliation(s)
- Zhongli Chen
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuan Ma
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sijin Wu
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Gao
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanyan Song
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minjie Lu
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Dai
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Hua
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Keping Chen
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|
4
|
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; 10:1722-1732. [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] [MESH Headings] [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%-5%; P < 0.001), whereas LVSP was not (1%; 95% CI: 0%-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.
Collapse
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
| |
Collapse
|
5
|
Graterol FR, Pujol-López M, Borràs R, Ayala B, Uribe L, Guasch E, Regany-Closa M, Niebla M, Carro E, Guichard JB, Castel MÁ, Arbelo E, Porta-Sánchez A, Sitges M, Brugada J, Roca-Luque I, Doltra A, Mont L, Tolosana JM. Predictors of failed left bundle branch pacing implant in heart failure with reduced ejection fraction: Importance of left ventricular diameter and QRS morphology. Heart Rhythm 2024:S1547-5271(24)02731-0. [PMID: 38906515 DOI: 10.1016/j.hrthm.2024.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/31/2024] [Accepted: 06/13/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Left bundle branch pacing (LBBP) is considered an alternative to cardiac resynchronization therapy (CRT). However, LBBP is not suitable for all patients with heart failure. OBJECTIVE The aim of our study was to identify predictors of unsuccessful LBBP implantation in CRT candidates. METHODS A cohort of consecutive patients with indications for CRT were included. Clinical, echocardiographic, and electrocardiographic variables were prospectively recorded. RESULTS A total of 187 patients were included in the analysis. LBBP implantation was successful in 152 of 187 patients (81.2%) and failed in 35 of 187 patients (18.7%). The causes of unsuccessful implantation were unsatisfactory paced QRS morphology (28 of 35 [80%]), inability to screw the helix (4 of 35 [11.4%]), lead instability (2 of 35 [5.7%]), and high pacing thresholds (1 of 35 [2.8%]). The left ventricular end-diastolic diameter (LVEDD), non-LBBB (left bundle branch block) QRS morphology, and QRS width were predictors of failed implantation according to the univariate analysis. According to the multivariate regression analysis, LVEDD (odds ratio 1.31 per 5-mm increase; 95% confidence interval 1.05-1.63 per 5-mm increase; P = .02) and non-LBBB (odds ratio 3.07; 95% confidence interval 1.08-8.72; P = .03) were found to be independent predictors of unsuccessful LBBP implantation. An LVEDD of 60 mm has 60% sensitivity and 71% specificity for predicting LBBP implant failure. CONCLUSION When LBBP was used as CRT, LVEDD and non-LBBB QRS morphology predicted unsuccessful implantation. Non-LBBB triples the likelihood of failed implantation independent of LVEDD. Caution should be taken when considering these parameters to plan the best pacing strategy for patients.
Collapse
Affiliation(s)
- Freddy R Graterol
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Margarida Pujol-López
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Roger Borràs
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red, Salud Mental (CIBERSAM), Instituto de Salut Carlos III, Madrid, Madrid, Spain
| | - Bernardo Ayala
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Laura Uribe
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Eduard Guasch
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Mariona Regany-Closa
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Mireia Niebla
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Esther Carro
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Jean-Baptiste Guichard
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - M Ángeles Castel
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Elena Arbelo
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Andreu Porta-Sánchez
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Marta Sitges
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Josep Brugada
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Ivo Roca-Luque
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Adelina Doltra
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Lluís Mont
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - José M Tolosana
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain.
| |
Collapse
|
6
|
Strocchi M, Wijesuriya N, Mehta V, de Vere F, Rinaldi CA, Niederer SA. Computational Modelling Enabling In Silico Trials for Cardiac Physiologic Pacing. J Cardiovasc Transl Res 2024; 17:685-694. [PMID: 37870689 PMCID: PMC11219462 DOI: 10.1007/s12265-023-10453-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
Conduction system pacing (CSP) has the potential to achieve physiological-paced activation by pacing the ventricular conduction system. Before CSP is adopted in standard clinical practice, large, randomised, and multi-centre trials are required to investigate CSP safety and efficacy compared to standard biventricular pacing (BVP). Furthermore, there are unanswered questions about pacing thresholds required to achieve optimal pacing delivery while preventing device battery draining, and about which patient groups are more likely to benefit from CSP rather than BVP. In silico studies have been increasingly used to investigate mechanisms underlying changes in cardiac function in response to pathologies and treatment. In the context of CSP, they have been used to improve our understanding of conduction system capture to optimise CSP delivery and battery life, and noninvasively compare different pacing methods on different patient groups. In this review, we discuss the in silico studies published to date investigating different aspects of CSP delivery.
