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Margulescu AD, Thomas DE, Awadalla M, Shah P, Khurana A, Aldalati O, Obaid DR, Chase AJ, Smith D. Prevalence and progression of LV dysfunction and dyssynchrony in patients with new-onset LBBB post TAVR. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024:S1553-8389(24)00154-4. [PMID: 38604832 DOI: 10.1016/j.carrev.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The impact of new-onset left bundle branch block (N-LBBB) developing after Transcatheter Aortic Valve Replacement (TAVR) on cardiac function and mechanical dyssynchrony is not well defined. METHODS We retrospectively screened all patients who underwent TAVR in our centre between Oct 2018 and Sept 2021 (n = 409). We identified 38 patients with N-LBBB post-operatively (of which 28 were persistent and 10 were transient), and 17 patients with chronic pre-existent LBBB (C-LBBB). We excluded patients requiring pacing post TAVR. For all groups, we retrospectively analysed stored echocardiograms at 3 time points: before TAVR (T0), early after TAVR (T1, 1.2 ± 1.1 days), and late follow-up (T2, 1.5 ± 0.8 years), comparing LV mass and volumes, indices of LV function (LV ejection fraction, LVEF; global longitudinal strain, GLS), and mechanical dyssynchrony indices (systolic stretch index, severity of septal flash). RESULTS At baseline (T0), C-LBBB had worse cardiac function, and larger LV volumes and LV mass, compared with patients with N-LBBB. At T1, N-LBBB resulted in mild dyssynchrony and decreased LVEF and GLS. Dyssynchrony progressed at T2 in persistent N-LBBB but not C-LBBB. In both groups however, LVEF remained stable at T2, although individual response was variable. Patients with better LVEF at baseline demonstrated a higher proportion of developing LBBB-induced LV dysfunction at T2. Lack of improvement of LVEF immediately after TAVR predicted deteriorating LVEF at T2. In transient LBBB, cardiac function and most dyssynchrony indices returned to baseline. CONCLUSIONS N-LBBB after TAVR results in an immediate reduction of cardiac function, in spite of only mild dyssynchrony. When LBBB persists, patients with better cardiac function before TAVR are more likely to have LBBB-induced LV dysfunction after TAVR.
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Affiliation(s)
- Andrei D Margulescu
- Department of Cardiology, Morriston Regional Cardiac Centre, Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK.
| | - Dewi E Thomas
- Department of Cardiology, Morriston Regional Cardiac Centre, Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK; Swansea University Medical School, Singleton Park, Swansea SA2 8PP, UK.
| | - Magid Awadalla
- Mater Private Network Hospital, Eccles Street, Dublin 7 D07 WKW8, Ireland.
| | - Parin Shah
- Department of Cardiology, Morriston Regional Cardiac Centre, Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK.
| | - Ayush Khurana
- Department of Cardiology, Morriston Regional Cardiac Centre, Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK.
| | - Omar Aldalati
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK.
| | - Daniel R Obaid
- Department of Cardiology, Morriston Regional Cardiac Centre, Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK; Swansea University Medical School, Singleton Park, Swansea SA2 8PP, UK.
| | - Alexander J Chase
- Department of Cardiology, Morriston Regional Cardiac Centre, Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK; Swansea University Medical School, Singleton Park, Swansea SA2 8PP, UK.
| | - David Smith
- Department of Cardiology, Morriston Regional Cardiac Centre, Morriston Hospital, Heol Maes Eglwys, Swansea SA6 6NL, UK; Swansea University Medical School, Singleton Park, Swansea SA2 8PP, UK.
