Reverse remodelling in heart failure with cardiac resynchronisation therapy

Clinical characteristics and long-term outcomes of patients with heart failure with improved ejection fraction. First Polish experience from LECRA-HF registry

PURPOSE

Heart failure (HF) with improved ejection fraction (HFimpEF) is a new category of HF introduced in the newest European Society of Cardiology guidelines. However, clinical characteristics and long-term outcomes of HFimpEF patients remain insufficiently elucidated. We sought to characterize Polish HFimpEF patients and determine their long-term mortality.

MATERIAL AND METHODS

Of 1186 patients enrolled in the single-center Lesser Poland Cracovian Heart Failure (LECRA-HF) registry between 2009 and 2019 and hospitalized due to HF decompensation, 340 (28.7%) were those with HF with reduced ejection fraction (HFrEF). Based on follow-up echocardiography, 61 (17.9%) of them were classified as HFimpEF and the remaining as HFnon-impEF.

RESULTS

HFimpEF patients were more frequently females (P ​< ​0.001), had higher baseline left ventricular ejection fraction (LVEF, P ​< ​0.001), had less often a history of diabetes (P ​= ​0.024), severe chronic kidney disease (P ​= ​0.026) or prior myocardial infarction (P ​= ​0.008) than HFnon-impEF patients. By multivariable analysis the HFimpEF diagnosis was independently predicted by baseline NYHA I/II (odds ratio [OR] 2.347, 95% confidence interval [95%CI] 1.020-5.405), non-ischemic etiology (OR 3.096, 95%CI 1.587-6.024), lack of diabetes mellitus (OR 2.016, 95%CI 1.059-3.846) and higher baseline LVEF (OR 1.084, 95%CI 1.042-1.126, per 1%). Within the median 49 (25-77) months all-cause mortality was lower in HFimpEF than in HFnon-impEF (10.8 vs 16.4%/year, P ​= ​0.004).

CONCLUSIONS

Our findings indicate that every sixth Polish patient with HFrEF has a chance to improve LVEF during follow-up and to become a HFimpEF patient. Baseline characteristics of HFimpEF patients are different from HFnon-impEF. Simultaneously, the HFimpEF diagnosis is associated with higher long-term survival.

Early reverse remodeling of left heart morphology and function evaluated by cardiac magnetic resonance in hypertrophic obstructive cardiomyopathy after transapical beating-heart septal myectomy

PURPOSE

This study aimed to evaluate the early morphology and function of the left heart in hypertrophic obstructive cardiomyopathy (HOCM) after transapical beating-heart septal myectomy (TA-BSM) using cardiovascular magnetic resonance (CMR).

MATERIALS AND METHODS

Between April 2022 and January 2023, HOCM patients who underwent CMR before and 3 months after TA-BSM were prospectively and consecutively enrolled in the study. Preoperative and postoperative cardiac morphological and functional parameters, including those for the left atrium (LA) and left ventricle (LV), were compared. The left ventricular remodeling index (LVRI) was defined as the ratio between left ventricular mass (LVM) and left ventricular end-diastolic volume (LVEDV). Healthy participants with a similar age and sex distribution were enrolled for comparison. Pearson or Spearman correlation analysis was used to investigate the relationships between the parameters and LVRI. Last, univariate and multivariate linear regression identified variables associated with the LVM index (LVMI) and LVRI.

RESULTS

Forty-one patients (mean age ± standard deviation, 46 ± 2 years; 27 males) and 41 healthy control participants were evaluated. Eighteen (44%) HOCM patients were classified as having a sigmoid septum, and 23 patients had a reverse septal curvature. LA volume, diameter and function were significantly improved postoperatively, but still worse than healthy controls (all p < 0.001). Compared to before the operation, left ventricular wall thickness, left ventricular ejection fraction (LVEF), LVMI, and LVRI decreased after TA-BSM (all p < 0.001). The left ventricular end-diastolic volume index (LVEDVI) and left ventricular end-diastolic diameter (LVEDD) decreased in patients with a sigmoid septum. However, LVEDVI and LVEDD increased in those with a reverse septal curvature (both p < 0.001). In addition, both preoperative and postoperative LVRI was positively correlated with LVMI (r = 0.734 and 0.853, both p < 0.001) and maximum wall thickness (r = 0.679 and 0.676, both p < 0.001), respectively. In the multivariable analysis, the weight of the resected myocardium (adjusted β = 0.476, p = 0.005) and △mitral regurgitation degree (adjusted β = - 0.245, p = 0.040) were associated with △LVRI. Last, the △LVOTG (adjusted β = 0.436, p = 0.018) and baseline LVMI (adjusted β = 0.323, p = 0.040) were independently associated with greater left ventricular mass regression after TA-BSM.

CONCLUSION

CMR confirmed early reverse remodeling of left heart morphology and function in HOCM patients following TA-BSM.

Left Bundle Branch Area Pacing over His Bundle Pacing: How Far Have We Come?

Implantable cardiac pacemakers have greatly evolved during the few past years, focusing on newer modalities of physiologic cardiac pacing [...].

Healing the Broken Hearts: A Glimpse on Next Generation Therapeutics

Cardiovascular diseases are the leading cause of death worldwide, accounting for 32% of deaths globally and thus representing almost 18 million people according to WHO. Myocardial infarction, the most prevalent adult cardiovascular pathology, affects over half a million people in the USA according to the last records of the AHA. However, not only adult cardiovascular diseases are the most frequent diseases in adulthood, but congenital heart diseases also affect 0.8–1.2% of all births, accounting for mild developmental defects such as atrial septal defects to life-threatening pathologies such as tetralogy of Fallot or permanent common trunk that, if not surgically corrected in early postnatal days, they are incompatible with life. Therefore, both congenital and adult cardiovascular diseases represent an enormous social and economic burden that invariably demands continuous efforts to understand the causes of such cardiovascular defects and develop innovative strategies to correct and/or palliate them. In the next paragraphs, we aim to briefly account for our current understanding of the cellular bases of both congenital and adult cardiovascular diseases, providing a perspective of the plausible lines of action that might eventually result in increasing our understanding of cardiovascular diseases. This analysis will come out with the building blocks for designing novel and innovative therapeutic approaches to healing the broken hearts.