Collapse
Affiliation(s)
- Marina Strocchi
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK.
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Felicity de Vere
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Steven A Niederer
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- The Alan Turing Institute, London, UK
| |
Collapse
|
7
|
Niazi I. Electrical Therapy for Heart Failure: The Year 2023 in Review. J Innov Card Rhythm Manag 2024; 15:5709-5712. [PMID: 38304089 PMCID: PMC10829410 DOI: 10.19102/icrm.2024.15018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Affiliation(s)
- Imran Niazi
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, University of Wisconsin School of Medicine and Public Health, University of Wisconsin–Madison, Madison, WI, USA
| |
Collapse
|
8
|
Chen Z, Ma X, Gao Y, Wu S, Xu N, Chen F, Song Y, Li C, Lu M, Dai Y, Gold MR, Zhao S, Chen K. Cardiac magnetic resonance-derived myocardial scar is associated with echocardiographic response and clinical prognosis of left bundle branch area pacing for cardiac resynchronization therapy. Europace 2023; 25:euad326. [PMID: 37926926 PMCID: PMC10639094 DOI: 10.1093/europace/euad326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023] Open
Abstract
AIMS Left bundle branch area pacing (LBBAP) is a novel approach for cardiac resynchronization therapy (CRT), but the impact of myocardial substrate on its effect is poorly understood. This study aims to assess the association of cardiac magnetic resonance (CMR)-derived scar burden and the response of CRT via LBBAP. METHODS AND RESULTS Consecutive patients with CRT indications who underwent CMR examination and successful LBBAP-CRT were retrospectively analysed. Cardiac magnetic resonance late gadolinium enhancement was used for scar assessment. Echocardiographic reverse remodelling and composite outcomes (defined as all-cause death or heart failure hospitalization) were evaluated. The echocardiographic response was defined as a ≥15% reduction of left ventricular end-systolic volume. Among the 54 patients included, LBBAP-CRT resulted in a 74.1% response rate. The non-responders had higher global, septal, and lateral scar burden (all P < 0.001). Global, septal, and lateral scar percentage all predicted echocardiographic response [area under the curve (AUC): 0.857, 0.864, and 0.822; positive likelihood ratio (+LR): 9.859, 5.594, and 3.059; and negative likelihood ratio (-LR): 0.323, 0.233, and 0.175 respectively], which was superior to QRS morphology criteria (Strauss left bundle branch abnormality: AUC: 0.696, +LR 2.101, and -LR 0.389). After a median follow-up time of 20.3 (11.5-38.7) months, higher global, lateral and septal scar burdens were all predictive of the composite outcome (hazard ratios: 4.996, 7.019, and 4.741, respectively; P's < 0.05). CONCLUSION Lower scar burden was associated with higher response rate of LBBAP-CRT. The pre-procedure CMR scar evaluation provides further useful information to identify potential responders and clinical outcomes.
Collapse
Affiliation(s)
- Zhongli Chen
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| | - Xuan Ma
- Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| | - Yuan Gao
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| | - Sijin Wu
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| | - Nan Xu
- Department of Echocardiography, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 10037, China
| | - Feng Chen
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| | - Yanyan Song
- Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| | - Chongqiang Li
- Catheterization Laboratory, National Center for Cardiovascular Diseases, Fuwai Hospotal, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 10037, China
| | - Minjie Lu
- Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| | - Yan Dai
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| | - Keping Chen
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 North Lishi Rd, Xicheng District, Beijing 100037, China
| |
Collapse
|
9
|
Domenichini G, Le Bloa M, Teres Castillo C, Graf D, Carroz P, Ascione C, Porretta AP, Pascale P, Pruvot E. Conduction System Pacing versus Conventional Biventricular Pacing for Cardiac Resynchronization Therapy: Where Are We Heading? J Clin Med 2023; 12:6288. [PMID: 37834932 PMCID: PMC10573781 DOI: 10.3390/jcm12196288] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/18/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
Over the last few years, pacing of the conduction system (CSP) has emerged as the new standard pacing modality for bradycardia indications, allowing a more physiological ventricular activation compared to conventional right ventricular pacing. CSP has also emerged as an alternative modality to conventional biventricular pacing for the delivery of cardiac resynchronization therapy (CRT) in heart failure patients. However, if the initial clinical data seem to support this new physiological-based approach to CRT, the lack of large randomized studies confirming these preliminary results prevents CSP from being used routinely in clinical practice. Furthermore, concerns are still present regarding the long-term performance of pacing leads when employed for CSP, as well as their extractability. In this review article, we provide the state-of-the-art of CSP as an alternative to biventricular pacing for CRT delivery in heart failure patients. In particular, we describe the physiological concepts supporting this approach and we discuss the future perspectives of CSP in this context according to the implant techniques (His bundle pacing and left bundle branch area pacing) and the clinical data published so far.
