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Impact of the ESC 2021 guidelines on cardiac pacing and cardiac resynchronization therapy left bundle branch block definition on CRT patient selection and survival. Europace 2022. [DOI: 10.1093/europace/euac053.491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
The recently published ESC 2021 guidelines on cardiac pacing and cardiac resynchronization therapy (CRT) underwent significant changes compared to the ESC 2013 guidelines regarding the definition of left bundle branch block (LBBB) by adding notching or slurring in 2 adjacent leads as a prerequisite. The level of recommendation for CRT depends on diagnosing LBBB or non-LBBB. These changes may have a significant impact on patient selection for CRT, as fewer patients may be diagnosed with LBBB and may therefore get a lower level of recommendation for CRT.
Purpose
In this study we investigated the impact of these changes in LBBB definition on patient selection and heart transplantation/left ventricular assist device (LVAD) free survival.
Methods
A large multicenter CRT database, consisting of consecutive patients implanted with a CRT device between 2001 and 2015 in 3 university hospitals in the Netherlands, was used for this study. Patient selection, device implantation, lead positioning and follow-up were according to then prevailing guidelines and local protocols. For this study, patients were selected with baseline sinus rhythm, QRS duration >130ms, and without right ventricular pacing. Patients were stratified according to ESC 2013 and ESC 2021 guideline definitions on LBBB.
Results
The current analyses included 1.202 CRT patients. 66% of patients were male with an age of 66±11 years. Heart failure etiology was ischemic in 49% of patients with baseline left ventricular ejection fraction of 25% and baseline NYHA class II-III in 93% of patients. There is a considerable difference in LBBB diagnoses when stratifying patients according to ESC 2013 and ESC 2021 guideline definitions as especially the number of LBBB patients is reduced from 80.9% to 31.6% (Figure 1). Heart transplantation/LVAD free survival analyses when stratifying according to ESC 2013 LBBB definition showed significant separation of the curves (p<0.0001) (Figure 2). Furthermore, there was a significant difference between the wide (QRS>150ms) LBBB and wide non-LBBB subgroup concerning heart transplantation/LVAD free survival (p<0.0001). In contrast, there was no significant separation of the curves when stratifying according to ESC 2021 LBBB definition (Figure 2).
Conclusion
The changes made in LBBB definition in the ESC 2021 CRT guidelines lead to a difference in stratification of LBBB and non-LBBB. The ESC 2013 LBBB definition, however, seems to be better in predicting heart transplantation/LVAD free survival after CRT.
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Change in QRS area by cardiac resynchronization therapy is associated with clinical outcomes and echocardiographic response. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Cardiac Resynchronization Therapy (CRT) is the cornerstone of treatment in patients with dyssynchronous heart failure. Recently, baseline QRS area proved to predict outcomes after CRT better than QRS duration and morphology.
Purpose
It was the aim of the study to investigate whether the change in QRS area (ΔQRS area) by CRT-pacing further improves the prediction of CRT outcomes.
Methods
We conducted a retrospective analysis on 1,299 patients, who were included in a CRT-registry from three Dutch University hospitals with both pre- (baseline) and post-implantation 12-lead ECGs. ΔQRS area and ΔQRS duration were defined as the decrease in their respective values after CRT. Optimal cut offs for ΔQRS area and ΔQRS duration by means of Youden indices were found at 62μVs and −11ms, respectively. Primary endpoint was a combination of all-cause mortality, heart transplantation, and left ventricular assist device implantation. Secondary endpoint was the relative reduction in left ventricular end-systolic volume (LVESV), and echocardiographic response being defined as ≥15% LVESV reduction.
Results
The primary endpoint occurred in 408 patients (31%). ΔQRS area was superior to ΔQRS duration for the primary and secondary endpoints. Primary endpoint analysis showed a lower risk in the ΔQRS area ≥62μVs than in the <62μVs group (HR 0.43; 0.33–0.56, p<0.001). In the multivariable analysis, both baseline QRS area and ΔQRS area remained significantly associated with both primary and secondary endpoints. Clinical outcome (left panel of figure) and echocardiographic response (right panel) were significantly worse in patients with baseline QRS area <109μVs (group 3) than in those with QRS area ≥109μVs. Within the latter group, outcomes were significantly better in patients with ΔQRS area ≥62μVs (group 1) as compared to ΔQRS area <62μVs (group 2) (figure). Baseline QRS duration and ΔQRS duration were not independently associated with both clinical outcome and echocardiographic response.
Conclusion
The combination of baseline QRS area and ΔQRS area has a stronger association with CRT response than baseline QRS area alone, and (Δ)QRS duration. These results suggest that especially in patients with a good electrical substrate (large baseline QRS area) it is worthwhile to adjust CRT to achieve the largest decrease in QRS area.
Funding Acknowledgement
Type of funding source: None
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