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Tracy C. Cardiac Resynchronization Therapy: When Is it Too Late? JACC Clin Electrophysiol 2021; 7:47-49. [PMID: 33478711 DOI: 10.1016/j.jacep.2020.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/24/2020] [Accepted: 07/28/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Cynthia Tracy
- Department of Medicine, Division of Cardiology, George Washington University, Washington, DC, USA.
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Singh JP, Berger RD, Doshi RN, Lloyd M, Moore D, Stone J, Daoud EG. Targeted Left Ventricular Lead Implantation Strategy for Non-Left Bundle Branch Block Patients. JACC Clin Electrophysiol 2020; 6:1171-1181. [DOI: 10.1016/j.jacep.2020.04.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/20/2020] [Accepted: 04/30/2020] [Indexed: 10/23/2022]
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Bortolotto AL, Verrier RL, Nearing BD, Marum AA, Araujo Silva B, Pedreira GC, Tessarolo Silva F, Medeiros SA, Sroubek J, Zimetbaum PJ, Chang JD. Preimplantation interlead ECG heterogeneity is superior to QRS complex duration in predicting mechanical super-response in patients with non-left bundle branch block receiving cardiac resynchronization therapy. Heart Rhythm 2020; 17:1887-1896. [PMID: 32497764 DOI: 10.1016/j.hrthm.2020.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Reliable quantitative preimplantation predictors of response to cardiac resynchronization therapy (CRT) are needed. OBJECTIVE We tested the utility of preimplantation R-wave and T-wave heterogeneity (RWH and TWH, respectively) compared to standard QRS complex duration in identifying mechanical super-responders to CRT and mortality risk. METHODS We analyzed resting 12-lead electrocardiographic recordings from all 155 patients who received CRT devices between 2006 and 2018 at our institution and met class I and IIA American College of Cardiology/American Heart Association/Heart Rhythm Society guidelines with echocardiograms before and after implantation. Super-responders (n=35, 23%) had ≥20% increase in left ventricular ejection fraction and/or ≥20% decrease in left ventricular end-systolic diameter and were compared with non-super-responders (n=120, 77%), who did not meet these criteria. RWH and TWH were measured using second central moment analysis. RESULTS Among patients with non-left bundle branch block (LBBB), preimplantation RWH was significantly lower in super-responders than in non-super-responders in 3 of 4 lead sets (P=.001 to P=.038) and TWH in 2 lead sets (both, P=.05), with the corresponding areas under the curve (RWH: 0.810-0.891, P<.001; TWH: 0.759-0.810, P≤.005). No differences were observed in the LBBB group. Preimplantation QRS complex duration also did not differ between super-responders and non-super-responders among patients with (P=.856) or without (P=.724) LBBB; the areas under the curve were nonsignificant (both, P=.69). RWHV1-3LILII ≥ 420 μV predicted 3-year all-cause mortality in the entire cohort (P=.037), with a hazard ratio of 7.440 (95% confidence interval 1.015-54.527; P=.048); QRS complex duration ≥ 150 ms did not predict mortality (P=.27). CONCLUSION Preimplantation interlead electrocardiographic heterogeneity but not QRS complex duration predicts mechanical super-response to CRT in patients with non-LBBB.
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Affiliation(s)
- Alexandre L Bortolotto
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Richard L Verrier
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Bruce D Nearing
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Alexandre A Marum
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Bruna Araujo Silva
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Giovanna C Pedreira
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Fernanda Tessarolo Silva
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Sofia A Medeiros
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Jakub Sroubek
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Peter J Zimetbaum
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - James D Chang
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Henin M, Ragy H, Mannion J, David S, Refila B, Boles U. Indications of Cardiac Resynchronization in Non-Left Bundle Branch Block: Clinical Review of Available Evidence. Cardiol Res 2020; 11:1-8. [PMID: 32095190 PMCID: PMC7011924 DOI: 10.14740/cr989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 12/16/2019] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) benefits have been firmly established in patients with heart failure and reduced left ventricular ejection fraction (HFrEF), who remain in New York Heart Association (NYHA) functional classes II and III, despite optimal medical therapy, and have a wide QRS complex. An important and consistent finding in published systematic reviews and in subgroup analyses is that the benefits of CRT are maximum for patients with a broader QRS durations, typically described as QRS duration > 150 ms, and for patients with a typical left bundle branch block (LBBB) QRS morphology. It remains uncertain whether patients with non-LBBB QRS complex morphology clearly benefit from CRT or only modestly respond.
