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Keene D, Miyazawa AA, Arnold AD, Naraen A, Kaza N, Mohal JS, Lefroy DC, Lim PB, Ng FS, Koa-Wing M, Qureshi NA, Linton NWF, Wright I, Peters NS, Kanagaratnam P, Shun-Shin MJ, Francis DP, Whinnett ZI. Therapeutic potential of conduction system pacing as a method for improving cardiac output during ventricular tachycardia. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01809-8. [PMID: 38649588 DOI: 10.1007/s10840-024-01809-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/15/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Ventricular tachycardia (VT) reduces cardiac output through high heart rates, loss of atrioventricular synchrony, and loss of ventricular synchrony. We studied the contribution of each mechanism and explored the potential therapeutic utility of His bundle pacing to improve cardiac output during VT. METHODS Study 1 aimed to improve the understanding of mechanisms of harm during VT (using pacing simulated VT). In 23 patients with left ventricular impairment, we recorded continuous ECG and beat-by-beat blood pressure measurements. We assessed the hemodynamic impact of heart rate and restoration of atrial and biventricular synchrony. Study 2 investigated novel pacing interventions during clinical VT by evaluating the hemodynamic effects of His bundle pacing at 5 bpm above the VT rate in 10 patients. RESULTS In Study 1, at progressively higher rates of simulated VT, systolic blood pressure declined: at rates of 125, 160, and 190 bpm, -22.2%, -42.0%, and -58.7%, respectively (ANOVA p < 0.0001). Restoring atrial synchrony alone had only a modest beneficial effect on systolic blood pressure (+ 3.6% at 160 bpm, p = 0.2117), restoring biventricular synchrony alone had a greater effect (+ 9.1% at 160 bpm, p = 0.242), and simultaneously restoring both significantly increased systolic blood pressure (+ 31.6% at 160 bpm, p = 0.0003). In Study 2, the mean rate of clinical VT was 143 ± 21 bpm. His bundle pacing increased systolic blood pressure by + 14.2% (p = 0.0023). In 6 of 10 patients, VT terminated with His bundle pacing. CONCLUSIONS Restoring atrial and biventricular synchrony improved hemodynamic function in simulated and clinical VT. Conduction system pacing could improve VT tolerability and treatment.
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Affiliation(s)
- Daniel Keene
- Imperial College Healthcare NHS Trust, London, UK.
- Imperial College London, National Heart and Lung Institute, London, UK.
- National Heart and Lung Institute, Hammersmith Hospital, London, W12 0HS, UK.
| | - Alejandra A Miyazawa
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Ahran D Arnold
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Akriti Naraen
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Nandita Kaza
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Jagdeep S Mohal
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | | | - Phang Boon Lim
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Fu Siong Ng
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Michael Koa-Wing
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Norman A Qureshi
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Nick W F Linton
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Ian Wright
- Imperial College Healthcare NHS Trust, London, UK
| | - Nicholas S Peters
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Matthew J Shun-Shin
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Darrel P Francis
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
| | - Zachary I Whinnett
- Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, National Heart and Lung Institute, London, UK
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Pharithi RB, Ayeni M, Makharia M, Keene D, Khiani R. Optimizing conduction system pacing lead placement utilizing the image overlay technique. Pacing Clin Electrophysiol 2024; 47:260-264. [PMID: 37221915 DOI: 10.1111/pace.14725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/25/2023]
Abstract
The His-bundle has several locations from which conduction system pacing can be achieved. Some locations offer better sensing, thresholds and paced QRS durations. Existing techniques to aid repositioning of an already deployed, but sub-optimally placed lead, include either simple memory of the initial lead position combined with its observation on an x-ray review screen or utilizing an additional vascular access and pacing lead with the first lead serving as a real-time marker (Two-lead technique). We describe a novel, readily available, cost-efficient, imaging-based approach to assist in the re-positioning of a pacing lead for His-bundle pacing (the Image Overlay Technique).
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Affiliation(s)
- Rebabonye B Pharithi
- Department of Cardiology, Royal Free Hospital, Foundation Trust, London, UK
- Department of Medical Education, University College London, UK
| | - Michael Ayeni
- Department of Radiology, Hospital, Royal Free Foundation Trust, London, UK
| | - Manoj Makharia
- Department of Cardiology, Royal Free Hospital, Foundation Trust, London, UK
| | - Daniel Keene
- Department of Cardiology, Royal Free Hospital, Foundation Trust, London, UK
- Imperial College London, National Heart and Lung Institute, UK
| | - Raj Khiani
- Department of Cardiology, Royal Free Hospital, Foundation Trust, London, UK
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3
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Sau A, Ahmed A, Chen JY, Pastika L, Wright I, Li X, Handa B, Qureshi N, Koa-Wing M, Keene D, Malcolme-Lawes L, Varnava A, Linton NWF, Lim PB, Lefroy D, Kanagaratnam P, Peters NS, Whinnett Z, Ng FS. Machine learning-derived cycle length variability metrics predict spontaneously terminating ventricular tachycardia in implantable cardioverter defibrillator recipients. Eur Heart J Digit Health 2024; 5:50-59. [PMID: 38264702 PMCID: PMC10802825 DOI: 10.1093/ehjdh/ztad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/06/2023] [Accepted: 10/16/2023] [Indexed: 01/25/2024]
Abstract
Aims Implantable cardioverter defibrillator (ICD) therapies have been associated with increased mortality and should be minimized when safe to do so. We hypothesized that machine learning-derived ventricular tachycardia (VT) cycle length (CL) variability metrics could be used to discriminate between sustained and spontaneously terminating VT. Methods and results In this single-centre retrospective study, we analysed data from 69 VT episodes stored on ICDs from 27 patients (36 spontaneously terminating VT, 33 sustained VT). Several VT CL parameters including heart rate variability metrics were calculated. Additionally, a first order auto-regression model was fitted using the first 10 CLs. Using features derived from the first 10 CLs, a random forest classifier was used to predict VT termination. Sustained VT episodes had more stable CLs. Using data from the first 10 CLs only, there was greater CL variability in the spontaneously terminating episodes (mean of standard deviation of first 10 CLs: 20.1 ± 8.9 vs. 11.5 ± 7.8 ms, P < 0.0001). The auto-regression coefficient was significantly greater in spontaneously terminating episodes (mean auto-regression coefficient 0.39 ± 0.32 vs. 0.14 ± 0.39, P < 0.005). A random forest classifier with six features yielded an accuracy of 0.77 (95% confidence interval 0.67 to 0.87) for prediction of VT termination. Conclusion Ventricular tachycardia CL variability and instability are associated with spontaneously terminating VT and can be used to predict spontaneous VT termination. Given the harmful effects of unnecessary ICD shocks, this machine learning model could be incorporated into ICD algorithms to defer therapies for episodes of VT that are likely to self-terminate.
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Affiliation(s)
- Arunashis Sau
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Amar Ahmed
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
| | - Jun Yu Chen
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
| | - Libor Pastika
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
| | - Ian Wright
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Xinyang Li
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
| | - Balvinder Handa
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Norman Qureshi
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Michael Koa-Wing
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Daniel Keene
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Louisa Malcolme-Lawes
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Amanda Varnava
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Nicholas W F Linton
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Phang Boon Lim
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - David Lefroy
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Nicholas S Peters
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Zachary Whinnett
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
| | - Fu Siong Ng
- National Heart and Lung Institute, Hammersmith Campus, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, 72 Du Cane Road, W12 0HS, London, UK
- Department of Cardiology, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, SW10 9NH, London, UK
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Reddy RK, Howard JP, Ahmad Y, Shun-Shin MJ, Simader FA, Miyazawa AA, Saleh K, Naraen A, Samways JW, Katritsis G, Mohal JS, Kaza N, Porter B, Keene D, Linton NWF, Francis DP, Whinnett ZI, Luther V, Kanagaratnam P, Arnold AD. Catheter Ablation for Ventricular Tachycardia After MI: A Reconstructed Individual Patient Data Meta-analysis of Randomised Controlled Trials. Arrhythm Electrophysiol Rev 2023; 12:e26. [PMID: 38124803 PMCID: PMC10731517 DOI: 10.15420/aer.2023.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/24/2023] [Indexed: 12/23/2023] Open
Abstract
Background The prognostic impact of ventricular tachycardia (VT) catheter ablation is an important outstanding research question. We undertook a reconstructed individual patient data meta-analysis of randomised controlled trials comparing ablation to medical therapy in patients developing VT after MI. Methods We systematically identified all trials comparing catheter ablation to medical therapy in patients with VT and prior MI. The prespecified primary endpoint was reconstructed individual patient assessment of all-cause mortality. Prespecified secondary endpoints included trial-level assessment of all-cause mortality, VT recurrence or defibrillator shocks and all-cause hospitalisations. Prespecified subgroup analysis was performed for ablation approaches involving only substrate modification without VT activation mapping. Sensitivity analyses were performed depending on the proportion of patients with prior MI included. Results Eight trials, recruiting a total of 874 patients, were included. Of these 874 patients, 430 were randomised to catheter ablation and 444 were randomised to medical therapy. Catheter ablation reduced all-cause mortality compared with medical therapy when synthesising individual patient data (HR 0.63; 95% CI [0.41-0.96]; p=0.03), but not in trial-level analysis (RR 0.91; 95% CI [0.67-1.23]; p=0.53; I2=0%). Catheter ablation significantly reduced VT recurrence, defibrillator shocks and hospitalisations compared with medical therapy. Sensitivity analyses were consistent with the primary analyses. Conclusion In patients with postinfarct VT, catheter ablation reduces mortality.
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Affiliation(s)
- Rohin K Reddy
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale UniversityNew Haven, CT, US
| | | | | | | | - Keenan Saleh
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Akriti Naraen
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Jack W Samways
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - George Katritsis
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Jagdeep S Mohal
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Nandita Kaza
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Bradley Porter
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | | | - Darrel P Francis
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | | | - Vishal Luther
- National Heart and Lung Institute, Imperial College LondonLondon, UK
| | | | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College LondonLondon, UK
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5
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Vernooy K, Keene D, Huang W, Vijayaraman P. Implant, assessment, and management of conduction system pacing. Eur Heart J Suppl 2023; 25:G15-G26. [PMID: 37970519 PMCID: PMC10637838 DOI: 10.1093/eurheartjsupp/suad115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
His bundle pacing and left bundle branch pacing, together referred to as conduction system pacing, have (re)gained considerable interest over the past years as it has the potential to preserve and/or restore a more physiological ventricular activation when compared with right ventricular pacing and may serve as an alternative for cardiac resynchronization therapy. This review manuscript dives deeper into the implantation techniques and the relevant anatomy of the conduction system for both pacing strategies. Furthermore, the manuscript elaborates on better understanding of conduction system capture with its various capture patterns, its potential complications as well as appropriate follow-up care. Finally, the limitations and its impact on clinical care for both His bundle pacing and left bundle branch pacing are being discussed.
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Affiliation(s)
- Kevin Vernooy
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, UK
| | - Weijian Huang
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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6
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Kaza N, Keene D, Vijayaraman P, Whinnett Z. Frontiers in conduction system pacing: treatment of long PR in patients with heart failure. Eur Heart J Suppl 2023; 25:G27-G32. [PMID: 37970515 PMCID: PMC10637839 DOI: 10.1093/eurheartjsupp/suad116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Patients with heart failure who have a prolonged PR interval are at a greater risk of adverse clinical outcomes than those with a normal PR interval. Potential mechanisms of harm relating to prolonged PR intervals include reduced ventricular filling and also the potential progression to a higher degree heart block. There has, however, been relatively little work specifically focusing on isolated PR prolongation as a therapeutic target. Secondary analyses of trials of biventricular pacing in heart failure have suggested that PR prolongation is both a prognostic marker and a promising treatment target. However, while biventricular pacing offers an improved activation pattern, it is nonetheless less physiological than native conduction in patients with a narrow QRS duration, and thus, may not be the ideal option for achieving therapeutic shortening of atrioventricular delay. Conduction system pacing aims to preserve physiological ventricular activation and may therefore be the ideal method for ventricular pacing in patients with isolated PR prolongation. Acute haemodynamic experiments and the recently reported His-optimized pacing evaluated for heart failure (HOPE HF) Randomised Controlled Trial demonstrates the potential benefits of physiological ventricular pacing on patient symptoms and left ventricular function in patients with heart failure.
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Affiliation(s)
- Nandita Kaza
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Pugazhendhi Vijayaraman
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Zachary Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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7
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Ali N, Saqi K, Arnold AD, Miyazawa AA, Keene D, Chow JJ, Little I, Peters NS, Kanagaratnam P, Qureshi N, Ng FS, Linton NWF, Lefroy DC, Francis DP, Boon Lim P, Tanner MA, Muthumala A, Agarwal G, Shun-Shin MJ, Cole GD, Whinnett ZI. Left bundle branch pacing with and without anodal capture: impact on ventricular activation pattern and acute haemodynamics. Europace 2023; 25:euad264. [PMID: 37815462 PMCID: PMC10563660 DOI: 10.1093/europace/euad264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/27/2023] [Indexed: 10/11/2023] Open
Abstract
AIMS Left bundle branch pacing (LBBP) can deliver physiological left ventricular activation, but typically at the cost of delayed right ventricular (RV) activation. Right ventricular activation can be advanced through anodal capture, but there is uncertainty regarding the mechanism by which this is achieved, and it is not known whether this produces haemodynamic benefit. METHODS AND RESULTS We recruited patients with LBBP leads in whom anodal capture eliminated the terminal R-wave in lead V1. Ventricular activation pattern, timing, and high-precision acute haemodynamic response were studied during LBBP with and without anodal capture. We recruited 21 patients with a mean age of 67 years, of whom 14 were males. We measured electrocardiogram timings and haemodynamics in all patients, and in 16, we also performed non-invasive mapping. Ventricular epicardial propagation maps demonstrated that RV septal myocardial capture, rather than right bundle capture, was the mechanism for earlier RV activation. With anodal capture, QRS duration and total ventricular activation times were shorter (116 ± 12 vs. 129 ± 14 ms, P < 0.01 and 83 ± 18 vs. 90 ± 15 ms, P = 0.01). This required higher outputs (3.6 ± 1.9 vs. 0.6 ± 0.2 V, P < 0.01) but without additional haemodynamic benefit (mean difference -0.2 ± 3.8 mmHg compared with pacing without anodal capture, P = 0.2). CONCLUSION Left bundle branch pacing with anodal capture advances RV activation by stimulating the RV septal myocardium. However, this requires higher outputs and does not improve acute haemodynamics. Aiming for anodal capture may therefore not be necessary.
