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Prominent differences in left ventricular performance and myocardial properties between right ventricular and left ventricular-based pacing modes in rats. Sci Rep 2017; 7:5931. [PMID: 28725029 PMCID: PMC5517524 DOI: 10.1038/s41598-017-06197-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 05/30/2017] [Indexed: 01/16/2023] Open
Abstract
Biventricular pacing is an important modality to improve left ventricular (LV) synchronization and long-term function. However, the biological effects of this treatment are far from being elucidated and existing animal models are limited and demanding. Recently, we introduced an implanted device for double-site epicardial pacing in rats and echocardiographically demonstrated favorable effects of LV and biventricular (LV-based) pacing modes typically observed in humans. Here, this new animal model was further characterized. Electrodes were implanted either on the right atria (RA) and right ventricle (RV) or on the RV and LV. Following recovery, rats were either used for invasive hemodynamic measurements (pressure-volume analysis) or exposed to sustained RV vs. biventricular tachypacing for 3 days. RV pacing compromised, while LV-based pacing modes markedly enhanced cardiac performance. Changes in LV performance were associated with prominent compensatory changes in arterial resistance. Sustained RV tachypacing increased the electrocardiogram QTc interval by 7.9 ± 3.1 ms (n = 6, p < 0.05), dispersed refractoriness between the right and left pacing sites and induced important molecular changes mainly in the early-activated septal tissue. These effects were not observed during biventricular tachypacing (n = 6). Our results demonstrate that the rat is an attractive new model to study the biological consequences of LV dyssynchrony and resynchronization.
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Panthee N, Okada JI, Washio T, Mochizuki Y, Suzuki R, Koyama H, Ono M, Hisada T, Sugiura S. Tailor-made heart simulation predicts the effect of cardiac resynchronization therapy in a canine model of heart failure. Med Image Anal 2016; 31:46-62. [PMID: 26973218 DOI: 10.1016/j.media.2016.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 11/25/2022]
Abstract
Despite extensive studies on clinical indices for the selection of patient candidates for cardiac resynchronization therapy (CRT), approximately 30% of selected patients do not respond to this therapy. Herein, we examined whether CRT simulations based on individualized realistic three-dimensional heart models can predict the therapeutic effect of CRT in a canine model of heart failure with left bundle branch block. In four canine models of failing heart with dyssynchrony, individualized three-dimensional heart models reproducing the electromechanical activity of each animal were created based on the computer tomographic images. CRT simulations were performed for 25 patterns of three ventricular pacing lead positions. Lead positions producing the best and the worst therapeutic effects were selected in each model. The validity of predictions was tested in acute experiments in which hearts were paced from the sites identified by simulations. We found significant correlations between the experimentally observed improvement in ejection fraction (EF) and the predicted improvements in ejection fraction (P<0.01) or the maximum value of the derivative of left ventricular pressure (P<0.01). The optimal lead positions produced better outcomes compared with the worst positioning in all dogs studied, although there were significant variations in responses. Variations in ventricular wall thickness among the dogs may have contributed to these responses. Thus CRT simulations using the individualized three-dimensional heart models can predict acute hemodynamic improvement, and help determine the optimal positions of the pacing lead.