Predictive Value of Left Atrial Remodeling for Response to Cardiac Resynchronization Therapy

Aim

Response to cardiac resynchronization therapy varies significantly among patients, with one third of them failing to demonstrate left ventricular reverse remodeling after cardiac resynchronization therapy. Left atrial size and function is increasingly recognized as a marker of disease severity in the heart failure population. The aim of this study was to evaluate whether echocardiographic left atrial indices predict left ventricular reverse remodeling after cardiac resynchronization therapy.

Materials and methods

Ninety-nine cardiac resynchronization therapy candidates were prospectively included in the study and underwent echocardiography before and 3-months after cardiac resynchronization therapy implantation. Cardiac resynchronization therapy response was defined as a 15% relative reduction in left ventricular end-systolic volume. Indexed left atrial volume, left atrial reservoir strain, left ventricular end-diastolic volume, and left ventricular ejection fraction along with other known predictors of cardiac resynchronization therapy response (gender, etiology of heart failure, presence of typical left bundle branch block pattern, QRS duration >150 ms) were included in a multivariate logistic regression model to identify predictors for cardiac resynchronization therapy response.

Results

Cardiac resynchronization therapy response occurred in n = 63 (64%) patients. The presence of a typical left bundle branch block (OR 4.2, 95 CI: 1.4-12.1, p = 0.009), QRS duration >150 ms (OR 4.2, 95 CI: 1.4-11.0, p = 0.029), and left atrial volume index (OR: 0.6, 95 CI: 0.4-0.9, p = 0.012) remained the only significant predictors for cardiac resynchronization therapy response after three months. None of the baseline left ventricular parameters showed an independent predictive value.

Conclusion

Left atrial size at baseline is an independent predictor and is inversely proportional to left ventricular volumetric reverse remodeling in cardiac resynchronization therapy candidates.

Left ventricular reverse remodelling and its predictors in non-ischaemic cardiomyopathy

Adverse remodelling following an initial insult is the hallmark of heart failure (HF) development and progression. It is manifested as changes in size, shape, and function of the myocardium. While cardiac remodelling may be compensatory in the short term, further neurohumoral activation and haemodynamic overload drive this deleterious process that is associated with impaired prognosis. However, in some patients, the changes may be reversed. Left ventricular reverse remodelling (LVRR) is characterized as a decrease in chamber volume and normalization of shape associated with improvement in both systolic and diastolic function. LVRR might occur spontaneously or more often in response to therapeutic interventions that either remove the initial stressor or alleviate some of the mechanisms that contribute to further deterioration of the failing heart. Although the process of LVRR in patients with new‐onset HF may take up to 2 years after initiating treatment, there is a significant portion of patients who do not improve despite optimal therapy, which has serious clinical implications when considering treatment escalation towards more aggressive options. On the contrary, in patients that achieve delayed improvement in cardiac function and architecture, waiting might avoid untimely implantable cardioverter‐defibrillator implantation. Therefore, prognostication of successful LVRR based on clinical, imaging, and biomarker predictors is of utmost importance. LVRR has a positive impact on prognosis. However, reverse remodelled hearts continue to have abnormal features. In fact, most of the molecular, cellular, interstitial, and genome expression abnormalities remain and a susceptibility to dysfunction redevelopment under biomechanical stress persists in most patients. Hence, a distinction should be made between reverse remodelling and true myocardial recovery. In this comprehensive review, current evidence on LVRR, its predictors, and implications on prognostication, with a specific focus on HF patients with non‐ischaemic cardiomyopathy, as well as on novel drugs, is presented.

Prognostic value of ventricular mechanical dyssynchrony in patients with left ventricular aneurysm: A comparative study of medical and surgical treatment

BACKGROUND

The prognostic value of left ventricular (LV) mechanical dyssynchrony (MD) in patients with LV aneurysm (LVA) is unclear. This study aimed to investigate the long-term prognostic value of LVMD in LVA patients.

METHODS

92 consecutive patients who underwent 99mTc-sestamibi-gated SPECT myocardial perfusion imaging (GSPECT) were retrospectively analyzed and followed-up for a median of 63 months (range, 1-73 months). LV function and histogram bandwidth (BW) were analyzed by QGS software. LVMD was defined by ROC analysis. Cardiac death was defined as the primary endpoint, and the composite of cardiac deaths and severe or acute heart failure (MACE) as the secondary endpoint.

RESULTS

The annual cardiac mortality rate of LVA patients with LVMD and treated by surgical therapy was significantly lower than those treated by medical therapy (2.40% vs. 6.40%, P < .05) but not annual MACE rate (6.61% vs. 10.06%, P > .05). In patients without LVMD, no significant difference in survival and MACE-free survival between medical and surgical treatment. In addition, the occurrence of LVMD is related to the worsen cardiac outcome in terms of MACE and cardiac death, independent of the treatment methods. BW was an independent predictor for MACE (HR 1.010, P < .01) and LVEF (HR .928, P < .05) was an independent predictor for cardiac death in all LVA patients.

CONCLUSIONS

LVA patients with LVMD might be associated with high risk for cardiac death and surgical treatment might improve cardiac survival compared to medical therapy in these patients.

The usefulness of proximal anchor balloon technique during implantation of a cardiac resynchronization therapy device in a patient with complex coronary venous anatomy: a case report

Background

Cardiac resynchronization therapy (CRT) is an accepted device treatment in stable heart failure (HF) patients. In recent years increased awareness of coronary anatomy and implantation techniques have significantly impacted this evolving therapy.