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Affiliation(s)
- Nadine Ali
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Khulat Saqi
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Ahran D Arnold
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Alejandra A Miyazawa
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Daniel Keene
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Ji-Jian Chow
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | | | - Nicholas S Peters
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Prapa Kanagaratnam
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Norman Qureshi
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Fu Siong Ng
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Nick W F Linton
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - David C Lefroy
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Darrel P Francis
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Phang Boon Lim
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Mark A Tanner
- St Richard’s Hospital, University Hospitals Sussex NHS Foundation Trust, Watford, UK
| | - Amal Muthumala
- St Bartholomew’s Hospital and North Middlesex University Hospital, Watford, UK
| | - Girija Agarwal
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Graham D Cole
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute—Cardiovascular Science, The Hammersmith Hospital, Imperial College London,B-Block South, 2nd Floor, Du Cane Road, London W12 0NN, UK
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8
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Shi X, Sau A, Li X, Patel K, Bajaj N, Varela M, Wu H, Handa B, Arnold A, Shun-Shin M, Keene D, Howard J, Whinnett Z, Peters N, Christensen K, Jensen HJ, Ng FS. Information theory-based direct causality measure to assess cardiac fibrillation dynamics. J R Soc Interface 2023; 20:20230443. [PMID: 37817583 PMCID: PMC10565370 DOI: 10.1098/rsif.2023.0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/19/2023] [Indexed: 10/12/2023] Open
Abstract
Understanding the mechanism sustaining cardiac fibrillation can facilitate the personalization of treatment. Granger causality analysis can be used to determine the existence of a hierarchical fibrillation mechanism that is more amenable to ablation treatment in cardiac time-series data. Conventional Granger causality based on linear predictability may fail if the assumption is not met or given sparsely sampled, high-dimensional data. More recently developed information theory-based causality measures could potentially provide a more accurate estimate of the nonlinear coupling. However, despite their successful application to linear and nonlinear physical systems, their use is not known in the clinical field. Partial mutual information from mixed embedding (PMIME) was implemented to identify the direct coupling of cardiac electrophysiology signals. We show that PMIME requires less data and is more robust to extrinsic confounding factors. The algorithms were then extended for efficient characterization of fibrillation organization and hierarchy using clinical high-dimensional data. We show that PMIME network measures correlate well with the spatio-temporal organization of fibrillation and demonstrated that hierarchical type of fibrillation and drivers could be identified in a subset of ventricular fibrillation patients, such that regions of high hierarchy are associated with high dominant frequency.
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Affiliation(s)
- Xili Shi
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Arunashis Sau
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Xinyang Li
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Kiran Patel
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Nikesh Bajaj
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Marta Varela
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Huiyi Wu
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Balvinder Handa
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Ahran Arnold
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Matthew Shun-Shin
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - James Howard
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Zachary Whinnett
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Nicholas Peters
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
| | - Kim Christensen
- Department of Physics, Imperial College London, London, UK
- Centre for Complexity Science, Imperial College London, London, UK
| | - Henrik Jeldtoft Jensen
- Department of Mathematics, Imperial College London, London, UK
- Centre for Complexity Science, Imperial College London, London, UK
- Institute of Innovative Research, Tokyo Institute of Technology, Yokohama, Japan
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, UK
- Department of Cardiology, Chelsea and Westminster NHS Foundation Trust, London, UK
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9
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Ali N, Arnold AD, Miyazawa AA, Keene D, Peters NS, Kanagaratnam P, Qureshi N, Ng FS, Linton NWF, Lefroy DC, Francis DP, Lim PB, Kellman P, Tanner MA, Muthumala A, Shun-Shin M, Whinnett ZI, Cole GD. Septal scar as a barrier to left bundle branch area pacing. Pacing Clin Electrophysiol 2023; 46:1077-1084. [PMID: 37594233 DOI: 10.1111/pace.14804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 07/07/2023] [Accepted: 08/05/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND The use of left bundle branch area pacing (LBBAP) for bradycardia pacing and cardiac resynchronization is increasing, but implants are not always successful. We prospectively studied consecutive patients to determine whether septal scar contributes to implant failure. METHODS Patients scheduled for bradycardia pacing or cardiac resynchronization therapy were prospectively enrolled. Recruited patients underwent preprocedural scar assessment by cardiac MRI with late gadolinium enhancement imaging. LBBAP was attempted using a lumenless lead (Medtronic 3830) via a transeptal approach. RESULTS Thirty-five patients were recruited: 29 male, mean age 68 years, 10 ischemic, and 16 non-ischemic cardiomyopathy. Pacing indication was bradycardia in 26% and cardiac resynchronization in 74%. The lead was successfully deployed to the left ventricular septum in 30/35 (86%) and unsuccessful in the remaining 5/35 (14%). Septal late gadolinium enhancement was significantly less extensive in patients where left septal lead deployment was successful, compared those where it was unsuccessful (median 8%, IQR 2%-18% vs. median 54%, IQR 53%-57%, p < .001). CONCLUSIONS The presence of septal scar appears to make it more challenging to deploy a lead to the left ventricular septum via the transeptal route. Additional implant tools or alternative approaches may be required in patients with extensive septal scar.
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Affiliation(s)
- Nadine Ali
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Nicholas S Peters
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Norman Qureshi
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Nick W F Linton
- National Heart and Lung Institute, Imperial College London, London, UK
| | - David C Lefroy
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes for Health, Bethesda, USA
| | - Mark A Tanner
- St Richards Hospital, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Amal Muthumala
- St Bartholomew's Hospital and North Middlesex University Hospital, London, UK
| | - Matthew Shun-Shin
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Graham D Cole
- National Heart and Lung Institute, Imperial College London, London, UK
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10
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Keene D, Anselme F, Burri H, Pérez ÓC, Čurila K, Derndorfer M, Foley P, Gellér L, Glikson M, Huybrechts W, Jastrzebski M, Kaczmarek K, Katsouras G, Lyne J, Verdú PP, Restle C, Richter S, Timmer S, Vernooy K, Whinnett Z. Conduction system pacing, a European survey: insights from clinical practice. Europace 2023; 25:euad019. [PMID: 36916199 PMCID: PMC10227660 DOI: 10.1093/europace/euad019] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/06/2023] [Indexed: 03/14/2023] Open
Abstract
AIMS The field of conduction system pacing (CSP) is evolving, and our aim was to obtain a contemporary picture of European CSP practice. METHODS AND RESULTS A survey was devised by a European CSP Expert Group and sent electronically to cardiologists utilizing CSP. A total of 284 physicians were invited to contribute of which 171 physicians (60.2%; 85% electrophysiologists) responded. Most (77%) had experience with both His-bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Pacing indications ranked highest for CSP were atrioventricular block (irrespective of left ventricular ejection fraction) and when coronary sinus lead implantation failed. For patients with left bundle branch block (LBBB) and heart failure (HF), conventional biventricular pacing remained first-line treatment. For most indications, operators preferred LBBAP over HBP as a first-line approach. When HBP was attempted as an initial approach, reasons reported for transitioning to utilizing LBBAP were: (i) high threshold (reported as >2 V at 1 ms), (ii) failure to reverse bundle branch block, or (iii) > 30 min attempting to implant at His-bundle sites. Backup right ventricular lead use for HBP was low (median 20%) and predominated in pace-and-ablate scenarios. Twelve-lead electrocardiogram assessment was deemed highly important during follow-up. This, coupled with limitations from current capture management algorithms, limits remote monitoring for CSP patients. CONCLUSIONS This survey provides a snapshot of CSP implementation in Europe. Currently, CSP is predominantly used for bradycardia indications. For HF patients with LBBB, most operators reserve CSP for biventricular implant failures. Left bundle branch area pacing ostensibly has practical advantages over HBP and is therefore preferred by many operators. Practical limitations remain, and large randomized clinical trial data are currently lacking.
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Affiliation(s)
- Daniel Keene
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK
| | - Frédéric Anselme
- Department of Cardiology, Centre Hospitalier Universitaire de Rouen Charles Nicolle, Rouen, France
| | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland
| | - Óscar Cano Pérez
- Unidad de Arritmias, Servicio de Cardiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Department of Cardiology, Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares, Madrid, Spain
| | - Karol Čurila
- Department of Cardiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Michael Derndorfer
- Department of Internal Medicine 2 with Cardiology, Angiology and Intensive Care, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Paul Foley
- Wiltshire Cardiac Centre, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - László Gellér
- Semmelweis University, Cardiovascular Center, Budapest, Hungary
| | - Michael Glikson
- Department of Cardiology, Shaare Zedek Medical Center and Hebrew University faculty of medicine, Jerusalem, Israel
| | - Wim Huybrechts
- Department of Cardiology, University Hospital Antwerp, Edegem, Belgium
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Medical College, Kraków, Poland
| | | | - Grigorios Katsouras
- Department of Cardiology, ‘F. Miulli’ Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Jonathan Lyne
- Cardiology Department, Beacon Hospital, Dublin, Ireland
| | - Pablo Peñafiel Verdú
- Arrhythmia Unit, Department of Cardiology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Christian Restle
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Sergio Richter
- Department of Cardiology, Heart Center Dresden, University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Stefan Timmer
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Zachary Whinnett
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12, UK
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11
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Hennayake S, Cervellione R, Goyal A, Keene D, Cserni T, De Silva A, Rossi A, Bianchi A. Commentary: Symptomatic corpus spongiosum defect in adolescents and young adults who underwent distal hypospadias repair during childhood. J Pediatr Urol 2023:S1477-5131(23)00148-1. [PMID: 37147141 DOI: 10.1016/j.jpurol.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 05/07/2023]
Affiliation(s)
- S Hennayake
- Paediatric Urology Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.
| | - R Cervellione
- Paediatric Urology Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - A Goyal
- Paediatric Urology Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - D Keene
- Paediatric Urology Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - T Cserni
- Paediatric Urology Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - A De Silva
- Paediatric Urology Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - A Rossi
- Paediatric Urology Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
| | - A Bianchi
- Paediatric Urology Department, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK
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12
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Sau A, Ibrahim S, Kramer DB, Waks JW, Qureshi N, Koa-Wing M, Keene D, Malcolme-Lawes L, Lefroy DC, Linton NW, Lim PB, Varnava A, Whinnett ZI, Kanagaratnam P, Mandic D, Peters NS, Ng FS. Artificial intelligence-enabled electrocardiogram to distinguish atrioventricular re-entrant tachycardia from atrioventricular nodal re-entrant tachycardia. Cardiovasc Digit Health J 2023; 4:60-67. [PMID: 37101944 PMCID: PMC10123507 DOI: 10.1016/j.cvdhj.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background Accurately determining arrhythmia mechanism from a 12-lead electrocardiogram (ECG) of supraventricular tachycardia can be challenging. We hypothesized a convolutional neural network (CNN) can be trained to classify atrioventricular re-entrant tachycardia (AVRT) vs atrioventricular nodal re-entrant tachycardia (AVNRT) from the 12-lead ECG, when using findings from the invasive electrophysiology (EP) study as the gold standard. Methods We trained a CNN on data from 124 patients undergoing EP studies with a final diagnosis of AVRT or AVNRT. A total of 4962 5-second 12-lead ECG segments were used for training. Each case was labeled AVRT or AVNRT based on the findings of the EP study. The model performance was evaluated against a hold-out test set of 31 patients and compared to an existing manual algorithm. Results The model had an accuracy of 77.4% in distinguishing between AVRT and AVNRT. The area under the receiver operating characteristic curve was 0.80. In comparison, the existing manual algorithm achieved an accuracy of 67.7% on the same test set. Saliency mapping demonstrated the network used the expected sections of the ECGs for diagnoses; these were the QRS complexes that may contain retrograde P waves. Conclusion We describe the first neural network trained to differentiate AVRT from AVNRT. Accurate diagnosis of arrhythmia mechanism from a 12-lead ECG could aid preprocedural counseling, consent, and procedure planning. The current accuracy from our neural network is modest but may be improved with a larger training dataset.