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Affiliation(s)
- Nirmal Panthee
- Department of Cardiac Surgery, School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655 Japan
| | - Jun-ichi Okada
- Department of Human and Engineered Environmental Studies, Graduate School of Frontier Sciences, The University of Tokyo, 178-4-4 Wakashiba, Kashiwa, Chiba, 277-0871 Japan; UT-Heart Inc. 3-25-8 Nozawa, Setagaya-ku, Tokyo 154-0003 Japan
| | - Takumi Washio
- Department of Human and Engineered Environmental Studies, Graduate School of Frontier Sciences, The University of Tokyo, 178-4-4 Wakashiba, Kashiwa, Chiba, 277-0871 Japan; UT-Heart Inc. 3-25-8 Nozawa, Setagaya-ku, Tokyo 154-0003 Japan
| | - Youhei Mochizuki
- Laboratory of Veterinary Internal Medicine, Nippon Veterinary and Life Science University, 1-7-1 Kyonancho, Musashino-shi, Tokyo 180-8602 Japan
| | - Ryohei Suzuki
- Laboratory of Veterinary Internal Medicine, Nippon Veterinary and Life Science University, 1-7-1 Kyonancho, Musashino-shi, Tokyo 180-8602 Japan
| | - Hidekazu Koyama
- Laboratory of Veterinary Internal Medicine, Nippon Veterinary and Life Science University, 1-7-1 Kyonancho, Musashino-shi, Tokyo 180-8602 Japan
| | - Minoru Ono
- Department of Cardiac Surgery, School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655 Japan
| | - Toshiaki Hisada
- Department of Human and Engineered Environmental Studies, Graduate School of Frontier Sciences, The University of Tokyo, 178-4-4 Wakashiba, Kashiwa, Chiba, 277-0871 Japan; UT-Heart Inc. 3-25-8 Nozawa, Setagaya-ku, Tokyo 154-0003 Japan
| | - Seiryo Sugiura
- Department of Human and Engineered Environmental Studies, Graduate School of Frontier Sciences, The University of Tokyo, 178-4-4 Wakashiba, Kashiwa, Chiba, 277-0871 Japan; UT-Heart Inc. 3-25-8 Nozawa, Setagaya-ku, Tokyo 154-0003 Japan.
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Jackson T, Claridge S, Behar J, Sammut E, Webb J, Carr-White G, Razavi R, Rinaldi CA. Narrow QRS systolic heart failure: is there a target for cardiac resynchronization? Expert Rev Cardiovasc Ther 2015; 13:783-97. [PMID: 26048215 DOI: 10.1586/14779072.2015.1049945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiac resynchronization therapy has revolutionized the management of systolic heart failure in patients with prolonged QRS during the past 20 years. Initially, the use of this treatment in patients with shorter QRS durations showed promising results, which have since been opposed by larger randomized controlled trials. Despite this, some questions remain, such as, whether correction of mechanical dyssynchrony is the therapeutic target by which biventricular pacing may confer benefit in this group, or are there other mechanisms that need consideration? In addition, novel techniques of cardiac resynchronization therapy delivery such as endocardial and multisite pacing may reduce potential detrimental effects of biventricular pacing, thereby improving the benefit/harm balance of this therapy in some patients.
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Affiliation(s)
- Tom Jackson
- Department of Cardiovascular Imaging, 4th Floor Lambeth Wing, St Thomas' Hospital, London, SE1 7EH, UK
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Boe E, Russell K, Remme EW, Gjesdal O, Smiseth OA, Skulstad H. Cardiac responses to left ventricular pacing in hearts with normal electrical conduction: beneficial effect of improved filling is counteracted by dyssynchrony. Am J Physiol Heart Circ Physiol 2014; 307:H370-8. [PMID: 24906920 DOI: 10.1152/ajpheart.00089.2014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cardiac resynchronization therapy (CRT) has been proposed in heart failure patients with narrow QRS, but the mechanism of a potential beneficial effect is unknown. The present study investigated the hypothesis that left ventricular (LV) pacing increases LV end-diastolic volume (LVEDV) by allowing the LV to start filling before the right ventricle (RV) during narrow QRS in an experimental model. LV and biventricular pacing were studied in six anesthetized dogs before and after the induction of LV failure. Function was evaluated by pressures and dimensions, and dyssynchrony was evaluated by electromyograms and deformation. In the nonfailing heart, LV pacing gave the LV a head start in filling relative to the RV (P < 0.05) and increased LVEDV (P < 0.05). The response was similar during LV failure when RV diastolic pressure was elevated. The pacing-induced increase in LVEDV was attributed to a rightward shift of the septum (P < 0.01) due to an increased left-to-right transseptal pressure gradient (P < 0.05). LV pacing, however, also induced dyssynchrony (P < 0.05) and therefore reduced LV stroke work (P < 0.05) during baseline, and similar results were seen in failing hearts. Biventricular pacing did not change LVEDV, but systolic function was impaired. This effect was less marked than with LV pacing. In conclusion, pacing of the LV lateral wall increased LVEDV by displacing the septum rightward, suggesting a mechanism for a favorable effect of CRT in narrow QRS. The pacing, however, induced dyssynchrony and therefore reduced LV systolic function. These observations suggest that detrimental effects should be considered when applying CRT in patients with narrow QRS.