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Calle S, Duchenne J, Beela AS, Stankovic I, Puvrez A, Winter S, Fehske W, Aarones M, De Buyzere M, De Pooter J, Voigt JU, Timmermans F. Clinical and Experimental Evidence for a Strain-Based Classification of Left Bundle Branch Block-Induced Cardiac Remodeling. Circ Cardiovasc Imaging 2022; 15:e014296. [PMID: 36330792 DOI: 10.1161/circimaging.122.014296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Septal strain patterns measured by echocardiography reflect the severity of left bundle branch block (LBBB)-induced left ventricular (LV) dysfunction. We investigated whether these LBBB strain stages predicted the response to cardiac resynchronization therapy in an observational study and developed a sheep model of LBBB-induced cardiomyopathy. METHODS The clinical study enrolled cardiac resynchronization therapy patients who underwent echocardiographic examination with speckle-tracking strain analysis before cardiac resynchronization therapy implant. In an experimental sheep model with pacing-induced dyssynchrony, LV remodeling and strain were assessed at baseline, at 8 and 16 weeks. Septal strain curves were classified into 5 patterns (LBBB-0 to LBBB-4). RESULTS The clinical study involved 250 patients (age 65 [58; 72] years; 79% men; 89% LBBB) with a median LV ejection fraction of 25 [21; 30]%. Across the stages, cardiac resynchronization therapy resulted in a gradual volumetric response, ranging from no response in LBBB-0 patients (ΔLV end-systolic volume 0 [-12; 15]%) to super-response in LBBB-4 patients (ΔLV end-systolic volume -44 [-64; -18]%) (P<0.001). LBBB-0 patients had a less favorable long-term outcome compared with those in stage LBBB≥1 (log-rank P=0.003). In 13 sheep, acute right ventricular pacing resulted in LBBB-1 (23%) and LBBB-2 (77%) patterns. Over the course of 8-16 weeks, continued pacing resulted in progressive LBBB-induced dysfunction, coincident with a transition to advanced strain patterns (92% LBBB-2 and 8% LBBB-3 at week 8; 75% LBBB-3 and 25% LBBB-4 at week 16) (P=0.023). CONCLUSIONS The strain-based LBBB classification reflects a pathophysiological continuum of LBBB-induced remodeling over time and is associated with the extent of reverse remodeling in observational cardiac resynchronization therapy-eligible patients.
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Affiliation(s)
- Simon Calle
- Department of Cardiology, University Hospital Ghent, Belgium (S.C., M.D.B., J.D.P., F.T.)
| | - Jürgen Duchenne
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Department of Cardiovascular Diseases, University Hospital Leuven, Belgium (J.D., A.P., J.-U.V.)
| | - Ahmed S Beela
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht, the Netherlands (A.S.B.).,Department of Cardiovascular Diseases, Suez Canal University, Egypt (A.S.B.)
| | - Ivan Stankovic
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Clinical Hospital Centre Zemun, Faculty of Medicine, University of Belgrade, Serbia (I.S.)
| | - Alexis Puvrez
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Department of Cardiovascular Diseases, University Hospital Leuven, Belgium (J.D., A.P., J.-U.V.)
| | - Stefan Winter
- Department of Cardiology, St. Vinzenz Hospital, Germany (S.W., W.F.)
| | - Wolfgang Fehske
- Department of Cardiology, St. Vinzenz Hospital, Germany (S.W., W.F.)
| | - Marit Aarones
- Department of Medicine, Diakonhjemmet Hospital, Norway (M.A.H.)
| | - Marc De Buyzere
- Department of Cardiology, University Hospital Ghent, Belgium (S.C., M.D.B., J.D.P., F.T.)
| | - Jan De Pooter
- Department of Cardiology, University Hospital Ghent, Belgium (S.C., M.D.B., J.D.P., F.T.)
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, KU Leuven, Belgium (J.D., A.S.B., I.S., A.P., J.-U.V.).,Department of Cardiovascular Diseases, University Hospital Leuven, Belgium (J.D., A.P., J.-U.V.)
| | - Frank Timmermans
- Department of Cardiology, University Hospital Ghent, Belgium (S.C., M.D.B., J.D.P., F.T.)