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Affiliation(s)
- Arunashis Sau
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Safi Ibrahim
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Daniel B. Kramer
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jonathan W. Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Norman Qureshi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael Koa-Wing
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Louisa Malcolme-Lawes
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - David C. Lefroy
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nicholas W.F. Linton
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Amanda Varnava
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Zachary I. Whinnett
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Danilo Mandic
- Department of Electrical and Electronic Engineering, Imperial College London, London, United Kingdom
| | - Nicholas S. Peters
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Department of Cardiology, Imperial College Healthcare NHS Trust, London, United Kingdom
- Department of Cardiology, Chelsea & Westminster Hospital NHS Foundation Trust, London, United Kingdom
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13
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Kaza N, Htun V, Miyazawa A, Simader F, Porter B, Howard JP, Arnold AD, Naraen A, Luria D, Glikson M, Israel C, Francis DP, Whinnett ZI, Shun-Shin MJ, Keene D. Upgrading right ventricular pacemakers to biventricular pacing or conduction system pacing: a systematic review and meta-analysis. Europace 2023; 25:1077-1086. [PMID: 36352513 PMCID: PMC10062368 DOI: 10.1093/europace/euac188] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/08/2022] [Indexed: 11/11/2022] Open
Abstract
Guidelines recommend patients undergoing a first pacemaker implant who have even mild left ventricular (LV) impairment should receive biventricular or conduction system pacing (CSP). There is no corresponding recommendation for patients who already have a pacemaker. We conducted a meta-analysis of randomized controlled trials (RCTs) and observational studies assessing device upgrades. The primary outcome was the echocardiographic change in LV ejection fraction (LVEF). Six RCTs (randomizing 161 patients) and 47 observational studies (2644 patients) assessing the efficacy of upgrade to biventricular pacing were eligible for analysis. Eight observational studies recruiting 217 patients of CSP upgrade were also eligible. Fourteen additional studies contributed data on complications (25 412 patients). Randomized controlled trials of biventricular pacing upgrade showed LVEF improvement of +8.4% from 35.5% and observational studies: +8.4% from 25.7%. Observational studies of left bundle branch area pacing upgrade showed +11.1% improvement from 39.0% and observational studies of His bundle pacing upgrade showed +12.7% improvement from 36.0%. New York Heart Association class decreased by -0.4, -0.8, -1.0, and -1.2, respectively. Randomized controlled trials of biventricular upgrade found improvement in Minnesota Heart Failure Score (-6.9 points) and peak oxygen uptake (+1.1 mL/kg/min). This was also seen in observational studies of biventricular upgrades (-19.67 points and +2.63 mL/kg/min, respectively). In studies of the biventricular upgrade, complication rates averaged 2% for pneumothorax, 1.4% for tamponade, and 3.7% for infection over 24 months of mean follow-up. Lead-related complications occurred in 3.3% of biventricular upgrades and 1.8% of CSP upgrades. Randomized controlled trials show significant physiological and symptomatic benefits of upgrading pacemakers to biventricular pacing. Observational studies show similar effects between biventricular pacing upgrade and CSP upgrade.
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Affiliation(s)
- Nandita Kaza
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Varanand Htun
- School of Public Health, Imperial College London, London, UK
| | - Alejandra Miyazawa
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Florentina Simader
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Bradley Porter
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - James P Howard
- Warrington and Halton Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Akriti Naraen
- Warrington and Halton Hospitals NHS Foundation Trust, Liverpool, UK
| | - David Luria
- Hebrew University Jerusalem, Jerusalem, Israel
| | | | | | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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14
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Ali N, Arnold AD, Miyazawa AA, Keene D, Chow JJ, Little I, Peters NS, Kanagaratnam P, Qureshi N, Ng FS, Linton NWF, Lefroy DC, Francis DP, Phang Boon L, Tanner MA, Muthumala A, Shun-Shin MJ, Cole GD, Whinnett ZI. Comparison of methods for delivering cardiac resynchronization therapy: an acute electrical and haemodynamic within-patient comparison of left bundle branch area, His bundle, and biventricular pacing. Europace 2023; 25:1060-1067. [PMID: 36734205 PMCID: PMC10062293 DOI: 10.1093/europace/euac245] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/01/2022] [Indexed: 02/04/2023] Open
Abstract
AIMS Left bundle branch area pacing (LBBAP) is a promising method for delivering cardiac resynchronization therapy (CRT), but its relative physiological effectiveness compared with His bundle pacing (HBP) is unknown. We conducted a within-patient comparison of HBP, LBBAP, and biventricular pacing (BVP). METHODS AND RESULTS Patients referred for CRT were recruited. We assessed electrical response using non-invasive mapping, and acute haemodynamic response using a high-precision haemodynamic protocol. Nineteen patients were recruited: 14 male, mean LVEF of 30%. Twelve had time for BVP measurements. All three modalities reduced total ventricular activation time (TVAT), (ΔTVATHBP -43 ± 14 ms and ΔTVATLBBAP -35 ± 20 ms vs. ΔTVATBVP -19 ± 30 ms, P = 0.03 and P = 0.1, respectively). HBP produced a significantly greater reduction in TVAT compared with LBBAP in all 19 patients (-46 ± 15 ms, -36 ± 17 ms, P = 0.03). His bundle pacing and LBBAP reduced left ventricular activation time (LVAT) more than BVP (ΔLVATHBP -43 ± 16 ms, P < 0.01 vs. BVP, ΔLVATLBBAP -45 ± 17 ms, P < 0.01 vs. BVP, ΔLVATBVP -13 ± 36 ms), with no difference between HBP and LBBAP (P = 0.65). Acute systolic blood pressure was increased by all three modalities. In the 12 with BVP, greater improvement was seen with HBP and LBBAP (6.4 ± 3.8 mmHg BVP, 8.1 ± 3.8 mmHg HBP, P = 0.02 vs. BVP and 8.4 ± 8.2 mmHg for LBBAP, P = 0.3 vs. BVP), with no difference between HBP and LBBAP (P = 0.8). CONCLUSION HBP delivered better ventricular resynchronization than LBBAP because right ventricular activation was slower during LBBAP. But LBBAP was not inferior to HBP with respect to LV electrical resynchronization and acute haemodynamic response.
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Affiliation(s)
- Nadine Ali
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Ahran D Arnold
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Alejandra A Miyazawa
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Daniel Keene
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Ji-Jian Chow
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Ian Little
- Medtronic Limited, Building 9, Croxley Green Business Park, Watford WD18 8WW, UK
| | - Nicholas S Peters
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Prapa Kanagaratnam
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Norman Qureshi
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Fu Siong Ng
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Nick W F Linton
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - David C Lefroy
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Darrel P Francis
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
- Department of Cardiology, St Richards Hospital, University Hospitals Sussex NHS Foundation Trust., Spitalfield Ln, Chichester PO19 6SE, UK
| | - Lim Phang Boon
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Mark A Tanner
- Department of Cardiology, St Richards Hospital, University Hospitals Sussex NHS Foundation Trust., Spitalfield Ln, Chichester PO19 6SE, UK
| | - Amal Muthumala
- Department of Cardiology, St Bartholomew’s Hospital and North Middlesex University Hospital, W Smithfield, London EC1A 7BE, UK
| | - Matthew J Shun-Shin
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Graham D Cole
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
| | - Zachary I Whinnett
- Department of Cardiology, National Heart and Lung Institute, Imperial College London, Hammersmith Hospital Du Cane Road, London W120HS, UK
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15
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Coyle C, Koutsoftidis S, Kim MY, Porter B, Keene D, Luther V, Handa B, Kay J, Lim E, Malcolme-Lawes L, Koa-Wing M, Lim PB, Whinnett ZI, Ng FS, Qureshi N, Peters NS, Linton NWF, Drakakis E, Kanagaratnam P. Feasibility of mapping and ablating ectopy-triggering ganglionated plexus reproducibly in persistent atrial fibrillation. J Interv Card Electrophysiol 2023:10.1007/s10840-023-01517-9. [PMID: 36867371 DOI: 10.1007/s10840-023-01517-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/19/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Ablation of autonomic ectopy-triggering ganglionated plexuses (ET-GP) has been used to treat paroxysmal atrial fibrillation (AF). It is not known if ET-GP localisation is reproducible between different stimulators or whether ET-GP can be mapped and ablated in persistent AF. We tested the reproducibility of the left atrial ET-GP location using different high-frequency high-output stimulators in AF. In addition, we tested the feasibility of identifying ET-GP locations in persistent atrial fibrillation. METHODS Nine patients undergoing clinically-indicated paroxysmal AF ablation received pacing-synchronised high-frequency stimulation (HFS), delivered in SR during the left atrial refractory period, to compare ET-GP localisation between a custom-built current-controlled stimulator (Tau20) and a voltage-controlled stimulator (Grass S88, SIU5). Two patients with persistent AF underwent cardioversion, left atrial ET-GP mapping with the Tau20 and ablation (Precision™, Tacticath™ [n = 1] or Carto™, SmartTouch™ [n = 1]). Pulmonary vein isolation (PVI) was not performed. Efficacy of ablation at ET-GP sites alone without PVI was assessed at 1 year. RESULTS The mean output to identify ET-GP was 34 mA (n = 5). Reproducibility of response to synchronised HFS was 100% (Tau20 vs Grass S88; [n = 16] [kappa = 1, SE = 0.00, 95% CI 1 to 1)][Tau20 v Tau20; [n = 13] [kappa = 1, SE = 0, 95% CI 1 to 1]). Two patients with persistent AF had 10 and 7 ET-GP sites identified requiring 6 and 3 min of radiofrequency ablation respectively to abolish ET-GP response. Both patients were free from AF for > 365 days without anti-arrhythmics. CONCLUSIONS ET-GP sites are identified at the same location by different stimulators. ET-GP ablation alone was able to prevent AF recurrence in persistent AF, and further studies would be warranted.
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Affiliation(s)
- Clare Coyle
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | | | - Min-Young Kim
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Bradley Porter
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Daniel Keene
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Vishal Luther
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Balvinder Handa
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Jamie Kay
- NHLI, Imperial College London, London, UK
| | - Elaine Lim
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | | | - Michael Koa-Wing
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Phang Boon Lim
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Zachary I Whinnett
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Fu Siong Ng
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Norman Qureshi
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Nicholas S Peters
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Nicholas W F Linton
- NHLI, Imperial College London, London, UK
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
- Department of Bioengineering, Imperial College London, London, UK
| | | | - Prapa Kanagaratnam
- NHLI, Imperial College London, London, UK.
- Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
- Department of Cardiology, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK.
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Simader FA, Howard JP, Ahmad Y, Saleh K, Naraen A, Samways JW, Mohal J, Reddy RK, Kaza N, Keene D, Shun-Shin MJ, Francis DP, Whinnett ZI, Arnold AD. Catheter ablation improves cardiovascular outcomes in patients with atrial fibrillation and heart failure: a meta-analysis of randomized controlled trials. Europace 2023; 25:341-350. [PMID: 36305545 PMCID: PMC9934993 DOI: 10.1093/europace/euac173] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/23/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS The effect of atrial fibrillation catheter ablation on cardiovascular outcomes in heart failure is an important outstanding research question. We undertook a meta-analysis of randomized controlled trials comparing ablation to medical therapy in patients with AF and heart failure. METHODS AND RESULTS We systematically identified all trials comparing catheter ablation to medical therapy in patients with heart failure and atrial fibrillation. The pre-specified primary endpoint was all-cause mortality in trials with at least 2 years of follow-up. The secondary endpoint was heart failure hospitalization. Sensitivity analyses were performed for trials with any follow-up and trials deemed at low risk of bias. Eight trials (1390 patients) were included. Seven hundred and seven patients were randomized to catheter ablation and 683 to medical therapy. In the primary analysis (three trials, n = 977), catheter ablation reduced mortality compared with medical therapy [relative risk (RR): 0.61, 95% confidence interval (CI): 0.44 to 0.84, P = 0.003]. Catheter ablation also reduced heart failure hospitalizations compared with medical therapy (RR: 0.60, 95% CI: 0.49-0.74, P < 0.001). The effect on stroke was not statistically significant (RR: 0.62, 95% CI: 0.28-1.37, P = 0.237). There was low heterogeneity between studies. Sensitivity analyses were consistent with the primary analyses. CONCLUSION In patients with atrial fibrillation and heart failure, catheter ablation reduces mortality and the occurrence of heart failure hospitalizations.
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Affiliation(s)
- Florentina A Simader
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Yousif Ahmad
- Section of Cardiovascular Medicine, Yale University, 330 Cedar Street, New Haven, CT 06520-8056, USA
| | - Keenan Saleh
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Akriti Naraen
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Jack W Samways
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Jagdeep Mohal
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Rohin K Reddy
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Nandita Kaza
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London, W12 0HS, London, UK
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17
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Whinnett ZI, Shun‐Shin MJ, Tanner M, Foley P, Chandrasekaran B, Moore P, Adhya S, Qureshi N, Muthumala A, Lane R, Rinaldi A, Agarwal S, Leyva F, Behar J, Bassi S, Ng A, Scott P, Prasad R, Swinburn J, Tomson J, Sethi A, Shah J, Lim PB, Kyriacou A, Thomas D, Chuen J, Kamdar R, Kanagaratnam P, Mariveles M, Burden L, March K, Howard JP, Arnold A, Vijayaraman P, Stegemann B, Johnson N, Falaschetti E, Francis DP, Cleland JG, Keene D. Effects of haemodynamically atrio-ventricular optimized His bundle pacing on heart failure symptoms and exercise capacity: the His Optimized Pacing Evaluated for Heart Failure (HOPE-HF) randomized, double-blind, cross-over trial. Eur J Heart Fail 2023; 25:274-283. [PMID: 36404397 PMCID: PMC10946926 DOI: 10.1002/ejhf.2736] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/22/2022] Open
Abstract
AIMS Excessive prolongation of PR interval impairs coupling of atrio-ventricular (AV) contraction, which reduces left ventricular pre-load and stroke volume, and worsens symptoms. His bundle pacing allows AV delay shortening while maintaining normal ventricular activation. HOPE-HF evaluated whether AV optimized His pacing is preferable to no-pacing, in a double-blind cross-over fashion, in patients with heart failure, left ventricular ejection fraction (LVEF) ≤40%, PR interval ≥200 ms and either QRS ≤140 ms or right bundle branch block. METHODS AND RESULTS Patients had atrial and His bundle leads implanted (and an implantable cardioverter-defibrillator lead if clinically indicated) and were randomized to 6 months of pacing and 6 months of no-pacing utilizing a cross-over design. The primary outcome was peak oxygen uptake during symptom-limited exercise. Quality of life, LVEF and patients' holistic symptomatic preference between arms were secondary outcomes. Overall, 167 patients were randomized: 90% men, 69 ± 10 years, QRS duration 124 ± 26 ms, PR interval 249 ± 59 ms, LVEF 33 ± 9%. Neither peak oxygen uptake (+0.25 ml/kg/min, 95% confidence interval [CI] -0.23 to +0.73, p = 0.3) nor LVEF (+0.5%, 95% CI -0.7 to 1.6, p = 0.4) changed with pacing but Minnesota Living with Heart Failure quality of life improved significantly (-3.7, 95% CI -7.1 to -0.3, p = 0.03). Seventy-six percent of patients preferred His bundle pacing-on and 24% pacing-off (p < 0.0001). CONCLUSION His bundle pacing did not increase peak oxygen uptake but, under double-blind conditions, significantly improved quality of life and was symptomatically preferred by the clear majority of patients. Ventricular pacing delivered via the His bundle did not adversely impact ventricular function during the 6 months.