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Affiliation(s)
- Maged Henin
- University Hospital Waterford, Waterford, Ireland
| | - Hany Ragy
- National Heart Institute, Cairo, Egypt
| | | | - Santhosh David
- Cardiology Department, Letterkenny University Hospital, Donegal, Ireland
| | - Beshoy Refila
- Cardiology Department, Heart and Vascular Center, Mater Private Hospital, Dublin 7, Ireland
| | - Usama Boles
- Cardiology Department, Heart and Vascular Center, Mater Private Hospital, Dublin 7, Ireland
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Dauw J, Martens P, Mullens W. CRT Optimization: What Is New? What Is Necessary? CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:45. [PMID: 31342198 DOI: 10.1007/s11936-019-0751-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cardiac resynchronization therapy (CRT) has proven to improve quality of life, reduce heart failure hospitalization, and prolong life in selected heart failure patients with reduced ejection fraction, on optimal medical therapy and with electrical dyssynchrony. To ensure maximal benefit for CRT patients, optimization of care should be implemented. This begins with appropriate referring as well as selecting patients, knowing that the presence of left bundle branch block and QRS ≥ 150 ms is associated with the greatest reverse remodeling. The LV lead, preferably quadripolar, is best targeted in a postero-lateral position. After implantation, optimal device programming should aim for maximal biventricular pacing and in selected cases further electrical delay optimization might be of use. Even as important, is the implementation of thorough multidisciplinary heart failure care with medication uptitration, remote monitoring, rehabilitation, and patient education. The role of newer pacing strategies as endocardial or His-bundle pacing remains the subject of ongoing investigation.
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Affiliation(s)
- Jeroen Dauw
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, LCRC, Hasselt University, Diepenbeek, Belgium.
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O'Brien T, Park MS, Youn JC, Chung ES. The Past, Present and Future of Cardiac Resynchronization Therapy. Korean Circ J 2019; 49:384-399. [PMID: 31074211 PMCID: PMC6511527 DOI: 10.4070/kcj.2019.0114] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 04/10/2019] [Indexed: 01/28/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) has revolutionized the care of the patients with heart failure with reduced ejection fraction and electrical dyssynchrony. The current guidelines for patient selection include measurement of left ventricular systolic function, QRS duration and morphology, and functional classification. Despite consistent and increasing evidence supporting CRT use in appropriate patients, CRT has been underutilized. Notwithstanding the heterogeneous definitions of non-response, more than one-third of patients demonstrate a lack of echocardiographic reverse remodeling or poor clinical outcome following CRT. Since the causes of this non-response are multifactorial, it will require multidisciplinary efforts to overcome including optimal patient selection, procedural strategies, as well as optimizing post-implant care in patients undergoing CRT. The innovations of novel pacing approaches combined with advanced imaging technologies may eventually offer a personalized CRT system uniquely tailored to each patient's dyssynchrony signature.
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Affiliation(s)
- Thomas O'Brien
- The Christ Hospital Heart and Vascular Center, Cincinnati, OH, USA.,The Lindner Center for Research and Education, Cincinnati, OH, USA
| | - Myung Soo Park
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Jong Chan Youn
- Division of Cardiology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.
| | - Eugene S Chung
- The Christ Hospital Heart and Vascular Center, Cincinnati, OH, USA.,The Lindner Center for Research and Education, Cincinnati, OH, USA
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Singh JP, Berger RD, Doshi RN, Lloyd M, Moore D, Daoud EG. Rationale and design for ENHANCE CRT: QLV implant strategy for non-left bundle branch block patients. ESC Heart Fail 2018; 5:1184-1190. [PMID: 30264456 PMCID: PMC6300807 DOI: 10.1002/ehf2.12340] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/31/2018] [Accepted: 06/22/2018] [Indexed: 11/10/2022] Open
Abstract
AIMS Historically, cardiac resynchronization therapy (CRT) response in non-left bundle branch block (non-LBBB) patients has been suboptimal in comparison with that observed in left bundle branch block patients. The electrical activation pattern of the left ventricle (LV) is different between these two QRS morphologies. Small non-randomized studies have suggested that targeting the LV wall with greatest electrical delay may be superior to conventional anatomical pacing from the lateral wall in non-LBBB patients. This article outlines the design and rationale of a prospective, randomized, pilot study, which assesses the effect of a non-traditional LV lead implant strategy on the clinical composite score after 12 months of follow-up in a non-LBBB patient population. METHODS All patients will receive an Abbott quadripolar CRT-D system (Quartet 1458Q LV lead with Unify Quadra™, Quadra Assura™ CRT-D or any market-approved CRT-D device with quadripolar pacing capabilities). Patients will be randomized in a 2:1 ratio between a QLV-based implant strategy vs. standard of care. Up to 250 patients will be enrolled in the study. CONCLUSIONS If the primary endpoint is achieved, this study will provide important information about reducing the non-responder rate in non-LBBB patients and provide further evidence for the QLV-based implant strategy.
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Affiliation(s)
| | | | - Rahul N Doshi
- University of Southern California, Los Angeles, CA, USA
| | | | - Douglas Moore
- St John Hospital and Medical Center, Detroit, MI, USA
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- The Ohio State University, Columbus, OH, USA
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