Case presentation

In this article, we present a case describing the usefulness of the proximal balloon anchoring technique to enable initial coronary sinus (CS) cannulization and left ventricular (LV) lead placement in the tortuous coronary sinus during CRT implantation.

Conclusions

The proximal anchor balloon technique can easily enable coronary sinus cannulization and left ventricular lead placement in patients with complex venous anatomy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02484-1.

Clinical Determinants and Prognosis of Left Ventricular Reverse Remodelling in Non-Ischemic Dilated Cardiomyopathy

Aims: Non-ischaemic dilated cardiomyopathy (NIDCM) is characterized by left ventricular (LV) chamber enlargement and systolic dysfunction in the absence of coronary artery disease. Left ventricular reverse remodelling (LVRR) is the ability of a dilated ventricle to restore its normal size, shape and function. We sought to determine the frequency, clinical predictors and prognostic implications of LVRR, in a cohort of heart failure (HF) patients with NIDCM. Methods: We conducted a multicentre observational, retrospective cohort study of patients with NIDCM, with prospective serial echocardiography evaluations. LVRR was defined as an increase of ≥15% in left ventricular ejection fraction (LVEF) or as a LVEF increase ≥ 10% plus reduction of LV end-systolic diameter index ≥ 20%. We used multivariable logistic regression analyses to identify the baseline clinical predictors of LVRR and evaluate the prognostic impact of LVRR. Results: LVRR was achieved in 42.5% of 527 patients with NIDCM during the first year of follow-up (median LVEF 49%, median change +22%), Alcoholic aetiology, HF duration, baseline LVEF and the absence of LBBB (plus NT-proBNP levels when in the model), were the strongest predictors of LVRR. During a median follow-up of 47 months, 134 patients died (25.4%) and 7 patients (1.3%) received a heart transplant. Patients with LVRR presented better outcomes, regardless of other clinical conditions. Conclusions: In patients with NIDCM, LVRR was frequent and was associated with improved prognosis. Major clinical predictors of LVRR were alcoholic cardiomyopathy, absence of LBBB, shorter HF duration, and lower baseline LVEF and NT-proBNP levels. Our study advocates for clinical phenotyping of non-ischaemic dilated cardiomyopathy and intense gold-standard treatment optimization of patients according to current guidelines and recommendations in specialized HF units.

MitraClip implantation in real-world: clinical relevance of different patterns of left ventricular remodeling

OBJECTIVES

The role of left ventricular (LV) volumes and ejection fraction (EF) in the selection of patients candidates to MitraClip procedure remains matter of debate. To assess the pattern of LV remodeling and its clinical implications after MitraClip procedures, and to evaluate the role of LV ejection fraction (EF) in patient selection.

METHODS

Complete echocardiography was performed before, at discharge,1,6, and 12-month in 45 patients treated with MitraClip for severe mitral regurgitation (MR) [age 78.2±8.3 yrs, NYHA 3.74±0.44, EF 36.5±12.8%]. From baseline to 6-month reverse and adverse LV-R was defined as ≥15 % decrease and ≥10% increase in LV end-systolic volume, respectively.

RESULTS

At 6-month, sustained reduction of MR≤2 was observed in all patients, but 2; reverse, adverse and no LV-R occurred in 51% (N=23), 18% (N=8) and 31% (N=14) patients. Baseline LV end-diastolic volume was an independent predictor of reverse LV-R [P=0.004], whereas EF was not. During follow-up (17.5±9.3 months), freedom from the composite endpoint (mortality and hospitalization for heart failure) was observed in 50% of adverse/no LV-R vs. 95.7% of reverse LV-R patients (P=0.006). At Cox analysis, adverse LV-R and adverse/no LV-R were associated with composite endpoint with adjusted hazard ratio of 5.6 (95% CI 1.65-19.00) and 10.08 (95% CI 1.29-78.6), respectively.

CONCLUSIONS

After MitraClip implantation, sustained adverse or no LV-R occurred in one-in-two patients and was associated with poor prognosis. Large LV volumes may help us to avoid futility of procedure.

Modified design of stimulation of the left ventricular endocardium for cardiac resynchronization therapy in nonresponders, previously untreatable and high-risk upgrade patients (SOLVE-CRT) trial

The WiSE system is a novel, leadless endocardial system that can provide cardiac resynchronization therapy in patients who cannot be treated with a conventional epicardial left ventricular lead. Safety and efficacy were being evaluated in the pivotal, randomized, double-blind SOLVE-CRT Trial (Stimulation of the Left Ventricular Endocardium for Cardiac Resynchronization Therapy.) The trial was initiated in 2018; however, patient enrollment was significantly impacted by the COVID-19 pandemic necessitating a change in design. This article describes the revised trial and the scientific rationale for the specific changes in the protocol.

Short- and Long-Term Outcomes in Patients With New-Onset Persistent Left Bundle Branch Block After Transcatheter Aortic Valve Replacement

BACKGROUND

The impact of new-onset persistent left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) on all-cause mortality has been controversial.

METHODS

We conducted a systematic review and meta-analysis of eleven studies (7398 patients) comparing the short- and long- outcomes in patients who had new-onset LBBB after TAVR vs. those who did not.

RESULTS

During a mean follow-up of 20.5±14months, patients who had new-onset persistent LBBB after TAVR had a higher incidence of all-cause mortality (29.7% vs. 23.6%; OR 1.28 (1.04-1.58), p=0.02), rehospitalization for heart failure (HF) (19.5% vs. 17.3%; OR 1.4 (1.13-1.73), p=0.002), and permanent pacemaker implantation (PPMi) (19.7% vs. 7.1%; OR 2.4 (1.64-3.52), p<0.001) compared with those who did not. Five studies (4180 patients) reported adjusted hazard ratios (HR) for all-cause mortality; new LBBB remained associated with a higher risk of mortality (adjusted HR 1.43 (1.08-1.9), p<0.01, I²=81%).