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Affiliation(s)
- Zachary I. Whinnett
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
| | - Matthew J. Shun‐Shin
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
| | - Mark Tanner
- West Sussex Hospitals NHS TrustWest SussexUK
| | - Paul Foley
- Great Western Hospitals NHS Foundation TrustSwindonUK
| | | | - Philip Moore
- West Hertfordshire Hospitals NHS TrustHertfordshireUK
- Barts Health NHS TrustLondonUK
| | | | | | - Amal Muthumala
- Barts Health NHS TrustLondonUK
- North Middlesex University HospitalLondonUK
| | | | - Aldo Rinaldi
- Guy's and St. Thomas's NHS Foundation TrustLondonUK
| | | | | | | | - Sukh Bassi
- Sherwood Forest Hospitals NHS Foundation TrustUK
| | - Andre Ng
- Department of Cardiovascular SciencesUniversity of LeicesterLeicesterUK
| | | | | | | | | | - Amarjit Sethi
- London North West University Healthcare NHS TrustLondonUK
| | - Jaymin Shah
- London North West University Healthcare NHS TrustLondonUK
| | - Phang Boon Lim
- National Heart and Lung InstituteImperial College LondonLondonUK
| | | | - Dewi Thomas
- Morriston Hospital Regional Cardiac CentreWalesUK
| | - Jenny Chuen
- Nottingham University Hospitals NHS TrustNottinghamUK
| | | | | | | | - Leah Burden
- Imperial College Healthcare NHS TrustLondonUK
| | | | - James P. Howard
- National Heart and Lung InstituteImperial College LondonLondonUK
| | - Ahran Arnold
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
| | | | | | | | | | | | | | - Daniel Keene
- National Heart and Lung InstituteImperial College LondonLondonUK
- Imperial College Healthcare NHS TrustLondonUK
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Arnold AD, Shun-Shin MJ, Ali N, Keene D, Howard JP, Francis DP, Whinnett ZI. Contributions of Atrioventricular Delay Shortening and Ventricular Resynchronization to Hemodynamic Benefits of Biventricular Pacing. JACC Clin Electrophysiol 2023; 9:117-119. [PMID: 36697190 DOI: 10.1016/j.jacep.2022.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/26/2022] [Accepted: 07/31/2022] [Indexed: 01/28/2023]
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Kaza N, Htun V, Miyazawa A, Simader F, Porter B, Howard JP, Arnold A, Francis DP, Whinnett ZI, Shun-Shin MJ, Keene D. A systematic review and meta-analysis of upgrade to biventricular or conduction system pacing approaches. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Chronic RV pacing has been recognised as being harmful to cardiac function. Patients undergoing a de novo pacemaker implant with even mild LV impairment are recommended to instead receive a physiological pacing strategy (biventricular or conduction system pacing [CSP]). No corresponding guideline recommendation exists for patients who already have a pacemaker.
Methods
We undertook a random-effects meta-analysis of all RCTs and observational studies covering device upgrade to biventricular pacing or conduction system pacing.
Results
6 RCTs assessing effect of upgrade to BiV pacing randomising 161 patients were eligible for analysis. Eligible observational studies included 46 of BiV upgrade and 7 of CSP upgrade totalling 2795 patients.
Mean LVEF improved by +8.3% from 34.4% in BiV upgrade RCTs (p=0.001) and +8.3% from 25.7% in BiV upgrade observational studies (p<0.001).
In observational studies of upgrade to CSP, LVEF increased by +10.1% from 38.4% (p=0.001) despite less severe LV impairment at baseline (p=0.004 vs mean EF in BiV RCTs and p<0.0001 vs mean EF in BiV observational studies).
LVESV decreased significantly by −25.4 ml, −23.7 ml, and −19.8 ml in BiV RCTs, BiV observational studies and CSP observational studies. Significant changes were also seen in NYHA class (decreased by −0.4, −0.8 and −1.0 respectively).
Minnesota Heart Failure Score (−6.9 points) and peak oxygen uptake (+1.1 ml/kg/min) increased significantly in RCTs of BiV upgrade. This was also seen in observational studies of BiV upgrade (−21.0 points and +2.63 ml/kg/min respectively).
Conclusions
RCTs and observational studies of upgrade to BiV pacing show significant physiological and symptomatic benefit. Observational studies of CSP upgrade show similar benefit with significant improvements in LVEF, LVESV and NYHA class in patients with an even milder degree of baseline LV impairment.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- N Kaza
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - V Htun
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - A Miyazawa
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - F Simader
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - B Porter
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - J P Howard
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - A Arnold
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - D P Francis
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - Z I Whinnett
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - M J Shun-Shin
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - D Keene
- National Heart and Lung Institute Imperial College , London , United Kingdom
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Sau A, Ibrahim S, Ahmed A, Handa B, Kramer DB, Waks JW, Arnold AD, Howard JP, Qureshi N, Koa-Wing M, Keene D, Malcolme-Lawes L, Lefroy DC, Linton NWF, Lim PB, Varnava A, Whinnett ZI, Kanagaratnam P, Mandic D, Peters NS, Ng FS. Artificial intelligence-enabled electrocardiogram to distinguish cavotricuspid isthmus dependence from other atrial tachycardia mechanisms . Eur Heart J Digit Health 2022; 3:405-414. [PMID: 36712163 PMCID: PMC9708023 DOI: 10.1093/ehjdh/ztac042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/12/2022] [Indexed: 06/18/2023]
Abstract
Aims Accurately determining atrial arrhythmia mechanisms from a 12-lead electrocardiogram (ECG) can be challenging. Given the high success rate of cavotricuspid isthmus (CTI) ablation, identification of CTI-dependent typical atrial flutter (AFL) is important for treatment decisions and procedure planning. We sought to train a convolutional neural network (CNN) to classify CTI-dependent AFL vs. non-CTI dependent atrial tachycardia (AT), using data from the invasive electrophysiology (EP) study as the gold standard. Methods and results We trained a CNN on data from 231 patients undergoing EP studies for atrial tachyarrhythmia. A total of 13 500 five-second 12-lead ECG segments were used for training. Each case was labelled CTI-dependent AFL or non-CTI-dependent AT based on the findings of the EP study. The model performance was evaluated against a test set of 57 patients. A survey of electrophysiologists in Europe was undertaken on the same 57 ECGs. The model had an accuracy of 86% (95% CI 0.77-0.95) compared to median expert electrophysiologist accuracy of 79% (range 70-84%). In the two thirds of test set cases (38/57) where both the model and electrophysiologist consensus were in agreement, the prediction accuracy was 100%. Saliency mapping demonstrated atrial activation was the most important segment of the ECG for determining model output. Conclusion We describe the first CNN trained to differentiate CTI-dependent AFL from other AT using the ECG. Our model matched and complemented expert electrophysiologist performance. Automated artificial intelligence-enhanced ECG analysis could help guide treatment decisions and plan ablation procedures for patients with organized atrial arrhythmias.
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Affiliation(s)
- Arunashis Sau
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Safi Ibrahim
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - Amar Ahmed
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
| | - Balvinder Handa
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Daniel B Kramer
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Jonathan W Waks
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Norman Qureshi
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Michael Koa-Wing
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Louisa Malcolme-Lawes
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - David C Lefroy
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Nicholas W F Linton
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Amanda Varnava
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Danilo Mandic
- Department of Electrical and Electronic Engineering, Imperial College London, South Kensington Campus, Exhibition Road, London SW7 2AZ, UK
| | - Nicholas S Peters
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, Du Cane Road, London W12 0NN, UK
- Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, UK
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Kaza N, Keene D, Whinnett ZI. Generating Evidence to Support the Physiologic Promise of Conduction System Pacing: Status and Update on Conduction System Pacing Trials. Card Electrophysiol Clin 2022; 14:345-355. [PMID: 35715090 DOI: 10.1016/j.ccep.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Conduction system pacing avoids the potential deleterious effects of right ventricular pacing in patients with bradycardia and provides an alternative approach to cardiac resynchronization therapy. We focus on the available observational and randomized evidence and review studies supporting the safety, feasibility, and physiologic promise of conduction system approaches. We evaluate the randomized data generated from the available clinical trials of conduction system pacing, which have led to the recent inclusion of CSP in international guidelines. The scope for future randomized trials will building on the physiologic promise of conduction system approaches and offering information on clinical end points is explored.
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Affiliation(s)
- Nandita Kaza
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London W12 0HS, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London W12 0HS, UK.
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London W12 0HS, UK
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22
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Affiliation(s)
- Daniel Keene
- Department of Cardiology, Imperial College London, London, UK
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23
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Ali N, Arnold A, Miyazawa AA, Keene D, Peters NS, Kanagaratnam P, Qureshi NA, Ng FS, Linton NF, Lefroy DC, Francis DP, Lim PB, Tanner MA, Muthumala AG, Cole G, Whinnett ZI. PO-673-06 CARDIAC RESYNCHRONIZATION WITH LEFT BUNDLE AREA PACING COMPARED TO HIS BUNDLE AND BIVENTRICULAR PACING; AN ACUTE ELECTRICAL AND HAEMODYNAMIC WITHIN PATIENT COMPARISON. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ali N, Arnold A, Miyazawa AA, Keene D, Peters NS, Kanagaratnam P, Qureshi NA, Ng FS, Linton NF, Lefroy DC, Francis DP, Lim PB, Tanner MA, Muthumala AG, Whinnett ZI, Cole G. PO-673-01 SEPTAL SCAR PREDICTS FAILURE OF LEAD ADVANCEMENT TO THE LEFT BUNDLE AREA BUT NOT THE ABILITY TO STIMULATE THE LEFT BUNDLE. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Keene D, Miyazawa AA, Johal M, Arnold AD, Ali N, Saqi KA, March K, Burden L, Francis DP, Whinnett ZI, Shun‐Shin MJ. Optimizing atrio-ventricular delay in pacemakers using potentially implantable physiological biomarkers. Pacing Clin Electrophysiol 2022; 45:461-470. [PMID: 34967945 PMCID: PMC9305784 DOI: 10.1111/pace.14434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/25/2021] [Accepted: 12/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemodynamically optimal atrioventricular (AV) delay can be derived by echocardiography or beat-by-beat blood pressure (BP) measurements, but analysis is labor intensive. Laser Doppler perfusion monitoring measures blood flow and can be incorporated into future implantable cardiac devices. We assess whether laser Doppler can be used instead of BP to optimize AV delay. METHODS Fifty eight patients underwent 94 AV delay optimizations with biventricular or His-bundle pacing using laser Doppler and simultaneous noninvasive beat-by-beat BP. Optimal AV delay was defined using a curve of hemodynamic response to switching from AAI (reference state) to DDD (test state) at several AV delays (40-320 ms), with automatic quality control checking precision of the optimum. Five subsequent patients underwent an extended protocol to test the impact of greater numbers of alternations on optimization quality. RESULTS 55/94 optimizations passed quality control resulting in an optimal AV delay on laser Doppler similar to that derived by BP (median absolute deviation 12 ms). An extended protocol with increasing number of replicates consistently improved quality and reduced disagreement between laser Doppler and BP optima. With only five replicates, no optimization passed quality control, and the median absolute deviation would be 29 ms. These improved progressively until at 50 replicates, all optimizations passed quality control and the median absolute deviation was only 13 ms. CONCLUSIONS Laser Doppler perfusion produces hemodynamic optima equivalent to BP. Quality control can be automatic. Adding more replicates, consistently improves quality. Future implantable devices could use such methods to dynamically and reliably optimize AV delays.