Collapse
Affiliation(s)
- Giulia Domenichini
- Cardiology Service, University Hospital of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Mehta VS, Niederer S, Rinaldi CA. Editorial: Future directions in conduction system pacing to achieve cardiac resynchronization. Front Physiol 2023; 14:1281552. [PMID: 37781223 PMCID: PMC10535105 DOI: 10.3389/fphys.2023.1281552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 09/04/2023] [Indexed: 10/03/2023] Open
Affiliation(s)
- Vishal S. Mehta
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Biomedical Engineering, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Christopher A. Rinaldi
- Cardiology Department, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| |
Collapse
|
11
|
Parale C, Bootla D, Jain A, Satheesh S, Anantharaj A, Ahmed AS, Sukumaran SK, Balaguru S, Selvaraj R. Comparison of electrocardiographic parameters between left bundle optimized cardiac resynchronization therapy (LOT-CRT) and left bundle branch pacing-cardiac resynchronization therapy (LBBP-CRT). Pacing Clin Electrophysiol 2023; 46:840-847. [PMID: 37477545 DOI: 10.1111/pace.14793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/12/2023] [Accepted: 07/09/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND In patients undergoing cardiac resynchronization therapy using left bundle branch area pacing (LBBP-CRT), the addition of a coronary sinus lead, that is, Left bundle optimized CRT (LOT-CRT) might confer additional benefits. OBJECTIVES To compare the electrocardiographic characteristics between LBBP-CRT and LOT-CRT MATERIALS AND METHODS: Patients with non-ischemic cardiomyopathy (NICMP) and left bundle branch block (LBBB) with left ventricular ejection fraction <35% who underwent implantation of an atrial lead, a left bundle lead, and a coronary sinus lead were included in this prospective study. Digital 12-lead electrocardiograms were recorded in three pacing modes-AAI, DDD with pacing from the LBB lead (LBBP-CRT), and DDD with pacing from both left bundle and coronary sinus leads (LOT-CRT). QRS duration (QRSd), QRS area, QT interval, and T peak-T end (TpTe) intervals were compared. RESULTS Among 24 patients, QRSd reduced from 167 ± 21.2 ms to 134.5 ± 23.6 ms with LBBP-CRT (p < .001) and 129.5 ± 18.6 ms with LOT-CRT (p < .001) without a significant difference between LBBP-CRT and LOT-CRT (p = .15). Patients with QRS duration with LBBP-CRT > 131 ms showed a significant reduction in QRSd with LOT-CRT (p = .03). QT interval was reduced with both modes of CRT. LOT-CRT was associated with a greater reduction in QRS area (p = .001), TpTe interval (p = .03), and TpTe/QT ratio (p = .013) compared to LBBP-CRT. CONCLUSIONS In patients with NICMP and LBBB, there was no significant difference in QRSd with LOT-CRT compared to LBBP-CRT. However, in patients with QRSd > 131 ms after LBBP-CRT, LOT-CRT resulted in a significantly narrower QRS.
Collapse
Affiliation(s)
- Chinmay Parale
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Dinakar Bootla
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ashish Jain
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Santhosh Satheesh
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Avinash Anantharaj
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - A Shaheer Ahmed
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Suresh Kumar Sukumaran
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Sridhar Balaguru
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Raja Selvaraj
- Department of Cardiology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| |
Collapse
|
12
|
Guillem MS, Pujol-López M, Sanchez-Arciniegas J, Mont L. In silico experiments explain the non-consistent benefit of conduction system pacing over cardiac resynchronization therapy. The need to personalize therapy. J Cardiovasc Electrophysiol 2023; 34:994-996. [PMID: 36852911 DOI: 10.1111/jce.15871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 02/20/2023] [Indexed: 03/01/2023]
Affiliation(s)
- María S Guillem
- ITACA Institute, Universitat Politècnica de València, Valencia, Spain
| | - Margarida Pujol-López
- Secció d'Arrítmies, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain.,Institut de Recerca Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | | | - Lluís Mont
- Secció d'Arrítmies, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain.,Institut de Recerca Biomèdica August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| |
Collapse
|