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Affiliation(s)
- Espen Boe
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kristoffer Russell
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; and
| | - Espen W Remme
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; KG Jebsen Cardiac Research Center, University of Oslo, Oslo, Norway
| | - Ola Gjesdal
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; KG Jebsen Cardiac Research Center, University of Oslo, Oslo, Norway; Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Helge Skulstad
- Institute for Surgical Research, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; and
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Abstract
Heart failure (HF) is a global phenomenon, and the overall incidence and prevalence of the condition are steadily increasing. Medical therapies have proven efficacious, but only a small number of pharmacological options are in development. When patients cease to respond adequately to optimal medical therapy, cardiac resynchronization therapy has been shown to improve symptoms, reduce hospitalizations, promote reverse remodelling, and decrease mortality. However, challenges remain in identifying the ideal recipients for this therapy. The field of mechanical circulatory support has seen immense growth since the early 2000s, and left ventricular assist devices (LVADs) have transitioned over the past decade from large, pulsatile devices to smaller, more-compact, continuous-flow devices. Infections and haematological issues are still important areas that need to be addressed. Whereas LVADs were once approved only for 'bridge to transplantation', these devices are now used as destination therapy for critically ill patients with HF, allowing these individuals to return to the community. A host of novel strategies, including cardiac contractility modulation, implantable haemodynamic-monitoring devices, and phrenic and vagus nerve stimulation, are under investigation and might have an impact on the future care of patients with chronic HF.
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de Roest GJ, Allaart CP, Kleijn SA, Delnoy PPHM, Wu L, Hendriks ML, Bronzwaer JGF, van Rossum AC, de Cock CC. Prediction of long-term outcome of cardiac resynchronization therapy by acute pressure-volume loop measurements. Eur J Heart Fail 2012. [PMID: 23183349 DOI: 10.1093/eurjhf/hfs190] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIMS Invasive assessment of acute haemodynamic response to biventricular pacing has been proposed as a tool to determine individual response and to optimize the effects of CRT. However, the long-term results of this approach have been poorly studied. The present study relates acute haemodynamic effects of CRT to long-term outcome. METHODS AND RESULTS Forty-one patients were analysed in the present study. During temporary biventricular pacing before implantation, acute changes in LV pump function were assessed by pressure-volume loop measurements and related to long-term response after CRT. In the study population [30 (71%) men, NYHA class 2.9 ± 0.4, EF 28 ± 7%, QRS 150 ± 25 ms], baseline mean stroke work (SW) and dP/dt(max) were 4.6 ± 2.6 L × mmHg and 874 ± 259 mmHg/s, respectively. During biventricular pacing, mean SW and dP/dt(max) increased significantly by 43 ± 39% (+ 2.2 ± 2.4 L × mmHg, P < 0.001) and 13 ± 18% (+ 96 ± 136 mmHg/s, P < 0.001), respectively. In long-term responders (n = 29, 71%) compared with non-responders (n = 12, 29%), the acute increase in SW was significantly higher (+57 ± 33% vs. + 10 ± 30%, P < 0.001), whereas the acute increase in dP/dt(max) was not significantly different between responders and non-responders (+ 15 ± 18% vs. 6 ± 15%, P = 0.139). Receiver operating characteristic (ROC) curve analysis indicated that SW was superior to dP/dt(max), QRS duration and LV dyssynchrony in prediction of response to CRT. A cut-off value for SW of 20% yielded a sensitivity of 90% and specificity of 75% to predict reverse remodelling at 6 months. CONCLUSION Invasive assessment of acute haemodynamics is a reliable tool to determine individual response to CRT. An acute increase in SW predicts long-term response to CRT with a higher accuracy than an acute increase in dP/dt(max), baseline QRS duration, and degree of LV mechanical dyssynchrony.