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Affiliation(s)
- Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Alejandra A Miyazawa
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Monika Johal
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Nadine Ali
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Khulat A Saqi
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK
| | - Katherine March
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK
| | - Leah Burden
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
| | - Matthew J Shun‐Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith HospitalLondonUK,Imperial College Healthcare NHS Trust, Hammersmith HospitalLondonUK
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Bachtiger P, Petri CF, Scott FE, Ri Park S, Kelshiker MA, Sahemey HK, Dumea B, Alquero R, Padam PS, Hatrick IR, Ali A, Ribeiro M, Cheung WS, Bual N, Rana B, Shun-Shin M, Kramer DB, Fragoyannis A, Keene D, Plymen CM, Peters NS. Point-of-care screening for heart failure with reduced ejection fraction using artificial intelligence during ECG-enabled stethoscope examination in London, UK: a prospective, observational, multicentre study. Lancet Digit Health 2022; 4:e117-e125. [PMID: 34998740 PMCID: PMC8789562 DOI: 10.1016/s2589-7500(21)00256-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/21/2021] [Accepted: 11/01/2021] [Indexed: 02/06/2023]
Abstract
Background Most patients who have heart failure with a reduced ejection fraction, when left ventricular ejection fraction (LVEF) is 40% or lower, are diagnosed in hospital. This is despite previous presentations to primary care with symptoms. We aimed to test an artificial intelligence (AI) algorithm applied to a single-lead ECG, recorded during ECG-enabled stethoscope examination, to validate a potential point-of-care screening tool for LVEF of 40% or lower. Methods We conducted an observational, prospective, multicentre study of a convolutional neural network (known as AI-ECG) that was previously validated for the detection of reduced LVEF using 12-lead ECG as input. We used AI-ECG retrained to interpret single-lead ECG input alone. Patients (aged ≥18 years) attending for transthoracic echocardiogram in London (UK) were recruited. All participants had 15 s of supine, single-lead ECG recorded at the four standard anatomical positions for cardiac auscultation, plus one handheld position, using an ECG-enabled stethoscope. Transthoracic echocardiogram-derived percentage LVEF was used as ground truth. The primary outcome was performance of AI-ECG at classifying reduced LVEF (LVEF ≤40%), measured using metrics including the area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity, with two-sided 95% CIs. The primary outcome was reported for each position individually and with an optimal combination of AI-ECG outputs (interval range 0–1) from two positions using a rule-based approach and several classification models. This study is registered with ClinicalTrials.gov, NCT04601415. Findings Between Feb 6 and May 27, 2021, we recruited 1050 patients (mean age 62 years [SD 17·4], 535 [51%] male, 432 [41%] non-White). 945 (90%) had an ejection fraction of at least 40%, and 105 (10%) had an ejection fraction of 40% or lower. Across all positions, ECGs were most frequently of adequate quality for AI-ECG interpretation at the pulmonary position (979 [93·3%] of 1050). Quality was lowest for the aortic position (846 [80·6%]). AI-ECG performed best at the pulmonary valve position (p=0·02), with an AUROC of 0·85 (95% CI 0·81–0·89), sensitivity of 84·8% (76·2–91·3), and specificity of 69·5% (66·4–72·6). Diagnostic odds ratios did not differ by age, sex, or non-White ethnicity. Taking the optimal combination of two positions (pulmonary and handheld positions), the rule-based approach resulted in an AUROC of 0·85 (0·81–0·89), sensitivity of 82·7% (72·7–90·2), and specificity of 79·9% (77·0–82·6). Using AI-ECG outputs from these two positions, a weighted logistic regression with l2 regularisation resulted in an AUROC of 0·91 (0·88–0·95), sensitivity of 91·9% (78·1–98·3), and specificity of 80·2% (75·5–84·3). Interpretation A deep learning system applied to single-lead ECGs acquired during a routine examination with an ECG-enabled stethoscope can detect LVEF of 40% or lower. These findings highlight the potential for inexpensive, non-invasive, workflow-adapted, point-of-care screening, for earlier diagnosis and prognostically beneficial treatment. Funding NHS Accelerated Access Collaborative, NHSX, and the National Institute for Health Research.
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Ahmad Y, Kane C, Arnold AD, Cook CM, Keene D, Shun-Shin M, Cole G, Al-Lamee R, Francis DP, Howard JP. Randomized Blinded Placebo-Controlled Trials of Renal Sympathetic Denervation for Hypertension: A Meta-Analysis. Cardiovasc Revasc Med 2022; 34:112-118. [PMID: 33551282 PMCID: PMC8813172 DOI: 10.1016/j.carrev.2021.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/15/2021] [Accepted: 01/27/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND The efficacy of renal denervation has been controversial, but the procedure has now undergone several placebo-controlled trials. New placebo-controlled trial data has recently emerged, with longer follow-up of one trial and the full report of another trial (which constitutes 27% of the total placebo-controlled trial data). We therefore sought to evaluate the effect of renal denervation on ambulatory and office blood pressures in patients with hypertension. METHODS We systematically identified all blinded placebo-controlled randomized trials of catheter-based renal denervation for hypertension. The primary efficacy outcome was ambulatory systolic blood pressure change relative to placebo. A random-effects meta-analysis was performed. RESULTS 6 studies randomizing 1232 patients were eligible. 713 patients were randomized to renal denervation and 519 to placebo. Renal denervation significantly reduced ambulatory systolic blood pressure (-3.52 mmHg; 95% CI -4.94 to -2.09; p < 0.0001), ambulatory diastolic blood pressure (-1.93 mmHg; 95% CI -3.04 to -0.83, p = 0.0006), office systolic blood pressure size (-5.10 mmHg; 95% CI -7.31 to -2.90, p < 0.0001) and office diastolic pressure (effect size -3.11 mmHg; 95% CI -4.43 to -1.78, p < 0.0001). Adverse events were rare and not more common with denervation. CONCLUSIONS The totality of blinded, randomized placebo-controlled data shows that renal denervation is safe and provides genuine reduction in blood pressure for at least 6 months post-procedure. If this effect continues in the long term, renal denervation might provide a life-long 10% relative risk reduction in major adverse cardiac events and 7.5% relative risk reduction in all-cause mortality.
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Affiliation(s)
- Yousif Ahmad
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, USA.
| | - Christopher Kane
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Christopher M Cook
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Matthew Shun-Shin
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Graham Cole
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Bachtiger P, Scott F, Park S, Petri C, Padam PS, Sahemey H, Dumea B, Ribeiro M, Alquero R, Bual N, Cheung WS, Rana B, Keene D, Plymen CM, Peters NS. Multicentre validation of point-of-care screening tool for heart failure: single-lead ECG recorded by smart stethoscope predicts low ejection fraction using artificial intelligence. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Introduction
Artificial intelligence (AI) applied to 12-lead ECG can identify left ventricular ejection fraction (EF) ≤35% with a sensitivity and specificity of 86.3% and 85.7%, respectively. Whether AI algorithms trained on 12-lead can accurately predict EF from single-lead ECGs (recorded by a smart stethoscope) remains unknown. This could facilitate point-of-care screening for low EF during routine clinical examination.
Purpose
First independent multicentre real-world UK National Health Service (NHS) prospective validation of 12-lead-ECG-trained AI algorithm applied to single-lead ECG recorded by a smart stethoscope, with AI algorithm tuned to detect EF ≤40%.
Methods
Prospective recruitment of unselected patients attending for echocardiography across six urban NHS hospital sites (UK). In addition to transthoracic echocardiogram (routine care), all participants had 15 seconds of supine, single-lead ECG recorded at six different positions (figure), encompassing standard anatomical positions for cardiac auscultation. A convolutional neural network (CNN) previously trained on 35,970 independent pairings of 12-lead-ECG and echocardiograms was retrained to use the single-lead ECG as input. Accuracy of CNN detection of low EF (binary ≤40%) is reported at a threshold of 0.5 against gold-standard; echo-determined percentage EF.
Results
Among 353 patients recruited (mean age 63±17; 58% male, 43.1% non-white), 309 (87.5%) had an EF >40%, and 44 (12.5%) had EF ≤40%. The best single recording position in isolation was position 3 (sensitivity 57.9% [42.2–73.6], specificity 86.3% [82.2–90.3]). Taking any of the six positions performed during the examination as predicting EF ≤40%, this achieved a sensitivity of 81.2% and specificity of 61.5%.
Conclusion(s)
In this first prospective multicentre validation study the retrained AI algorithm reliably detected low EF from single-lead ECGs acquired using a novel ECG-enabled stethoscope in standard auscultation positions. The ability to identify patients with possible low EF during routine physical examination addresses a significant unmet clinical need in point-of-care ruling in/out of heart failure, and has potential to provide broader population-level screening for asymptomatic cardiovascular disease.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Research, Accelerated Access Collaborative & NHSX: Artificial Intelligence in Health & Social Care Award
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Affiliation(s)
- P Bachtiger
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - F Scott
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - S Park
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - C Petri
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - P S Padam
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - H Sahemey
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - B Dumea
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - M Ribeiro
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - R Alquero
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - N Bual
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - W S Cheung
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - B Rana
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - D Keene
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - C M Plymen
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - N S Peters
- National Heart and Lung Institute Imperial College, London, United Kingdom
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Bachtiger P, Park S, Letchford E, Scott F, Barton C, Ahmed FZ, Cole G, Keene D, Plymen CM, Peters NS. Triage-HF plus: 12-month study of remote monitoring pathway for triage of heart failure risk initiated during the Covid-19 pandemic. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.3082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Covid-19 pandemic necessitated rapid adoption of remote monitoring across cardiovascular patient cohorts. Most patients with cardiac implantable electronic devices (CIEDs) are now able to be remotely monitored using either scheduled, patient- or threshold-triggered transmissions. The validated “Triage Heart Failure Risk Score” (Triage-HFRS) is a medical algorithm within company-specific CIEDs that can risk-stratify patients as low-, medium- or high-risk of worsening heart failure (WHF) in the next 30 days based on integrated monitoring of physiological parameters. Building on a previous proof-of-concept of the Triage-HF Plus pathway, we integrated remote data with simple 5-question telephone triage within a clinical pathway to identify WHF during the first year of the Covid-19 pandemic.
Purpose
Prospective evaluation of clinical remote monitoring pathway integrating Triage-HFRS with protocolised telephone triage (Triage-HF Plus pathway).
Methods
Prospective, real-world evaluation of clinical pathway serving a large urban region over a 12-month period, using data from April 2020 to April 2021 (initiated during the first wave of Covid-19 pandemic in the UK). From a population of 435 patients with CIEDs, 87 “high” Triage-HFRS alerts were received and patients contacted for telephone triage assessment. Screening questions were designed to identify episodes of WHF and non-HF events. Intervention was at discretion of the clinical practitioner and in line with guideline-directed practice. A consecutive sample of 115 “medium” risk scores received the same triage.
Results
Successful contact was made with 72 (82.8%) high-risk patients. Classification for high scoring patients confirmed on triage included isolated heart failure (18.3%), heart failure concurrent to medical problem (5.7%), alternative medical problem (10.3%), and recent hospital admission (8.0%); triage reassured absence of acute cause of high score in 40.2%. The sensitivity and specificity for detection of WHF was 87.9% (0.77–0.99) and 59.4% (0.50–0.69) respectively. Positive and negative predictive values were 40.3% and 94.0%, respectively. Overall accuracy was 66.2%.
Conclusions
The Triage-HF Plus pathway served as a useful remote monitoring tool for identifying patients with WHF whose care had been otherwise disrupted by the Covid-19 pandemic, allowing timely intervention and cementing the longer-term role for such models of care delivery. Crucially, in this multimorbid, high-cost population, relevant non-HF issues were also identified. The high negative predictive value further highlights the potential of proactive surveillance over conventional, periodic follow up.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): Imperial Health Charity
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Affiliation(s)
- P Bachtiger
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - S Park
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - E Letchford
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - F Scott
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - C Barton
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - F Z Ahmed
- University of Manchester, Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, Manchester, United Kingdom
| | - G Cole
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - D Keene
- National Heart and Lung Institute Imperial College, London, United Kingdom
| | - C M Plymen
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - N S Peters
- National Heart and Lung Institute Imperial College, London, United Kingdom
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Wadham B, Connolly T, DeSilva A, Alshafei A, Keene D, Hennayake S. 1491 Hemi-Nephroureterectomy For Duplex Kidney in Children - The Resulting Effect on Renal Function. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Introduction
Urinary duplication systems occur in approximately 1% of the population, and may present with recurrent UTIs, incontinence, or be incidentally detected on imaging. DMSA (dimercaptosuccinic acid) imaging is used in these patients to assess split renal function. If found significantly reduced in a single moiety, children may be offered hemi-nephroureterectomy (HNU). We analysed the rate of remnant moiety loss following HNU comparing age and affected moiety.
Method
All HNUs performed at our paediatric tertiary centre 2005-2019 were analysed. Children <16yrs, with pre– and post-operative DMSA imaging were included. Renal loss was categorised as: significant (≥50% of pre-existing function), non-significant (≥25% pre-existing function), no renal loss (<25%), and complete loss (post-operative remnant moiety function ≤5%). Subgroup analysis was performed using χ² statistic.
Results
73 patients were included, mean age 2.1yrs. Median pre-operative function of the affected kidney was 42%. 12 patients (16.4%) had significant renal loss, 13 (17.8%) non-significant loss and 6 (8.2%) had complete renal loss. Children <2yrs had significant and complete renal loss more frequently than those aged ≥2yrs (9/35 and 5/35 vs 3/38 and 1/38 respectively, p = 0.069). Patients with upper moiety HNU (UMHNU) had higher rates of significant and complete renal loss than lower moiety HNU patients (12/53=significant, 6/53=complete vs 0/20 significant/complete, p = <0.05).
Conclusions
HNU for duplex kidney is associated with high rates of remnant moiety damage, with ¼ of patients experiencing significant or complete renal loss. Subgroup analysis suggests this risk is higher in children <2yrs or UMHNU. HNU should therefore only be reserved for symptomatic patients failing conservative management.