CONCLUSION

Post-TAVR persistent LBBB is associated with higher PPMi, HF hospitalizations, and all-cause mortality. While efforts to identify patients who need post-procedural PPMi are warranted, more studies are required to evaluate the best follow-up and treatment strategies, including the type of pacing device if required, to improve long-term outcomes in these patients.

Left ventricular phase entropy: Novel prognostic predictor in patients with dilated cardiomyopathy and narrow QRS

BACKGROUND

The prognostic impact and pathophysiology of global left ventricular mechanical dyssynchrony (LVMD), namely mechanical dyssynchrony of whole left ventricle, as assessed by phase analysis of electrocardiographically gated (ECG-gated) myocardial perfusion SPECT has not been clearly elucidated in patients with dilated cardiomyopathy (DCM) and narrow QRS complex (<120 ms).

METHODS AND RESULTS

Forty-six patients with DCM underwent ECG-gated myocardial 99mTc-sestamibi perfusion SPECT and endomyocardial biopsy. LV phase entropy was automatically calculated using a phase analysis of ECG-gated myocardial perfusion SPECT. The patients were divided into two groups according to the median phase entropy value: low-phase entropy (<0.61) (N = 23: LE group) and high-phase entropy (≥0.61) (N = 23: HE group). In the Kaplan-Meier survival analysis, the event-free survival rate was significantly lower in the HE group (log-rank P = 0.015). Moreover, high-phase entropy was an independent predictor of adverse cardiac events (hazard ratio, 5.77%; 95% confidence interval, 1.02-108.32; P = 0.047). Interestingly, the mRNA expression levels of sarcoplasmic reticulum Ca2+-ATPase (SERCA2a) in endomyocardial biopsy specimens were significantly lower in the HE group (P = 0.015).

CONCLUSION

LV phase entropy, which may reflect impairment of Ca2+ handling caused by decreased SERCA2a mRNA levels, is a novel prognostic predictor in patients with DCM and narrow QRS complex.

Osteopathic manual therapy in heart failure patients: A randomized clinical trial

BACKGROUND

Heart Failure (HF) patients usually present with increased arterial resistance and reduced blood pressure (BP) leading to an impaired functional capacity. Osteopathic Manual Therapy (OMT) focused on myofascial release techniques (MRT) and in the balancing of diaphragmatic tensions, has been shown to improve blood flow in individuals using the resistive index (RI). However, its effects in HF patients have not been examined.

PURPOSE

To evaluate the acute response of selected osteopathic techniques on RI, heart rate (HR), and BP in patients with HF.

METHODS

Randomized-controlled clinical trial of HF patients assigned to MRT (six different techniques with three aimed at the pelvis, two at the thorax, and one at the neck for 15 min) or Control group (subjects in supine position for 15 min without intervention). The RI of the femoral, brachial and carotid arteries was measured via doppler ultrasound while HR and BP were measured via sphygmomanometry before and after a single MRT or control intervention.

RESULTS

Twenty-two HF patients equally distributed (50% male, mean age 53 years; range 32-69 years) (ejection fraction = 35.6%, VO_2peak: 12.9 mL/kg^-1 min^-1) were evaluated. We found no intra or inter group differences in RI of the carotid (Δ_MRT: 0.07% vs Δ _Control:11.8%), brachial (Δ_MRT:0.17% vs Δ_Control: 2.9%), or femoral arteries (Δ_MRT:1.65% vs Δ_Control: 0.97%) (P > 0.05) and no difference in HR or BP (Δ_MRT:0.6% vs Δ_Control: 3%), (P > 0.05).

CONCLUSION

A single MRT session did not significantly change the RI, HR, or BP of HF patients.

Time to left ventricular reverse remodeling after cardiac resynchronization therapy: Better late than never

INTRODUCTION

Left ventricular reverse remodeling (LVRR), defined as reduction of end-diastolic and end-systolic dimensions and improvement of ejection fraction, is associated with the prognostic implications of cardiac resynchronization therapy (CRT). The time course of LVRR remains poorly characterized. Nevertheless, it has been suggested that it occurs ≤6 months after CRT.

OBJECTIVE

To characterize the long-term echocardiographic and clinical evolution of patients with LVRR occurring >6 months after CRT and to identify predictors of a delayed LVRR response.

METHODS

A total of 127 consecutive patients after successful CRT implantation were divided into three groups according to LVRR response: Group A, 19 patients (15%) with LVRR after >6 months (late LVRR); Group B, 58 patients (46%) with LVRR before 6 months (early LVRR); and Group C, 50 patients (39%) without LVRR during follow-up (no LVRR).

RESULTS

The late LVRR group was older, more often had ischemic etiology and fewer patients were in NYHA class ≤II. Overall, group A presented LVRR between group B and C. This was also the case with the percentage of clinical response (68.4% vs. 94.8% vs. 38.3%, respectively, p<0.001), and hospital readmissions due to decompensated heart failure (31.6% vs. 12.1% vs. 57.1%, respectively, p<0.001). Ischemic etiology (OR 0.044; p=0.013) and NYHA functional class <III (OR 0.056; p=0.063) were the variables with the highest predictive value for late LVRR.

CONCLUSIONS

Late LVRR has better clinical and echocardiographic outcomes than no LVRR, although with a suboptimal response compared to the early LVRR population. Ischemic etiology and NYHA functional class <III are predictors of late LVRR.