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Affiliation(s)
- Gerben J de Roest
- Department of Cardiology, VU University Medical Center, Amsterdam, The Netherlands.
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Ploux S, Whinnett Z, Lumens J, Denis A, Zemmoura A, De Guillebon M, Ramoul K, Ritter P, Jaïs P, Clementy J, Haïssaguerre M, Bordachar P. Acute hemodynamic response to biventricular pacing in heart failure patients with narrow, moderately, and severely prolonged QRS duration. Heart Rhythm 2012; 9:1247-50. [DOI: 10.1016/j.hrthm.2012.03.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Indexed: 10/28/2022]
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8
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Lim S. Possible harmful effect of implantable cardioverter-defibrillator (ICD) lead placement on tricuspid valve function. Pacing Clin Electrophysiol 2012; 35:500; author reply 501. [PMID: 22229307 DOI: 10.1111/j.1540-8159.2011.03294.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Donahue T, Niazi I, Leon A, Stucky M, Herrmann K. Acute and Chronic Response to CRT in Narrow QRS Patients. J Cardiovasc Transl Res 2011; 5:232-41. [DOI: 10.1007/s12265-011-9338-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 11/24/2011] [Indexed: 10/14/2022]
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Mele D, Ascione L, Caso P, Manuppelli V, Martiniello AR, Nipote C. Ruolo attuale dell’ecocardiografia nella terapia di resincronizzazione cardiaca. J Cardiovasc Echogr 2011. [DOI: 10.1016/j.jcecho.2011.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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de Roest GJ, Allaart CP, de Haan S, Hendriks ML, Bronzwaer JG, van Rossum AC, de Cock CC. Effects of QRS duration and pacing location on pressure-volume loop evaluation of cardiac resynchronization therapy in end-stage heart failure. Am J Cardiol 2011; 108:1581-8. [PMID: 21890082 DOI: 10.1016/j.amjcard.2011.07.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Revised: 07/06/2011] [Accepted: 07/06/2011] [Indexed: 10/17/2022]
Abstract
Cardiac resynchronization therapy (CRT) decreases the morbidity and mortality in patients with end-stage heart failure. However, patient selection remains challenging, because a considerable 30% to 50% do not respond. Controversy exists on the cutoff values for the QRS duration and the optimal lead location. The present study relates these parameters on an individual basis to acute pump function improvement using invasively obtained pressure-volume loops. Fifty-seven patients with symptomatic end-stage heart failure were included in our temporary biventricular stimulation study and were grouped according to the QRS duration (QRS <20 ms, QRS ≥120 ms but <150 ms, and QRS ≥150 ms). All patients underwent pressure-volume loop assessment of the response to biventricular pacing, comparing the baseline measurements to both right ventricular apex pacing combined with a left ventricular lead in the posterolateral and anterolateral region of the LV. Group analysis during conventional (posterolateral and right ventricular apex) CRT did not show improvement in stroke work and dP/dt(max) (-2%, p = NS; and -7%; p <0.001) in the narrow QRS group but a significant increase in the intermediate (+27%, p = 0.020, and +5%, p = 0.044) and wide (+48%, p = 0.002, and +18%, p <0.001) QRS groups. CRT using the anterolateral and right ventricular apex configuration evoked a consistently lower response compared to posterolateral and right ventricular apex, resulting in a significant hemodynamic deterioration in the narrow QRS group. However, analysis on an individual basis identified 25% of patients with narrow QRS duration showing possible hemodynamic benefit from CRT compared to 83% of patients with intermediate and wide QRS combined. In contrast, 15% of patients had deterioration by conventional (posterolateral right ventricular apex) CRT in the intermediate and wide QRS groups compared to 31% in the narrow QRS group; 19% of patients could be improved by lead placement in the anterolateral rather than the posterolateral region. In conclusion, the acute hemodynamic response to CRT is generally in line with the long-term results from large randomized trials; however, the individual variation is large. The temporary biventricular stimulation protocol might aid in individual patient selection and in research aiming at a reduction of nonresponders and improvement in lead positioning.