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Affiliation(s)
- B Wadham
- Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - T Connolly
- Manchester Royal Infirmary, Manchester, United Kingdom
| | - A DeSilva
- Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - A Alshafei
- Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - D Keene
- Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - S Hennayake
- Royal Manchester Children's Hospital, Manchester, United Kingdom
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Arnold AD, Shun-Shin MJ, Ali N, Keene D, Howard JP, Chow JJ, Qureshi NA, Koa-Wing M, Tanner M, Lefroy DC, Linton NW, Ng FS, Lim PB, Peters NS, Kanagaratnam P, Francis DP, Whinnett ZI. Left ventricular activation time and pattern are preserved with both selective and nonselective His bundle pacing. Heart Rhythm O2 2021; 2:439-445. [PMID: 34667958 PMCID: PMC8505200 DOI: 10.1016/j.hroo.2021.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND His bundle pacing (HBP) can be achieved in 2 ways: selective HBP (S-HBP), where the His bundle is captured alone, and nonselective HBP (NS-HBP), where local myocardium is also captured, resulting a pre-excited electrocardiogram appearance. OBJECTIVE We assessed the impact of this ventricular pre-excitation on left and right ventricular dyssynchrony. METHODS We recruited patients who displayed both S-HBP and NS-HBP. We performed noninvasive epicardial electrical mapping for left and right ventricular activation time (LVAT and RVAT) and pattern. RESULTS Twenty patients were recruited. In the primary analysis, the mean within-patient change in LVAT from S-HBP to NS-HBP was -5.5 ms (95% confidence interval: -0.6 to -10.4, noninferiority P < .0001). NS-HBP did not prolong RVAT (4.3 ms, -4.0 to 12.8, P = .296) but did prolong QRS duration (QRSd, 22.1 ms, 11.8 to 32.4, P = .0003). In patients with narrow intrinsic QRS (n = 6), NS-HBP preserved LVAT (-2.9 ms, -9.7 to 4.0, P = .331) but prolonged QRS duration (31.4 ms, 22.0 to 40.7, P = .0003) and mean RVAT (16.8 ms, -5.3 to 38.9, P = .108) compared to S-HBP. Activation pattern of the left ventricular surface was unchanged between S-HBP and NS-HBP, but NS-HBP produced early basal right ventricular activation that was not seen in S-HBP. CONCLUSION Compared to S-HBP, local myocardial capture during NS-HBP produces pre-excitation of the basal right ventricle resulting in QRS duration prolongation. However, NS-HBP preserves the left ventricular activation time and pattern of S-HBP. Left ventricular dyssynchrony is not an important factor when choosing between S-HBP and NS-HBP in most patients.
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Affiliation(s)
- Ahran D. Arnold
- Address reprint requests and correspondence: Dr Ahran D. Arnold, NHLI, Hammersmith Hospital, Du Cane Rd, London W120HS, UK.
| | | | - Nadine Ali
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James P. Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Ji-Jian Chow
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Norman A. Qureshi
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Michael Koa-Wing
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Mark Tanner
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - David C. Lefroy
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nick W.F. Linton
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Phang Boon Lim
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nicholas S. Peters
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Darrel P. Francis
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Zachary I. Whinnett
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Arnold A, Shun-Shin MJ, Ali N, Keene D, Howard J, Qureshi NA, Lefroy DC, Tanner MA, Ng FS, Muthumala AG, Koa-Wing M, Linton NF, Lim PB, Peters NS, Kanagaratnam P, Francis DP, Whinnett ZI. B-PO02-187 THE DOMINANT MECHANISM OF BIVENTRICULAR PACING IN LEFT BUNDLE BRANCH BLOCK IS SHORTENING OF ATRIOVENTRICULAR DELAY. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ali NADINE, Arnold AD, Miyazawa AA, Keene D, Peters NS, Kanagaratnam P, Qureshi N, Ng FS, Linton N, Lefroy D, Francis D, Lim PB, Whinnett ZI, Kellman P, Cole GD. Septal late gadolinium enhancement on Cardiac MRI predicts failure to achieve left bundle pacing. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeab090.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): British Heart Foundation
Background; Left bundle area pacing is a novel technique that provides direct stimulation of cardiac conduction tissue in order to deliver physiological ventricular activation. The approach for left bundle area pacing is transseptal lead implantation, where the lead is advanced from the right ventricular side of the septum to the left ventricular side to capture the proximal left bundle. Observational data suggests that whilst this is a safe and feasible method, implant success rate is not 100%, and appears to be lower in patients with a cardiac resynchronization therapy (CRT) indication rather than a bradycardia indication for pacing. The mechanisms for failure to advance the lead through the ventricular septum are not well understood.
Purpose; We used pre-procedural CMR to determine whether there are features which can help identify patients where lead implantation may be challenging. We assessed whether the extent and location of septal late gadolinium enhancement identified patients in whom left bundle area pacing will be challenging. We hypothesized that the presence of extensive scar in the septum impedes advancing the lead to the left ventricular septum and prevents capture of the left bundle.
Methods; Patients underwent cardiac MRI including motion corrected free-breathing late gadolinium enhancement imaging1 before implantation. Scar was quantified using the full height half maximum method and expressed as the overall proportion of myocardial mass in the basal anteroseptal and basal inferoseptal segments, as shown in Figure 1. Left bundle area pacing was then attempted in patients with a CRT indication for pacing. We compared the extent of septal scar between patients in whom left bundle area pacing was achieved and those where there was failure to advance the lead deep into the septum.
Results; 12 patients (11 male, 1 female), with average age 72 (IQR 63 to 78) and LVEF 30% (IQR 26 to 33) were studied. There was failure to advance the lead deep into the septum in 4 patients. There was a significantly higher basal septal scar burden in those patients where there was failure to advance the left bundle lead compared to those in which left bundle capture was achieved as shown in Figure 2 (median 55% and 5% respectively, p-value 0.02 by Wilcoxon signed rank test).
Conclusion; The presence and extent of late gadolinium enhancement in the basal septum appears to be an important determinant of successful implantation of left bundle pacing lead using current implant technology. This may be because extensive septal scar prevents advancement of the pacing lead through the septum. Cardiac MRI before left bundle area pacing is likely to be useful in procedural planning.
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Affiliation(s)
- NADINE Ali
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - AD Arnold
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - AA Miyazawa
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - D Keene
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - NS Peters
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - P Kanagaratnam
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - N Qureshi
- Imperial College Healthcare NHS Trust, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - FS Ng
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - N Linton
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - D Lefroy
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - D Francis
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - PB Lim
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - ZI Whinnett
- National Heart and Lung Institute Imperial College, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - P Kellman
- National Heart Lung and Blood Institute, MRI, Bethesda, United States of America
| | - GD Cole
- Imperial College Healthcare NHS Trust, Cardiology, London, United Kingdom of Great Britain & Northern Ireland
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Miyazawa A, Arnold A, Keene D, Shun-Shin MJ, Howard JP, Jelf D, Bangi S, Peters NS, Lefroy D, Lim PB, Ng FS, Linton N, Kanagaratnam P, Francis DP, Whinnett ZI. Laser doppler derived peripheral perfusion can distinguish haemodynamically tolerated VT from haemodynamically compromised VT. Europace 2021. [DOI: 10.1093/europace/euab116.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): NIHR Imperial Biomedical Research Centre
Introduction
Implantable Cardioverter-Defibrillators (ICDs) cannot distinguish between ventricular tachycardia (VT) with haemodynamic compromise from haemodynamically tolerated VT to ensure that therapies are delivered only when necessary. Currently, unnecessary therapies are reduced by longer duration thresholds and higher rate thresholds. This can result in ICDs withholding or delaying therapies during haemodynamically compromising VT while potentially still providing therapies during rapid or prolonged VT that is haemodynamically well tolerated.
Laser doppler perfusion monitoring (LDPM) allows assessment of peripheral blood flow as a surrogate for haemodynamic status. We have previously demonstrated that laser doppler perfusion signals, analysed using an electro-mechanical coupling algorithm (SafeShock), can reliably identify loss of perfusion during ventricular fibrillation (VF), as well as discriminate VF from simulated lead fractures and T wave over-sensing. The utility of LDPM signals in VT, however, has not been established.
Purpose
In this study we assessed the utility of LDPM using the SafeShock algorithm to discriminate haemodynamically tolerated VT from VT with haemodynamic compromise.
Methods
Recruited participants underwent a rapid ventricular pacing protocol to simulate VT at different rates. Pacing was performed using the right ventricular lead of an implanted pacing device or a temporary pacing wire in the right ventricular apex. 3-lead ECG, blood pressure (either invasively using a radial artery catheter or non-invasively using beat-by-beat finometry) and LDPM signal were continuously recorded during the protocol. LDPM signals during simulated VT were analysed using the SafeShock electro-mechanical algorithm and compared to blood pressure change from baseline intrinsic rhythm to simulated VT.
Results
We obtained 588 recordings of simulated VT in 56 patients at rates of 100 bpm, 120 bpm, 140 bpm, 160 bpm, 180 bpm and 200 bpm. Percentage change in systolic blood pressure from baseline to VT correlated with LDPM-derived perfusion value during VT (Spearman’s Rho = 0.7786, p < 0.0001).
Using a cut-off of 5 units, perfusion value predicted a 20% drop in systolic blood pressure in VT with an accuracy of 89.4% (sensitivity 94.8%, specificity 83.6%, p value <0.0001).
Conclusions
Peripheral perfusion measurements, analysed using an electro-mechanical algorithm, can accurately discriminate haemodynamically tolerated VT from VT with haemodynamic compromise. ICDs with integrated LDPM sensors and algorithms could make therapy decisions based on the circulatory status of patients with arrhythmias not just rate and duration parameters. This could reduce unnecessary therapies while facilitating prompt treatment of compromising arrhythmias. Abstract Figure 1
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Affiliation(s)
- A Miyazawa
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - A Arnold
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - D Keene
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - MJ Shun-Shin
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - JP Howard
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - D Jelf
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - S Bangi
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - NS Peters
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - D Lefroy
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - PB Lim
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - FS Ng
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - N Linton
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - P Kanagaratnam
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - DP Francis
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - ZI Whinnett
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
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Arnold A, Shun-Shin MJ, Keene D, Howard JP, Chow J, Miyazawa AA, Qureshi N, Lefroy DC, Koa-Wing M, Linton NWF, Lim PB, Peters NS, Kanagaratnam P, Francis DP, Whinnett ZI. Non-selective and selective His bundle pacing both preserve left ventricular activation time and pattern. Europace 2021. [DOI: 10.1093/europace/euab116.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public Institution(s). Main funding source(s): British Heart Foundation
Background: His bundle pacing can be achieved in two ways
selective His bundle pacing, where the His bundle is captured alone, and non-selective His bundle pacing, where local myocardium is also captured resulting a pre-excited ECG appearance. We assessed the impact of this ventricular pre-excitation on left and right ventricular dys-synchrony.
Methods
We recruited patients who displayed both selective and non-selective His bundle pacing. We performed non-invasive epicardial electrical mapping to determine left and right ventricular activation times and patterns.
Results
In the primary analysis (n = 20, all patients), non-selective His bundle pacing did not prolong LVAT compared to select His bundle pacing by a pre-specified non-inferiority margin of 10ms (LVAT prolongation: -5.5ms, 95% confidence interval (CI): -0.6 to -10.4, non-inferiority p < 0.0001). Non-selective His bundle pacing did not prolong right ventricular activation time (4.3ms, 95%CI: -4.0 to 12.8, p = 0.296) but did prolong QRS duration (22.1ms, 95%CI: 11.8 to 32.4, p = 0.0003).
In patients with narrow intrinsic QRS (n = 6), non-selective His bundle pacing preserved left ventricular activation time (-2.9ms, 95%CI: -9.7 to 4.0, p = 0.331) but prolonged QRS duration (31.4ms, 95%CI: 22.0 to 40.7, p = 0.0003) and mean right ventricular activation time (16.8ms, 95%CI: -5.3 to 38.9, p = 0.108) compared to selective His bundle pacing.
Activation pattern of the left ventricular surface was unchanged between selective and non-selective His bundle pacing. Non-selective His bundle pacing produced early basal right ventricular activation, which was not observed with selective His bundle pacing.
Conclusions
Compared to selective His bundle pacing, local myocardial capture during non-selective His bundle pacing produces right ventricular pre-excitation resulting in prolongation of QRS duration. However, non-selective His bundle pacing preserves the left ventricular activation time and pattern of selective His bundle pacing. When choosing between selective and non-selective His bundle pacing, left ventricular dyssynchrony is not an important factor. Abstract Figure: Selective vs Non-Selective HBP
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Affiliation(s)
- A Arnold
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - MJ Shun-Shin
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - D Keene
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - JP Howard
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - J Chow
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - AA Miyazawa
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - N Qureshi
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - DC Lefroy
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - M Koa-Wing
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - NWF Linton
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - PB Lim
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - NS Peters
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - P Kanagaratnam
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - DP Francis
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
| | - ZI Whinnett
- Imperial College London, London, United Kingdom of Great Britain & Northern Ireland
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Miyazawa AA, Keene D, Johal M, Arnold AD, Peters NS, Kanagaratnam P, Linton NWF, Lim PB, Lefroy DC, Ng FS, Qureshi NA, Koa-Wing M, Whinnett ZI, Francis DP, Shun-Shin MJ. A method for accurately and dynamically optimising pacemaker atrio-ventricular delay timing using implantable physiological biomarkers. Europace 2021. [DOI: 10.1093/europace/euab116.464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Other. Main funding source(s): BRAVO trial: BHF SP/10/002/28189, FS/10/038, FS/11/92/29122, FS/13/44/30291) National Institute for Health Research Imperial Biomedical Research Centre. HOPE-HF trial: British Heart Foundation (CS/15/3/31405, FS/13/44/30291, FS/15/53/31615, FS/14/27/30752, FS/10/038).
Introduction
The optimal atrioventricular (AV) delay for implantable cardiac devices can be derived by echocardiography or beat-by-beat blood pressure measurements. However, both of these approaches are labour intensive and neither could be incorporated into an implantable cardiac device for frequent repeated optimisations. Laser Doppler perfusion monitoring (LDPM) measures blood flow through tissue. LDPM has been miniaturised ready to be incorporated into future implantable cardiac devices.
Purpose
We studied if LDPM is a clinically reliable alternative method to blood-pressure measurements to determine optimal AV delay.