Systolic heart failure and cardiac resynchronization therapy: a focus on diastole

Conflicting data exist about the effects of cardiac resynchronization therapy (CRT) on diastolic function (DF). Aim of the study was to assess if and how CRT affects DF in systolic heart failure patients. We also investigated potential relations between CRT-induced left ventricular changes and the composite clinical endpoint of progressive heart failure and cardiac death over 3 years follow-up. 119 CRT patients underwent clinical evaluation and echocardiography before CRT and 4 months later. DF was quantified by transmitral velocities [E/A waves, deceleration time (DT), E/DT], early diastolic mitral annulus velocity (E'), E/E' ratio and 2-D speckle tracking strain rate during isovolumetric relaxation (IVR, SRivr). End-diastolic pressure-volume relationship (EDPVR) was also assessed noninvasively using a single-beat method. Overall stiffness was quantified by ventricular stiffness (Klv) normalized to end-diastolic volume (EDV). New York Heart Association class improved at 4 months (from 2.7 ± 0.7 to 1.9 ± 0.6, p < 0.001) as did ventricular filling (E/DT from 0.48 ± 0.29 to 0.39 ± 0.31 cm/s(2), p = 0.01). In contrast, relaxation (E', SRivr) and filling pressures (E/E', E/SRivr) did not change. Slope of EDPVR did not change with CRT. Such finding, together with an unmodified Klv/EDV and a 7 ± 18 % reduction in EDV (p = 0.001), suggested reverse remodelling towards a smaller equilibrium volume. Finally, end-systolic LV volume decreased from 147 ± 59 to 125 ± 52 ml and ejection fraction increased from 0.26 ± 0.07 to 0.32 ± 0.09 (both p < 0.001). Using a Cox regression model we found that only changes (Δ) in diastolic, but not systolic indexes, correlated with the composite clinical endpoint, with increments in ΔEDV20 and ΔE/DT, single or combined, greatly increasing risk of heart failure and/or cardiac death (p = 0.003). Ventricular reverse remodelling, together with improvement in ventricular filling, rather than improvements of systolic function, predict clinical prognosis long-term post-CRT.

Role of nuclear cardiology for guiding device therapy in patients with heart failure

Heart failure is a dynamic condition with high morbidity and mortality and its prognosis should be reassessed frequently, particularly in patients for whom critical treatment decisions may depend on the results of prognostication. In patients with heart failure, nuclear cardiology techniques are useful to establish the etiology and the severity of the disease, while fewer studies have explored the potential capability of nuclear cardiology to guide cardiac resynchronization therapy (CRT) and to select patients for implantable cardioverter defibrillators (ICD). Left ventricular synchrony may be assessed by radionuclide angiography or gated single-photon emission computed tomography myocardial perfusion scintigraphy. These modalities have shown promise as predictors of CRT outcome using phase analysis. Combined assessment of myocardial viability and left ventricular dyssynchrony is feasible using positron emission tomography and could improve conventional response prediction criteria for CRT. Preliminary data also exists on integrated positron emission tomography/computed tomography approach for assessing myocardial viability, identifying the location of biventricular pacemaker leads, and obtaining left ventricular functional data, including contractile phase analysis. Finally, cardiac imaging with autonomic radiotracers may be useful in predicting CRT response and for identifying patients at risk for sudden cardiac death, therefore potentially offering a way to select patients for both CRT and ICD therapy. Prospective trials where imaging is combined with image-test driven therapy are needed to better define the role of nuclear cardiology for guiding device therapy in patients with heart failure.

Prognostic significance of left ventricular dyssynchrony by phase analysis of gated SPECT in medically treated patients with dilated cardiomyopathy

PURPOSE

The study aimed to investigate the value of clinical variables and rest gated single-photon emission computed tomography (SPECT) in predicting cardiac deaths in medically treated dilated cardiomyopathy (DCM) patients.

METHODS

This is a retrospective study. Fifty-six consecutive hospitalized DCM patients who underwent rest gated SPECT myocardial perfusion imaging were initially recruited. Patients were further excluded for receiving heart transplantation, cardiac resynchronization treatment, and noncardiac death during follow-up. The remaining 48 medically treated DCM patients were selected into the final analysis. Phase analysis of gated SPECT was conducted to identify left ventricular (LV) dyssynchrony. Cardiac death during follow-up was considered as the only endpoint. Univariate and multivariate Cox proportional hazards regression analysis were performed to identify the independent predictors of cardiac death. Kaplan-Meier cumulative survival analysis with stratification was performed, and survival curves were compared by log-rank test.

RESULTS

The mean age was 47.5 ± 15.8 years (range, 15-76 yrs) and 85.4% were men. The mean LV ejection fraction was 22.2 ± 7.7%. During the follow-up period (22.7 ± 5.1 mos), 12 (25.0%) cardiac deaths occurred. Compared to survivors, patients with cardiac death had lower body mass index (BMI, P = 0.010), higher percent of prolonged QRS duration (QRSD, P = 0.043), and severe LV dyssynchrony (P = 0.002). Multivariate Cox analysis demonstrated that severe LV dyssynchrony [hazard ratio = 9.607, 95% confidential interval (95% CI) 2.064-44.713, P = 0.004] and BMI (hazard ratio = 0.851, 95% CI 0.732-0.989, P = 0.036) were predictive of cardiac death.

CONCLUSION

Left ventricular dyssynchrony assessed by phase analysis of gated SPECT and BMI are predictive of cardiac death in medically treated DCM patients.

[Cardiac resynchronisation therapy : new data and technical developments]

Cardiac resynchronisation therapy (CRT) has opened up new perspectives over the past 10 years for highly symptomatic patients with severe systolic heart failure. The present article analyses and comments on recent publications which have lead to an expansion of the indication to patients with mild symptoms of heart failure, and which resulted in the modification of current European guidelines in 2010. The data available from narrow QRS complex studies are critically examined. Furthermore, the latest technical innovations in the field of CRT, which have helped to ease the implantation procedure and achieve higher success rates, are presented. Finally, new wireless ultrasound technology to stimulate the left ventricle, currently in an early clinical phase of evaluation, is presented as a potential alternative in the future.