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Underestimation of duration of ventricular activation by 12-lead ECG compared with direct measurement of activation duration derived from implanted pacemaker leads. Int J Cardiol 2011; 152:35-42. [DOI: 10.1016/j.ijcard.2010.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 05/10/2010] [Accepted: 07/02/2010] [Indexed: 11/30/2022]
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Buga L, Cleland JGF. Increasing knowledge and changing views in cardiac resynchronization therapy. Heart Fail Rev 2011; 17:721-5. [DOI: 10.1007/s10741-011-9281-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Mau J, Menzie S, Huang Y, Ward M, Hunyor S. Nonsurround, nonuniform, biventricular-capable direct cardiac compression provides Frank-Starling recruitment independent of left ventricular septal damage. J Thorac Cardiovasc Surg 2011; 142:209-15. [DOI: 10.1016/j.jtcvs.2010.05.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2009] [Revised: 04/14/2010] [Accepted: 05/06/2010] [Indexed: 12/31/2022]
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Leyva F, Foley PWX, Chalil S, Ratib K, Smith REA, Prinzen F, Auricchio A. Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2011; 13:29. [PMID: 21668964 PMCID: PMC3141552 DOI: 10.1186/1532-429x-13-29] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 06/13/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT). METHODS 559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR). RESULTS Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group. CONCLUSIONS Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.
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Affiliation(s)
- Francisco Leyva
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, UK
| | - Paul WX Foley
- University of Birmingham, Department of Cardiology, Good Hope Hospital, Sutton Coldfield, UK
| | - Shajil Chalil
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, UK
| | - Karim Ratib
- University of Birmingham, Department of Cardiology, Good Hope Hospital, Sutton Coldfield, UK
| | - Russell EA Smith
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, UK
| | - Frits Prinzen
- Departments of Physiology and Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2011. [PMID: 21668964 DOI: 10.1186/1532-492x-13-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT). METHODS 559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR). RESULTS Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group. CONCLUSIONS Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.
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The Year in Heart Failure. J Am Coll Cardiol 2011; 57:1573-83. [DOI: 10.1016/j.jacc.2011.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 12/27/2010] [Accepted: 01/02/2011] [Indexed: 01/11/2023]
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Ghosh S, Silva JNA, Canham RM, Bowman TM, Zhang J, Rhee EK, Woodard PK, Rudy Y. Electrophysiologic substrate and intraventricular left ventricular dyssynchrony in nonischemic heart failure patients undergoing cardiac resynchronization therapy. Heart Rhythm 2011; 8:692-9. [PMID: 21232630 DOI: 10.1016/j.hrthm.2011.01.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 01/07/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Electrocardiographic imaging (ECGI) is a method for noninvasive epicardial electrophysiologic mapping. ECGI previously has been used to characterize the electrophysiologic substrate and electrical synchrony in a very heterogeneous group of patients with varying degrees of coronary disease and ischemic cardiomyopathy. OBJECTIVE The purpose of this study was to characterize the left ventricular electrophysiologic substrate and electrical dyssynchrony using ECGI in a homogeneous group of nonischemic cardiomyopathy patients who were previously implanted with a cardiac resynchronization therapy (CRT) device. METHODS ECGI was performed during different rhythms in 25 patients by programming their devices to biventricular pacing, single-chamber (left ventricular or right ventricular) pacing, and native rhythm. The electrical dyssynchrony index (ED) was computed as the standard deviation of activation times at 500 sites on the LV epicardium. RESULTS In all patients, native rhythm activation was characterized by lines of conduction block in a region with steep activation-recovery interval (ARI) gradients between the epicardial aspect of the septum and LV lateral wall. A native QRS duration (QRSd) >130 ms was associated with high ED (≥30 ms), whereas QRSd <130 ms was associated with minimal (25 ms) to large (40 ms) ED. CRT responders had very high dyssynchrony (ED = 35.5 ± 3.9 ms) in native rhythm, which was significantly lowered (ED = 23.2 ± 4.4 ms) during CRT. All four nonresponders in the study did not show significant difference in ED between native and CRT rhythms. CONCLUSION The electrophysiologic substrate in nonischemic cardiomyopathy is consistent among all patients, with steep ARI gradients co-localizing with conduction block lines between the epicardial aspect of the septum and the LV lateral wall. QRSd wider than 130 ms is indicative of substantial LV electrical dyssynchrony; however, among patients with QRSd <130 ms, LV dyssynchrony may vary widely.
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Affiliation(s)
- Subham Ghosh
- Cardiac Bioelectricity and Arrhythmia Center (CBAC), Washington University, St. Louis, Missouri 63130-4899, USA
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Kapa S, Bruce CJ, Friedman PA, Asirvatham SJ. Advances in Cardiac Pacing: Beyond the Transvenous Right Ventricular Apical Lead. Cardiovasc Ther 2010; 28:369-79. [PMID: 20553288 DOI: 10.1111/j.1755-5922.2010.00157.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Suraj Kapa
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Yu CM, Sanderson JE, Gorcsan J. Echocardiography, dyssynchrony, and the response to cardiac resynchronization therapy. Eur Heart J 2010; 31:2326-37. [PMID: 20709721 DOI: 10.1093/eurheartj/ehq263] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Biventricular pacing or cardiac resynchronization therapy (CRT) has been a considerable advance in the therapy of chronic heart failure. However, it is clear that not all patients benefit either in terms of symptoms or cardiac function, and some may be worsened by CRT. In this review, we consider the arguments, both clinical and economical, in favour of improved selection of patients for CRT other than those in current guidelines. It also seems clear that the fundamental mechanism of CRT is correction of dyssynchrony, and we review the various methodologies available to detect dyssynchrony. Other factors are probably also important in determining outcomes such as lead position, the extent and form of myocardial damage, optimizing pacemaker performance, and clinical expertise. The potential costs of inappropriate CRT implantation are high to our patients and to the health economy, and it behooves the cardiology community to develop better selection criteria. The current guidelines can and should be improved.
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Affiliation(s)
- Cheuk-Man Yu
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China.
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22
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Russell K, Opdahl A, Remme EW, Gjesdal O, Skulstad H, Kongsgaard E, Edvardsen T, Smiseth OA. Evaluation of Left Ventricular Dyssynchrony by Onset of Active Myocardial Force Generation. Circ Cardiovasc Imaging 2010; 3:405-14. [DOI: 10.1161/circimaging.109.905539] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kristoffer Russell
- From the University of Oslo, Medical Faculty and Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway
| | - Anders Opdahl
- From the University of Oslo, Medical Faculty and Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway
| | - Espen W. Remme
- From the University of Oslo, Medical Faculty and Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway
| | - Ola Gjesdal
- From the University of Oslo, Medical Faculty and Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway
| | - Helge Skulstad
- From the University of Oslo, Medical Faculty and Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway
| | - Erik Kongsgaard
- From the University of Oslo, Medical Faculty and Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway
| | - Thor Edvardsen
- From the University of Oslo, Medical Faculty and Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway
| | - Otto A. Smiseth
- From the University of Oslo, Medical Faculty and Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo University Hospital, Norway
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