Methods
Data from 58 patients undergoing 94 clinical AVD optimisations using LDPM and simultaneous non-invasive beat-by-beat blood pressure was obtained. The optimal AV delay for each method and for each optimisation was determined using a curve of haemodynamic response to switching from AAI (reference state) to DDD (test state) at a series of AV delays (40, 80, 120, 160, 200, 240 ms). We then compared the derived optimal AV delays between the two measurement approaches. We also assessed the impact of the paced heart-rate on agreement between laser Doppler and Blood-Pressure derived optimal AV delays.
Results
The AV delay derived using LDPM was not clinically significant different from that derived by blood pressure changes. The median difference was -9ms (IQR -26 to 7, p = 0.05). Variability between the two methods was low (median absolute deviation 17ms). Optimisations performed at higher heart-rates resulted in a non-significant smaller difference between the LDPM and blood-pressure derived AV delays (median absolute deviation 12 vs 22 ms, p = 0.11).
Conclusions
Optimal AVDs derived from non-invasive blood-pressure or laser Doppler perfusion methods are clinically equivalent. The addition of laser Doppler to future implantable cardiac devices may enable devices to dynamically and reliably optimise AV delays. Abstract Figure 1
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Affiliation(s)
- AA Miyazawa
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - D Keene
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - M Johal
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - AD Arnold
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - NS Peters
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - P Kanagaratnam
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - NWF Linton
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - PB Lim
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - DC Lefroy
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - FS Ng
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - NA Qureshi
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - M Koa-Wing
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - ZI Whinnett
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - DP Francis
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
| | - MJ Shun-Shin
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain & Northern Ireland
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Arnold AD, Shun‐Shin MJ, Keene D, Howard JP, Chow J, Lim E, Lampridou S, Miyazawa AA, Muthumala A, Tanner M, Qureshi NA, Lefroy DC, Koa‐Wing M, Linton NWF, Boon Lim P, Peters NS, Kanagaratnam P, Auricchio A, Francis DP, Whinnett ZI. Electrocardiographic predictors of successful resynchronization of left bundle branch block by His bundle pacing. J Cardiovasc Electrophysiol 2021; 32:428-438. [PMID: 33345379 PMCID: PMC8607473 DOI: 10.1111/jce.14845] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/26/2020] [Accepted: 12/06/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND His bundle pacing (HBP) is an alternative to biventricular pacing (BVP) for delivering cardiac resynchronization therapy (CRT) in patients with heart failure and left bundle branch block (LBBB). It is not known whether ventricular activation times and patterns achieved by HBP are equivalent to intact conduction systems and not all patients with LBBB are resynchronized by HBP. OBJECTIVE To compare activation times and patterns of His-CRT with BVP-CRT, LBBB and intact conduction systems. METHODS In patients with LBBB, noninvasive epicardial mapping (ECG imaging) was performed during BVP and temporary HBP. Intrinsic activation was mapped in all subjects. Left ventricular activation times (LVAT) were measured and epicardial propagation mapping (EPM) was performed, to visualize epicardial wavefronts. Normal activation pattern and a normal LVAT range were determined from normal subjects. RESULTS Forty-five patients were included, 24 with LBBB and LV impairment, and 21 with normal 12-lead ECG and LV function. In 87.5% of patients with LBBB, His-CRT successfully shortened LVAT by ≥10 ms. In 33.3%, His-CRT resulted in complete ventricular resynchronization, with activation times and patterns indistinguishable from normal subjects. EPM identified propagation discontinuity artifacts in 83% of patients with LBBB. This was the best predictor of whether successful resynchronization was achieved by HBP (logarithmic odds ratio, 2.19; 95% confidence interval, 0.07-4.31; p = .04). CONCLUSION Noninvasive electrocardiographic mapping appears to identify patients whose LBBB can be resynchronized by HBP. In contrast to BVP, His-CRT may deliver the maximum potential ventricular resynchronization, returning activation times, and patterns to those seen in normal hearts.
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Affiliation(s)
- Ahran D. Arnold
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Matthew J. Shun‐Shin
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | | | - James P. Howard
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Ji‐Jian Chow
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Elaine Lim
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Smaragda Lampridou
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Alejandra A. Miyazawa
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Amal Muthumala
- Cardiology DepartmentNorth Middlesex University Hospital NHS TrustLondonUK
- Cardiology DepartmentSt. Bartholomew's Hospital, Barts Health NHS TrustLondonUK
| | - Mark Tanner
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Norman A. Qureshi
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - David C. Lefroy
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Michael Koa‐Wing
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Nick W. F. Linton
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Phang Boon Lim
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Nicholas S. Peters
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Prapa Kanagaratnam
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Angelo Auricchio
- Division of CardiologyFondazione Cardiocentro TicinoLuganoSwitzerland
| | - Darrel P. Francis
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
| | - Zachary I. Whinnett
- National Heart and Lung InstituteImperial College London, Hammersmith HospitalLondonUK
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Keene D, Shun-Shin MJ, Arnold AD, March K, Qureshi N, Ng FS, Tanner M, Linton N, Lim PB, Lefroy D, Kanagaratnam P, Peters NS, Francis DP, Whinnett ZI. Within-patient comparison of His-bundle pacing, right ventricular pacing, and right ventricular pacing avoidance algorithms in patients with PR prolongation: Acute hemodynamic study. J Cardiovasc Electrophysiol 2020; 31:2964-2974. [PMID: 32976636 DOI: 10.1111/jce.14763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/04/2020] [Accepted: 09/15/2020] [Indexed: 11/28/2022]
Abstract
AIMS A prolonged PR interval may adversely affect ventricular filling and, therefore, cardiac function. AV delay can be corrected using right ventricular pacing (RVP), but this induces ventricular dyssynchrony, itself harmful. Therefore, in intermittent heart block, pacing avoidance algorithms are often implemented. We tested His-bundle pacing (HBP) as an alternative. METHODS Outpatients with a long PR interval (>200 ms) and intermittent need for ventricular pacing were recruited. We measured within-patient differences in high-precision hemodynamics between AV-optimized RVP and HBP, as well as a pacing avoidance algorithm (Managed Ventricular Pacing [MVP]). RESULTS We recruited 18 patients. Mean left ventricular ejection fraction was 44.3 ± 9%. Mean intrinsic PR interval was 266 ± 42 ms and QRS duration was 123 ± 29 ms. RVP lengthened QRS duration (+54 ms, 95% CI 42-67 ms, p < .0001) while HBP delivered a shorter QRS duration than RVP (-56 ms, 95% CI -67 to -46 ms, p < .0001). HBP did not increase QRS duration (-2 ms, 95% CI -8 to 13 ms, p = .6). HBP improved acute systolic blood pressure by mean of 5.0 mmHg (95% CI 2.8-7.1 mmHg, p < .0001) compared to RVP and by 3.5 mmHg (95% CI 1.9-5.0 mmHg, p = .0002) compared to the pacing avoidance algorithm. There was no significant difference in hemodynamics between RVP and ventricular pacing avoidance (p = .055). CONCLUSIONS HBP provides better acute cardiac function than pacing avoidance algorithms and RVP, in patients with prolonged PR intervals. HBP allows normalization of prolonged AV delays (unlike pacing avoidance) and does not cause ventricular dyssynchrony (unlike RVP). Clinical trials may be justified to assess whether these acute improvements translate into longer term clinical benefits in patients with bradycardia indications for pacing.
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Affiliation(s)
- Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Katherine March
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Norman Qureshi
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Mark Tanner
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Nicholas Linton
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Phang B Lim
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - David Lefroy
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | | | - Nicholas S Peters
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
| | - Darrel P Francis
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, UK
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
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Breeze J, Bowley DM, Naumann DN, Marsden MER, Fryer RN, Keene D, Ramasamy A, Lewis EA. Torso body armour coverage defined according to feasibility of haemorrhage control within the prehospital environment: a new paradigm for combat trauma protection. BMJ Mil Health 2020; 168:399-403. [PMID: 33109734 DOI: 10.1136/bmjmilitary-2020-001582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 11/03/2022]
Abstract
Developments in military personal armour have aimed to achieve a balance between anatomical coverage, protection and mobility. When death is likely to occur within 60 min of injury to anatomical structures without damage control surgery, then these anatomical structures are defined as 'essential'. However, the medical terminology used to describe coverage is challenging to convey in a Systems Requirements Document (SRD) for acquisition of new armour and to ultimately translate to the correct sizing and fitting of personal armour. Many of those with Ministry of Defence responsible for the procurement of personal armour and thereby using SRDs will likely have limited medical knowledge; therefore, the potentially complex medical terminology used to describe the anatomical boundaries must be translated into easily recognisable and measurable external landmarks. We now propose a complementary classification for ballistic protection coverage, termed threshold and objective, based on the feasibility of haemorrhage control within the prehospital environment.
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Affiliation(s)
- Johno Breeze
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK .,Department of Bioengineering, Imperial College London, London, UK
| | - D M Bowley
- Surgery, 16 Medical Regiment, Colchester, UK
| | - D N Naumann
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - M E R Marsden
- Department of General Surgery, Queen Alexandra Hospital, Cosham, UK
| | | | - D Keene
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, Birmingham, UK
| | - A Ramasamy
- The Royal British Legion Centre for Blast Injury Studies, Imperial College London, London, UK.,Trauma and Orthopaedics, Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, UK
| | - E A Lewis
- Defence Equipment and Support, Ministry of Defence Abbey Wood, Bristol, UK
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Arnold AD, Howard JP, Chiew K, Kerrigan WJ, de Vere F, Johns HT, Churlilov L, Ahmad Y, Keene D, Shun-Shin MJ, Cole GD, Kanagaratnam P, Sohaib SMA, Varnava A, Francis DP, Whinnett ZI. Right ventricular pacing for hypertrophic obstructive cardiomyopathy: meta-analysis and meta-regression of clinical trials. Eur Heart J Qual Care Clin Outcomes 2020; 5:321-333. [PMID: 30715300 PMCID: PMC6775860 DOI: 10.1093/ehjqcco/qcz006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 01/25/2019] [Accepted: 01/31/2019] [Indexed: 01/25/2023]
Abstract
Aims Right ventricular pacing for left ventricular outflow tract gradient reduction in hypertrophic obstructive cardiomyopathy remains controversial. We undertook a meta-analysis for echocardiographic and functional outcomes. Methods and results Thirty-four studies comprising 1135 patients met eligibility criteria. In the four blinded randomized controlled trials (RCTs), pacing reduced gradient by 35% [95% confidence interval (CI) 23.2–46.9, P < 0.0001], but there was only a trend towards improved New York Heart Association (NYHA) class [odds ratio (OR) 1.82, CI 0.96–3.44; P = 0.066]. The unblinded observational studies reported a 54.3% (CI 44.1–64.6, P < 0.0001) reduction in gradient, which was a 18.6% greater reduction than the RCTs (P = 0.0351 for difference between study designs). Observational studies reported an effect on unblinded NYHA class at an OR of 8.39 (CI 4.39–16.04, P < 0.0001), 450% larger than the OR in RCTs (P = 0.0042 for difference between study designs). Across all studies, the gradient progressively decreased at longer follow durations, by 5.2% per month (CI 2.5–7.9, P = 0.0001). Conclusion Right ventricular pacing reduces gradient in blinded RCTs. There is a non-significant trend to reduction in NYHA class. The bias in assessment of NYHA class in observational studies appears to be more than twice as large as any genuine treatment effect.
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Affiliation(s)
- Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Kayla Chiew
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - William J Kerrigan
- Cardiology Department, Imperial College Healthcare NHS Trust, Du Cane Road, London, UK
| | - Felicity de Vere
- Cardiology Department, Imperial College Healthcare NHS Trust, Du Cane Road, London, UK
| | - Hannah T Johns
- University of Melbourne, Burgundy Street, Heidelberg, Victoria, Australia
| | - Leonid Churlilov
- University of Melbourne, Burgundy Street, Heidelberg, Victoria, Australia
| | - Yousif Ahmad
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Graham D Cole
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - S M Afzal Sohaib
- Cardiology Department, St Bartholomew's Hospital, W Smithfield, London, UK
| | - Amanda Varnava
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
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Affiliation(s)
- Andrew J M Lewis
- 1 Department of Cardiology Great Western Hospitals NHS Foundation Trust Swindon United Kingdom.,2 Radcliffe Department of Medicine and British Heart Centre for Research Excellence John Radcliffe Hospital University of Oxford United Kingdom
| | - Paul Foley
- 1 Department of Cardiology Great Western Hospitals NHS Foundation Trust Swindon United Kingdom
| | - Zachary Whinnett
- 3 Imperial College London Hammersmith Hospital London United Kingdom
| | - Daniel Keene
- 3 Imperial College London Hammersmith Hospital London United Kingdom
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Ponakala A, Yenamandra V, Teng C, Barriga M, Dolorito J, Gorell E, Nguyen N, Tufa S, Rieger K, Keene D, Tang J, Marinkovich M. 304 Type VII collagen NC2 domain expression differentiates severe from milder recessive dystrophic epidermolysis bullosa subtypes. J Invest Dermatol 2020. [DOI: 10.1016/j.jid.2020.03.310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Arnold AD, Howard JP, Gopi A, Chan CP, Ali N, Keene D, Shun-Shin MJ, Ahmad Y, Wright IJ, Ng FS, Linton NW, Kanagaratnam P, Peters NS, Rueckert D, Francis DP, Whinnett ZI. Discriminating electrocardiographic responses to His-bundle pacing using machine learning. Cardiovasc Digit Health J 2020; 1:11-20. [PMID: 32954375 PMCID: PMC7484933 DOI: 10.1016/j.cvdhj.2020.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND His-bundle pacing (HBP) has emerged as an alternative to conventional ventricular pacing because of its ability to deliver physiological ventricular activation. Pacing at the His bundle produces different electrocardiographic (ECG) responses: selective His-bundle pacing (S-HBP), non-selective His bundle pacing (NS-HBP), and myocardium-only capture (MOC). These 3 capture types must be distinguished from each other, which can be challenging and time-consuming even for experts. OBJECTIVE The purpose of this study was to use artificial intelligence (AI) in the form of supervised machine learning using a convolutional neural network (CNN) to automate HBP ECG interpretation. METHODS We identified patients who had undergone HBP and extracted raw 12-lead ECG data during S-HBP, NS-HBP, and MOC. A CNN was trained, using 3-fold cross-validation, on 75% of the segmented QRS complexes labeled with their capture type. The remaining 25% was kept aside as a testing dataset. RESULTS The CNN was trained with 1297 QRS complexes from 59 patients. Cohen kappa for the neural network's performance on the 17-patient testing set was 0.59 (95% confidence interval 0.30 to 0.88; P <.0001), with an overall accuracy of 75%. The CNN's accuracy in the 17-patient testing set was 67% for S-HBP, 71% for NS-HBP, and 84% for MOC. CONCLUSION We demonstrated proof of concept that a neural network can be trained to automate discrimination between HBP ECG responses. When a larger dataset is trained to higher accuracy, automated AI ECG analysis could facilitate HBP implantation and follow-up and prevent complications resulting from incorrect HBP ECG analysis.