Patient-specific electromechanical models of the heart for the prediction of pacing acute effects in CRT: a preliminary clinical validation

Cardiac resynchronisation therapy (CRT) is an effective treatment for patients with congestive heart failure and a wide QRS complex. However, up to 30% of patients are non-responders to therapy in terms of exercise capacity or left ventricular reverse remodelling. A number of controversies still remain surrounding patient selection, targeted lead implantation and optimisation of this important treatment. The development of biophysical models to predict the response to CRT represents a potential strategy to address these issues. In this article, we present how the personalisation of an electromechanical model of the myocardium can predict the acute haemodynamic changes associated with CRT. In order to introduce such an approach as a clinical application, we needed to design models that can be individualised from images and electrophysiological mapping of the left ventricle. In this paper the personalisation of the anatomy, the electrophysiology, the kinematics and the mechanics are described. The acute effects of pacing on pressure development were predicted with the in silico model for several pacing conditions on two patients, achieving good agreement with invasive haemodynamic measurements: the mean error on dP/dt(max) is 47.5±35mmHgs(-1), less than 5% error. These promising results demonstrate the potential of physiological models personalised from images and electrophysiology signals to improve patient selection and plan CRT.

Initial experience of a cohort of patients with hypertrophic cardiomyopathy undergoing biventricular pacing

BACKGROUND

Dual chamber pacing improves functional status and reduces left ventricular outflow tract gradients in some, but not all patients with hypertrophic cardiomyopathy (HCM) by altering ventricular depolarisation. We investigated the use of biventricular (BIV) pacing in symptomatic patients with HCM.

METHOD

8 patients aged 58±7yrs with symptomatic HCM underwent BIV pacing. 5 patients had LVOT gradients >30mmHg. Ventricular electrodes were placed in the right ventricle (RV) and a branch of the coronary sinus. An atrial electrode was inserted to achieve BIV pacing with a short AV delay. The short-term effects of different pacing modalities were assessed using 2-D and Doppler echocardiography. Symptoms and exercise tolerance were assessed after a month of each pacing mode. Long-term follow up data was available for 5 years.

RESULTS

Baseline EF was 67±14% and mean QRS duration was 132±26msecs. BIV pacing reduced QRS duration compared to RV pacing (129±46 vs. 205±54msecs, p<0.005). Five of the seven patients had baseline LVOT gradients (mean 67±25mmHg) that decreased to 41±15mm Hg with RV pacing (p<0.01) and 25±15mmHg with BIV pacing (p<0.005). Improvements in exercise time with active pacing occurred in six out of eight patients (75%), three (37.5%) had optimal exercise times with RV pacing and three with BIV pacing. Of the three patients with short term improvements with BIV pacing, one died 4 years post implant, one deteriorated with LV dilatation and one had the system explanted for infection.

CONCLUSION

BIV pacing showed short-term beneficial effects in some patients over and above RV pacing alone.

Effect of cardiac resynchronization therapy in patients with New York Heart Association functional class IV heart failure

Cardiac resynchronization therapy (CRT) is considered a class I indication in treatment of patients with New York Heart Association (NYHA) functional class III and IV heart failure. However, only small numbers of patients in large clinical trials have been in NYHA functional class IV. Therefore, little is known about the effects of CRT in this group. Therefore, we evaluated the effects of CRT in patients with NYHA functional class IV heart failure. Of all patients referred for CRT implantation, 61 patients with symptoms according to NYHA functional class IV were included. All patients were evaluated before implantation and at 6-month follow-up for clinical changes according to the clinical composite score and changes in left ventricular (LV) volumes and function. In addition, survival was evaluated during long-term follow-up. At 6-month follow-up, 9 patients (15%) had died and 2 patients (3%) were admitted for worsening heart failure. The remaining 39 patients (64%) showed improvement according to the clinical composite score. Decreases in LV end-systolic volume (from 167 ± 88 to 147 ± 93 ml, p = 0.009) and LV end-diastolic volume (from 211 ± 100 to 199 ± 113 ml, p = 0.135) were observed, as was a significant increase in LV ejection fraction (from 22 ± 8% to 28 ± 9%, p <0.001). During a mean follow-up of 30 ± 26 months, 36 patients (59%) died, 27 (75%) from worsening heart failure. Respective 1- and 2-year mortality rates were 25% and 38%. In conclusion, CRT decreases LV volumes and improves cardiac function in patients with NYHA functional class IV heart failure. Nevertheless, (heart failure) mortality remains high in these patients.

Familial aggregation of left ventricular geometry and association with parental heart failure: the Framingham Heart Study

BACKGROUND

Data regarding the familial aggregation of left ventricular (LV) geometry and its relations to parental heart failure (HF) are limited.

METHODS AND RESULTS

We evaluated concordance of LV geometry within 1093 nuclear families in 5758 participants of the original (parents) (n=2351) and offspring (n=3407) cohorts of the Framingham Heart Study undergoing routine echocardiography in mid- to late adulthood. LV geometry was categorized based on cohort- and sex-specific 80th percentile cutoffs of LV mass and relative wall thickness (RWT) into normal (both <80th percentile), concentric remodeling (LV mass <80th percentile; RWT >80th percentile), concentric hypertrophy (both >80th percentile), and eccentric hypertrophy (LV mass >80th percentile; RWT <80th percentile). Within nuclear families, LV geometry was concordant among related pairs (parent-child, sibling-sibling) (P=0.0015) but not among unrelated spousal pairs (P=0.60), a finding that remained unchanged after adjusting for clinical covariates known to influence LV remodeling (age, systolic blood pressure, body mass index), excluding individuals with prevalent HF and myocardial infarction, and varying the thresholds for defining LV geometry. The prevalence of abnormal LV geometry was higher in family members of affected individuals, with recurrence risks of 1.4 for concentric remodeling (95% CI, 1.2 to 1.7) and eccentric hypertrophy (95% CI, 1.1 to 1.8) and 3.9 (95% CI, 3.2 to 4.6) for concentric hypertrophy. In a subset of 1497 offspring, we observed an association between parental HF (n=458) and eccentric hypertrophy in offspring (P<0.0001).