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Jin XY, Petrou M, Hu JT, Nicol ED, Pepper JR. Challenges and opportunities in improving left ventricular remodelling and clinical outcome following surgical and trans-catheter aortic valve replacement. Front Med 2021; 15:416-437. [PMID: 34047933 DOI: 10.1007/s11684-021-0852-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 02/20/2021] [Indexed: 11/26/2022]
Abstract
Over the last half century, surgical aortic valve replacement (SAVR) has evolved to offer a durable and efficient valve haemodynamically, with low procedural complications that allows favourable remodelling of left ventricular (LV) structure and function. The latter has become more challenging among elderly patients, particularly following trans-catheter aortic valve implantation (TAVI). Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss, valvular-vascular impedance to myocardial activation, force-velocity relationship, and myocardial strain. LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour. Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome. Physiological pacing via the His-Purkinje system for conduction abnormalities, further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression, LV coordinate contraction, and global vascular function. TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions. Until comparable long-term durability and the resolution of TAVI related complications become available, SAVR remains the first choice for lower risk younger patients.
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Affiliation(s)
- Xu Yu Jin
- Surgical Echo-Cardiology Services, Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK.
- Cardiac Surgical Physiology and Genomics Group, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK.
| | - Mario Petrou
- Department of Cardiac Surgery, Royal Brompton Hospital, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, SW3 6LY, UK
| | - Jiang Ting Hu
- Cardiac Surgical Physiology and Genomics Group, Nuffield Division of Clinical Laboratory Sciences, Radcliffe Department of Medicine, University of Oxford, Oxford, OX3 9DU, UK
| | - Ed D Nicol
- National Heart and Lung Institute, Imperial College London, London, SW3 6LY, UK
- Department of Cardiology, Royal Brompton Hospital, London, SW3 6NP, UK
| | - John R Pepper
- Department of Cardiac Surgery, Royal Brompton Hospital, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, London, SW3 6LY, UK
- NIHR Imperial Biomedical Research Centre, London, W2 1NY, UK
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A Strain-Based Staging Classification of Left Bundle Branch Block-Induced Cardiac Remodeling. JACC Cardiovasc Imaging 2021; 14:1691-1702. [PMID: 33865764 DOI: 10.1016/j.jcmg.2021.02.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/15/2021] [Accepted: 02/11/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study speculated that longitudinal strain curves in left bundle branch block (LBBB) could be shaped by the degree of LBBB-induced cardiac remodeling. BACKGROUND LBBB independently affects left ventricular (LV) structure and function, but large individual variability may exist in LBBB-induced adverse remodeling. METHODS Consecutive patients with LBBB with septal flash (LBBB-SF) underwent thorough echocardiographic assessment, including speckle tracking-based strain analysis. Four major septal longitudinal strain patterns (LBBB-1 through LBBB-4) were discerned and staged on the basis of: 1) correlation analysis with echocardiographic indexes of cardiac remodeling, including the extent of SF; 2) strain pattern analysis in cardiac resynchronization therapy (CRT) super-responders; and 3) strain pattern analysis in patients with acute procedural-induced LBBB. RESULTS The study enrolled 237 patients with LBBB-SF (mean age: 67 ± 13 years; 57% men). LBBB-1 was observed in 60 (26%), LBBB-2 in 118 (50%), LBBB-3 in 29 (12%), and LBBB-4 in 26 (11%) patients. Patients at higher LBBB stages had larger end-diastolic volumes, lower LV ejection fractions, longer QRS duration, increased mechanical dyssynchrony, and more prominent SF compared with less advanced stages (p < 0.001 for all). Among CRT super-responders (n = 30; mean age: 63 ± 10 years), an inverse transition from stages LBBB-3 and -4 (pre-implant) to stages LBBB-1 and -2 (pace-off, median follow-up of 66 months [interquartile range: 32 to 78 months]) was observed (p < 0.001). Patients with acute LBBB (n = 27; mean age: 83 ± 5.1 years) only presented with a stage LBBB-1 (72%) or -2 pattern (24%). CONCLUSIONS The proposed classification suggests a pathophysiological continuum of LBBB-induced LV remodeling and may be valuable to assess the attribution of LBBB to the extent of LV remodeling and dysfunction.
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