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Affiliation(s)
- Ahran D. Arnold
- Address reprint requests and correspondence: Dr Ahran D. Arnold, Hammersmith Hospital, London W12 0HS, United Kingdom.
| | | | - Aiswarya Gopi
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Cheng Pou Chan
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Nadine Ali
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Matthew J. Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Yousif Ahmad
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Ian J. Wright
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Fu Siong Ng
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Nick W.F. Linton
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Prapa Kanagaratnam
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Nicholas S. Peters
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Daniel Rueckert
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | | | - Zachary I. Whinnett
- National Heart and Lung Institute, Imperial College London, Hammersmith Hospital, London, United Kingdom
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Hogg P, Holmes K, McNulty J, Newman D, Keene D, Beardmore C. Covid-19: Free resources to support radiographers. Radiography (Lond) 2020; 26:189-191. [PMID: 32419768 PMCID: PMC7225700 DOI: 10.1016/j.radi.2020.05.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/07/2020] [Indexed: 12/24/2022]
Affiliation(s)
- P Hogg
- University of Salford, UK.
| | | | - J McNulty
- EFRS, European Federation of Radiographer Societies, Catharijnesingel 73, 3511 GM, Utrecht, the Netherlands
| | - D Newman
- ISRRT, Sanford Health System in Fargo, North Dakota, USA
| | - D Keene
- The Society and College of Radiographers, UK
| | - C Beardmore
- The Society and College of Radiographers, UK
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Abstract
Although permanent His bundle pacing was first reported almost 2 decades ago, it is only recently gaining wider adoption, following facilitation of the implant procedure by dedicated tools. An additional challenge is programming the system, as His bundle pacing may have specific configurations and require special considerations which current implantable pulse generators are not designed for. The aim of this article is to provide practical recommendations for programming His bundle pacing, to deliver optimal therapy and ensure patient safety.
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Affiliation(s)
- Haran Burri
- Cardiology Department, University Hospital of Geneva, Switzerland (H.B.)
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London (D.K., Z.W.).,Imperial College Healthcare NHS Trust, London, United Kingdom (D.K.)
| | - Zachary Whinnett
- National Heart and Lung Institute, Imperial College London (D.K., Z.W.)
| | - Francesco Zanon
- Arrhythmia and Electrophysiology Unit, Cardiology Department, Santa Maria Della Misericordia Hospital, Rovigo, Italy (F.Z.)
| | - Pugazhendhi Vijayaraman
- Geisinger Commonwealth School of Medicine, Geisinger heart Institute, Wilkes Barre, PA (P.V.)
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Shun-Shin MJ, Miyazawa AA, Keene D, Sterliński M, Sokal A, Van Heuverswyn F, Rinaldi CA, Cornelussen R, Stegemann B, Francis DP, Whinnett Z. How to deliver personalized cardiac resynchronization therapy through the precise measurement of the acute hemodynamic response: Insights from the iSpot trial. J Cardiovasc Electrophysiol 2019; 30:1610-1619. [PMID: 31115945 DOI: 10.1111/jce.14001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 05/17/2019] [Accepted: 05/19/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION New pacing technologies offer a greater choice of left ventricular pacing sites and greater personalization of cardiac resynchronization therapy (CRT). The effects on cardiac function of novel pacing configurations are often compared using multi-beat averages of acute hemodynamic measurements. In this analysis of the iSpot trial, we explore whether this is sufficient. MATERIALS AND METHODS The iSpot trial was an international, prospective, acute hemodynamic trial that assessed seven CRT configurations: standard CRT, MultiSpot (posterolateral vein), and MultiVein (anterior and posterior vein) pacing. Invasive and noninvasive blood pressure, and left ventricular (LV) dP/dtmax were recorded. Eight beats were recorded before and after an alternation from AAI to the tested pacing configuration and vice-versa. Eight alternations were performed for each configuration at each of the five atrioventricular delays. RESULTS Twenty-five patients underwent the full protocol of eight alternations. Only four (16%) patients had a statistically significant >3 mm Hg improvement over conventional CRT configuration (posterolateral vein, distal electrode). However, if only one alternation was analyzed (standard multi-beat averaging protocol), 15 (60%) patients falsely appeared to have a superior nonconventional configuration. Responses to pacing were significantly correlated between the different hemodynamic measures: invasive systolic blood pressure (SBP) vs noninvasive SBP r = 0.82 (P < .001); invasive SBP vs LV dP/dt r = 0.57, r2 = 0.32 (P < .001). CONCLUSIONS Current standard multibeat acquisition protocols are unfortunately unable to prevent false impressions of optimality arising in individual patients. Personalization processes need to include distinct repeated transitions to the tested pacing configuration in addition to averaging multiple beats. The need is not only during research stages but also during clinical implementation.
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Affiliation(s)
- Matthew J Shun-Shin
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Alejandra A Miyazawa
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Daniel Keene
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Maciej Sterliński
- The Second Department of Coronary Artery Disease, Institute of Cardiology, Warsaw, Poland
| | - Adam Sokal
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center of Heart Disease, Zabrze, Poland
| | | | | | - Richard Cornelussen
- Bakken Research Center B.V., Research and Technology, Maastricht, The Netherlands
| | - Berthold Stegemann
- Bakken Research Center B.V., Research and Technology, Maastricht, The Netherlands
| | - Darrel P Francis
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Zachary Whinnett
- International Centre for Circulatory Health, Imperial College London, Hammersmith Hospital, London, United Kingdom
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Keene D, Arnold AD, Jastrzębski M, Burri H, Zweibel S, Crespo E, Chandrasekaran B, Bassi S, Joghetaei N, Swift M, Moskal P, Francis DP, Foley P, Shun-Shin MJ, Whinnett ZI. His bundle pacing, learning curve, procedure characteristics, safety, and feasibility: Insights from a large international observational study. J Cardiovasc Electrophysiol 2019; 30:1984-1993. [PMID: 31310403 PMCID: PMC7038224 DOI: 10.1111/jce.14064] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/01/2019] [Accepted: 07/07/2019] [Indexed: 11/28/2022]
Abstract
Background His‐bundle pacing (HBP) provides physiological ventricular activation. Observational studies have demonstrated the techniques’ feasibility; however, data have come from a limited number of centers. Objectives We set out to explore the contemporary global practice in HBP focusing on the learning curve, procedural characteristics, and outcomes. Methods This is a retrospective, multicenter observational study of patients undergoing attempted HBP at seven centers. Pacing indication, fluoroscopy time, HBP thresholds, and lead reintervention and deactivation rates were recorded. Where centers had systematically recorded implant success rates from the outset, these were collated. Results A total of 529 patients underwent attempted HBP during the study period (2014‐19) with a mean follow‐up of 217 ± 303 days. Most implants were for bradycardia indications. In the three centers with the systematic collation of all attempts, the overall implant success rate was 81%, which improved to 87% after completion of 40 cases. All seven centers reported data on successful implants. The mean fluoroscopy time was 11.7 ± 12.0 minutes, the His‐bundle capture threshold at implant was 1.4 ± 0.9 V at 0.8 ± 0.3 ms, and it was 1.3 ± 1.2 V at 0.9 ± 0.2 ms at last device check. HBP lead reintervention or deactivation (for lead displacement or rise in threshold) occurred in 7.5% of successful implants. There was evidence of a learning curve: fluoroscopy time and HBP capture threshold reduced with greater experience, plateauing after approximately 30‐50 cases. Conclusion We found that it is feasible to establish a successful HBP program, using the currently available implantation tools. For physicians who are experienced at pacemaker implantation, the steepest part of the learning curve appears to be over the first 30‐50 cases.
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Affiliation(s)
- Daniel Keene
- National Heart and Lung Institute, Imperial College London, London
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, London
| | - Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Haran Burri
- Department of Cardiology, University Hospital, Cardiology, Geneva, Switzerland
| | - Steven Zweibel
- Department of Interventional Electrophysiology, Hartford Hospital, Interventional Electrophysiology, Hartford
| | - Eric Crespo
- Department of Interventional Electrophysiology, Hartford Hospital, Interventional Electrophysiology, Hartford
| | | | - Sukhbinder Bassi
- Cardiology Department, Sherwood Forest Hospitals NHS Foundation Trust, Sutton, Ashfield
| | - Nader Joghetaei
- Department of Cardiology, Klinikum Landkreis Erding, Cardiology, Munich, Germany
| | - Matthew Swift
- Cardiology Department, Great Western Hospitals NHS Foundation Trust, Swindon
| | - Pawel Moskal
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University Collegium Medicum, Krakow, Poland
| | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, London
| | - Paul Foley
- Cardiology Department, Great Western Hospitals NHS Foundation Trust, Swindon
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Keene D, Shun-Shin MJ, Arnold AD, Howard JP, Lefroy D, Davies DW, Lim PB, Ng FS, Koa-Wing M, Qureshi NA, Linton NWF, Shah JS, Peters NS, Kanagaratnam P, Francis DP, Whinnett ZI. Quantification of Electromechanical Coupling to Prevent Inappropriate Implantable Cardioverter-Defibrillator Shocks. JACC Clin Electrophysiol 2019; 5:705-715. [PMID: 31221358 PMCID: PMC6597902 DOI: 10.1016/j.jacep.2019.01.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/10/2019] [Accepted: 01/17/2019] [Indexed: 11/01/2022]
Abstract
OBJECTIVES This study sought to test specialized processing of laser Doppler signals for discriminating ventricular fibrillation (VF) from common causes of inappropriate therapies. BACKGROUND Inappropriate implantable cardioverter-defibrillator (ICD) therapies remain a clinically important problem associated with morbidity and mortality. Tissue perfusion biomarkers, implemented to assist automated diagnosis of VF, sometimes mistake artifacts and random noise for perfusion, which could lead to shocks being inappropriately withheld. METHODS The study tested a novel processing algorithm that combines electrogram data and laser Doppler perfusion monitoring as a method for assessing circulatory status. Fifty patients undergoing VF induction during ICD implantation were recruited. Noninvasive laser Doppler and continuous electrograms were recorded during both sinus rhythm and VF. Two additional scenarios that might have led to inappropriate shocks were simulated for each patient: ventricular lead fracture and T-wave oversensing. The laser Doppler was analyzed using 3 methods for reducing noise: 1) running mean; 2) oscillatory height; and 3) a novel quantification of electromechanical coupling which gates laser Doppler relative to electrograms. In addition, the algorithm was tested during exercise-induced sinus tachycardia. RESULTS Only the electromechanical coupling algorithm found a clear perfusion cut off between sinus rhythm and VF (sensitivity and specificity of 100%). Sensitivity and specificity remained at 100% during simulated lead fracture and electrogram oversensing. (Area under the curve running mean: 0.91; oscillatory height: 0.86; electromechanical coupling: 1.00). Sinus tachycardia did not cause false positive results. CONCLUSIONS Quantifying the coupling between electrical and perfusion signals increases reliability of discrimination between VF and artifacts that ICDs may interpret as VF. Incorporating such methods into future ICDs may safely permit reductions of inappropriate shocks.
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Affiliation(s)
- Daniel Keene
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom.
| | - Matthew J Shun-Shin
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Ahran D Arnold
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James P Howard
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - David Lefroy
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom
| | - D Wyn Davies
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom
| | - Phang Boon Lim
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Fu Siong Ng
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Michael Koa-Wing
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Norman A Qureshi
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nick W F Linton
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Jaymin S Shah
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom
| | - Nicholas S Peters
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Prapa Kanagaratnam
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Darrel P Francis
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Zachary I Whinnett
- Department of Cardiology, Imperial College Hospitals National Health Service Trust, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Hogervorst M, van Berkel M, Oort C, Marinkovich M, Keene D, Ritsema T, Swildens J, Haisma I. 371 The use of human skin equivalents to evaluate the effectivity of QR-313, an antisense oligonucleotide, in gel formulation. J Invest Dermatol 2019. [DOI: 10.1016/j.jid.2019.03.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Twaroski K, Eide C, Riddle M, Lees C, Mathews W, Keene D, McGrath J, Tolar J. 396 Revertant mosaic fibroblasts in recessive dystrophic epidermolysis bullosa. J Invest Dermatol 2019. [DOI: 10.1016/j.jid.2019.03.472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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