CONCLUSIONS

Our investigation of a 2-generational community-based sample demonstrates familial aggregation of LV geometry, with the greatest recurrence risk for concentric LV geometry, and establishes an association between eccentric LV geometry and parental HF.

Morbidity and mortality in heart failure patients treated with cardiac resynchronization therapy: influence of pre-implantation characteristics on long-term outcome

AIMS

Cardiac resynchronization therapy (CRT) improves cardiac function, heart failure symptoms, and prognosis in selected patients. Many baseline characteristics associated with heart failure may influence prognosis after CRT. The objective of this study was to evaluate the effect of several baseline characteristics in relation to long-term prognosis in heart failure patients treated with CRT.

METHODS AND RESULTS

A total of 716 consecutive heart failure patients treated with CRT were included in an observational registry. All available data, including clinical and echocardiographic measurements, were analysed in relation to two endpoints: all-cause mortality and a combined endpoint of all-cause mortality or major cardiovascular event. Outcome data were collected by chart review, device interrogation, and telephone contact. Mean follow-up was 25 ± 19 months. During follow-up, 141 patients (20%) died (primary endpoint). Most of these patients (61%) died due to worsening heart failure. A total of 214 patients (30%) reached the secondary endpoint. Larger left ventricular end-systolic volume, less distance covered in the 6 min walking test, poor renal function, more severe heart failure, male gender, presence of atrial fibrillation, no posterolateral left ventricular (LV) lead, and no LV dyssynchrony were associated with poor prognosis after CRT.

CONCLUSION

In this large single-centre registry, several baseline clinical and echocardiographic characteristics were associated with prognosis after CRT. Worsening heart failure was the main cause of death in heart failure patients treated with CRT.

Radionuclide angiographic determination of regional left ventricular systolic function during rest and exercise in patients with nonischemic cardiomyopathy treated with cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) can improve global left ventricular (LV) function. However, limited data are available on regional LV contractility at rest and during exercise. The aim of the present study was to prospectively investigate the effects of CRT on regional LV ejection fraction (EF), global LVEF, and dyssynchrony, during rest and exercise, using radionuclide angiography. A total of 32 consecutive patients with heart failure and nonischemic cardiomyopathy underwent technetium-99m radionuclide angiography with bicycle exercise immediately after CRT implantation (during spontaneous rhythm and after CRT activation) and 3 months later. The regional EF was assessed in the interventricular septum and the lateral wall (LW). Intraventricular dyssynchrony was evaluated using Fourier phase analysis. During spontaneous rhythm, the EF was severely depressed in the septum compared to in the LW. CRT improved septal EF at rest and during exercise both at baseline (p <0.001) and after 3 months (p <0.05). The basal LW EF decreased during CRT (p <0.05, both at rest and during exercise). LV dyssynchrony decreased both at baseline and during follow-up, and the global LVEF showed improvement only at 3 months (p <0.001). In conclusion, in patients with nonischemic cardiomyopathy, CRT affects regional LV function by increasing the septal EF and reducing LW contractility, both at rest and during exercise. This was associated with an improvement in global LVEF and dyssynchrony.

Left ventricular mechanical activity detected by impedance recording

Aims

Recording and analysing impedance fluctuation along the cardiac cycle in the right (RV) and left ventricles (LV).

Methods and results

During a biventricular (BiV) implantation procedure, impedance was sequentially derived between the atrial ring electrode and either electrode (tip or ring) of the RV lead [transvalvular impedance (TVI)], and between the atrial ring and either the tip or ring electrode of a coronary sinus lead, positioned in a cardiac vein [left ventricle impedance (LVI)]. The LVI signal was also recorded by the implanted pacemaker at the 1 day and 3 months follow-ups. With intrinsic conduction, TVI showed an average increase of 53 ± 29 Ω during ventricular systole, whereas at the same time, LVI decreased by 45 ± 21 Ω (25 and 23 patients, respectively, out of 28 tested cases). Transvalvular impedance and LVI displayed a similar time course, which appeared to be related to the systolic timing in the RV and LV. Both LVI amplitude and duration decreased as a function of the cardiac rate. The LVI deflection started immediately after LV stimulation, and often anticipated the R-wave sensing after contralateral pacing. At the 3-month follow-up, LVI amplitude was decreased in 70% of cases and increased in the remainder, with a non-significant average change of −5 ± 85% with respect to the acute recordings.

Conclusion

Transvalvular impedance properties are consistent with the assumption of an inverse relationship with RV volume. Though LVI requires a different physical interpretation, the waveform duration might reflect the timing of LV myocardial contraction. In this hypothesis, the relationship between TVI and LVI could provide insight into the effects of BiV pacing on mechanical synchronization.

Long-term reverse remodeling with cardiac resynchronization therapy: results of extended echocardiographic follow-up

OBJECTIVES

The purpose of this study was to describe the long-term course of left ventricular remodeling induced by cardiac resynchronization therapy (CRT), adjusting for the confounding effect of patient loss due to disease.

BACKGROUND

Reverse remodeling has been identified as the primary mechanism of improved symptoms and outcome in heart failure patients.

METHODS

A total of 313 consecutive patients who underwent CRT with available baseline echocardiograms and subsequent clinical and echocardiographic follow-up were included in the analysis. Long-term follow-up included all-cause mortality, heart transplantation, and implantation of a left ventricular assist device. Longitudinal data analysis of left ventricular end-systolic volume index (LVESVi) was performed to adjust for the confounding effect of patient loss during follow-up.

RESULTS

Patients with uneventful survival had a lower baseline LVESVi (Delta = 8.6 ml/m(2), SE = 4.6 ml/m(2), p < 0.0001) and a decreased LVESVi by -0.11 ml/m(2)/day during first 6 months, whereas the LVESVi remained unchanged in patients with adverse events (p < 0.0001). Beyond 6 months, the LVESVi remained unchanged in patients with uneventful survival, whereas the LVESVi continued to increase in those with adverse events at a rate of 0.01 ml/m(2)/day (p < 0.0001). Predictors of reverse remodeling were nonischemic etiology, female sex, and a wider QRS duration (p < 0.0001, p = 0.014, and p = 0.001, respectively). In the majority of patients, 6 months indicates a break point after which reverse remodeling becomes significantly less pronounced.

CONCLUSIONS

CRT patients with uneventful survival show a significant decrease in the LVSVi at 6 months and generally maintain this response in the long term. Those with adverse outcomes are characterized by left ventricular dilation despite CRT.

Value of tissue Doppler echocardiography in predicting response to cardiac resynchronization therapy in patients with heart failure

Several studies have demonstrated a relation between left ventricular (LV) dyssynchrony and response to cardiac resynchronization therapy (CRT). Many methods of determining LV dyssynchrony have been proposed, including a value of 65 ms as assessed by tissue Doppler imaging. The aim of the present validation study was to prospectively test the predictive accuracy of the 65-ms cutoff for LV dyssynchrony in a large cohort of patients with heart failure undergoing CRT. The study included 361 patients who had undergone CRT. The clinical and echocardiographic parameters were assessed at baseline and at 6 months of follow-up. The clinical response was defined as an improvement of > or = 1 New York Heart Association class, and the echocardiographic response was defined as a reduction in LV end-systolic volume of > or = 15%. At 6 months of follow-up, 259 patients (72%) had a clinical response and 187 patients (52%) had an echocardiographic response. The patients with a response had more LV dyssynchrony than did those without a response (91 + or - 49 ms vs 50 + or - 44 ms for the clinical response and 101 + or - 46 ms vs 55 + or - 45 ms for the echocardiographic response). On multivariate analysis, LV dyssynchrony remained predictive of the response, independent of other characteristics. In conclusion, LV dyssynchrony of > or = 65 ms was an independent predictor of both the clinical and the echocardiographic response in patients with heart failure who underwent CRT in this validation study.

Chronic left ventricular failure: the role of imaging in diagnosis and planning of conventional and novel therapies

Heart failure is the leading cause of hospitalisation in the UK, and its prevalence is expected to increase further in the future due partly to an aging population. Although pharmacological agents remain the mainstay of therapy, an increasing number of surgical and novel minimally invasive interventions have been developed for the treatment of both acute and chronic heart failure. Imaging is essential for diagnosis, guiding therapeutic options, and monitoring therapy and its complications. As a result, radiologists should be familiar with the pathogenesis, treatment options, and imaging-related issues pertaining to the management of these patients.

Diastolic heart failure: state of the science on best treatment practices

PURPOSE

The purpose of this article is to increase awareness among nurse practitioners (NPs) of the current state of the science on diastolic heart failure (DHF), the American College of Cardiology (ACC) and the American Heart Association (AHA) guidelines for DHF, and pathophysiology, diagnosis, and nonpharmacological and pharmacological management of DHF.

DATA SOURCES

The articles included in the review of the state of the science were retrieved by a search of PUBMED literature using the following key search terms: heart failure, diastolic heart failure, preserved systolic function, heart failure management, treatment of diastolic heart failure, treatment of diastolic dysfunction, and treatment of preserved systolic function. Current published guidelines from the ACC and AHA were reviewed to establish clinical recommendations for patients with DHF.

CONCLUSIONS

The state of the science and clinical recommendations for DHF are in the early stages compared to those for systolic heart failure (SHF). The need for more randomized clinical trials on nonpharmacological and pharmacological management and the development of standardized guidelines for DHF patients are clearly apparent.

IMPLICATIONS FOR PRACTICE

Both nonpharmacologic and pharmacologic management are effective and necessary to control the clinical signs and symptoms of DHF and improve overall quality of life. Successful tailoring of a treatment plan to suit each individual patient's needs and including the family are important for the NP to consider.

Future potential of echocardiography in heart failure

Echocardiography represents a convenient, portable and noninvasive method to provide important anatomic and physiologic information to inform the management of heart failure patients. Traditional echo assessments include diagnostic, etiologic and prognostic data from ventricular size, geometry and performance. Newer echocardiographic techniques are receiving greater utilization, however, and promise to further enhance diagnostic abilities in heart failure. This article reviews traditional anatomic assessments, echo-based cardiac hemodynamics, 3D echocardiography, quantification of myocardial tissue mechanics and hand-carried echocardiography. These developments in echocardiography underlie future trends toward echo objectivity, improved imaging of patients with poor acoustic windows, miniaturization and simplicity in focused exams and the expanded application of old and new techniques.

Quantification of regional left ventricular dyssynchrony by magnetic resonance imaging

Cardiac resynchronization therapy is an established treatment in patients with symptomatic heart failure and intraventricular conduction delay. Electrical dyssynchrony is typically adopted to represent myocardial activation dyssynchrony, which should be compensated by cardiac resynchronization therapy. One third of the patients, however, does not respond to the therapy. Therefore, imaging modalities aimed at the mechanical dyssynchrony estimation have been recently proposed to improve patient selection criteria. This paper presents a novel fully automated method for regional mechanical left ventricular dyssynchrony quantification in short-axis magnetic resonance imaging. The endocardial movement is described by time-displacement curves with respect to an automatically determined reference point. Different methods are proposed for time-displacement curve analysis aimed at the regional contraction timing estimation. These methods were evaluated in two groups of subjects with (nine patients) and without (six patients) left bundle branch block. The contraction timing standard deviation showed a significant increase for left bundle branch block patients with all the methods. A novel method based on phase spectrum analysis may be however preferred due to a better specificity (99.7%) and sensitivity (99.0%). In conclusion, this method provides a valuable prognostic indicator for heart failure patients with dyssynchronous ventricular contraction and it opens new possibilities for regional timing analysis.