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Leinveber P, Halamek J, Curila K, Prinzen F, Lipoldova J, Matejkova M, Smisek R, Plesinger F, Nagy A, Novak M, Viscor I, Vondra V, Jurak P. Ultra-high-frequency ECG volumetric and negative derivative epicardial ventricular electrical activation pattern. Sci Rep 2024; 14:5681. [PMID: 38454102 PMCID: PMC10920693 DOI: 10.1038/s41598-024-55789-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 02/27/2024] [Indexed: 03/09/2024] Open
Abstract
From precordial ECG leads, the conventional determination of the negative derivative of the QRS complex (ND-ECG) assesses epicardial activation. Recently we showed that ultra-high-frequency electrocardiography (UHF-ECG) determines the activation of a larger volume of the ventricular wall. We aimed to combine these two methods to investigate the potential of volumetric and epicardial ventricular activation assessment and thereby determine the transmural activation sequence. We retrospectively analyzed 390 ECG records divided into three groups-healthy subjects with normal ECG, left bundle branch block (LBBB), and right bundle branch block (RBBB) patients. Then we created UHF-ECG and ND-ECG-derived depolarization maps and computed interventricular electrical dyssynchrony. Characteristic spatio-temporal differences were found between the volumetric UHF-ECG activation patterns and epicardial ND-ECG in the Normal, LBBB, and RBBB groups, despite the overall high correlations between both methods. Interventricular electrical dyssynchrony values assessed by the ND-ECG were consistently larger than values computed by the UHF-ECG method. Noninvasively obtained UHF-ECG and ND-ECG analyses describe different ventricular dyssynchrony and the general course of ventricular depolarization. Combining both methods based on standard 12-lead ECG electrode positions allows for a more detailed analysis of volumetric and epicardial ventricular electrical activation, including the assessment of the depolarization wave direction propagation in ventricles.
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Affiliation(s)
- Pavel Leinveber
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic.
| | - Josef Halamek
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
| | - Karol Curila
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Frits Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Jolana Lipoldova
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Magdalena Matejkova
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Radovan Smisek
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
- Department of Biomedical Engineering, Faculty of Electrical Engineering and Communication, Brno University of Technology, Brno, Czech Republic
| | - Filip Plesinger
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
| | - Andrej Nagy
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Miroslav Novak
- International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
- First Department of Internal Medicine and Cardioangiology, St. Anne's University Hospital Brno, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ivo Viscor
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
| | - Vlastimil Vondra
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
| | - Pavel Jurak
- Institute of Scientific Instruments, The Czech Academy of Sciences, Brno, Czech Republic
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Sivakumar S, Young MJ, Popilevsky L. New-Onset Intermittent Deceleration-Dependent Left Bundle Branch Block Following Induction of General Anesthesia in a Healthy Patient: A Case Report. Cureus 2024; 16:e55211. [PMID: 38425331 PMCID: PMC10902872 DOI: 10.7759/cureus.55211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 03/02/2024] Open
Abstract
This case report aims to highlight an atypical presentation of deceleration-dependent aberrancy (DDA) following the induction of general anesthesia in a patient with no known cardiac history. It emphasizes the critical role of intraoperative monitoring and the potential effects of anesthetic agents on the cardiac conduction system. A 46-year-old Hispanic male with no significant past medical or surgical history presented for surgical repair of a comminuted radial fracture. Following anesthesia induction with propofol, midazolam, and fentanyl, he developed a transient left bundle branch block (LBBB) exhibiting deceleration-dependent characteristics. Despite stable hemodynamics, the LBBB pattern appeared at heart rates below 60 beats per minute and resolved with heart rates above 90 beats per minute. This was managed intraoperatively with glycopyrrolate. Postoperative evaluations, including a 12-lead ECG, echocardiogram, and nuclear stress test, indicated normal biventricular function with a small to moderate reversible perfusion defect. The patient did not report cardiac symptoms postoperatively and did not prefer to undergo a coronary angiogram. This report underscores the importance of recognizing rate-dependent LBBB as a potential intraoperative complication, even in patients without pre-existing cardiac conditions. The transient nature of DDA, influenced by anesthetic agents and managed through careful monitoring and pharmacological intervention, highlights the necessity for vigilance in perioperative settings. This case contributes to a growing body of evidence suggesting that anesthetic management may require tailored approaches for patients experiencing or at risk for conduction abnormalities. This case illustrates the complexities of cardiac conduction disturbances such as DDA in the context of general anesthesia, serving as a reminder of the importance of thorough monitoring and the judicious use of rate-modifying drugs. It fosters a deeper understanding of the interaction between anesthesia and cardiac electrophysiology. Further research is needed to explore the mechanisms and management strategies for anesthetic-related cardiac conduction abnormalities.
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Affiliation(s)
| | - Mark J Young
- Anesthesiology, Metropolitan Hospital Center, New York, USA
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Brandtvig TO, Marinko S, Farouq M, Brandt J, Mörtsell D, Wang L, Chaudhry U, Saba S, Borgquist R. Association between left ventricular lead position and intrinsic QRS morphology with regard to clinical outcome in cardiac resynchronization therapy for heart failure. Ann Noninvasive Electrocardiol 2023:e13065. [PMID: 37200452 DOI: 10.1111/anec.13065] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/17/2023] [Accepted: 05/02/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND Left ventricular (LV) lead position may be an important factor for delivering effective cardiac resynchronization therapy (CRT). We therefore aimed to evaluate the effects of LV lead position, stratified by native QRS morphology, regarding the clinical outcome. METHODS A total of 1295 CRT-implanted patients were retrospectively evaluated. LV lead position was classified as lateral, anterior, inferior, or apical, and was determined using the left and right anterior oblique X-ray views. Kaplan Meier and Cox regression were performed to evaluate the effects on all-cause mortality and heart failure hospitalization, and the potential interaction between LV lead position and native ECG morphologies. RESULTS A total of 1295 patients were included. Patients were aged 69 ± 7 years, 20% were female, 46% received a CRT-Pacemaker (vs. CRT-Defibrillator), mean LVEF was 25% ± 7%, and median follow-up was 3.3 years [IQR 1.6-5-7 years]. Eight hundred and eighty-two patients (68%) had a lateral LV lead location, 207 (16%) anterior, 155 (12%) apical, and 51 (4%) inferior. Patients with lateral LV lead position had larger QRS reduction (-13 ± 27 ms vs. -3 ± 24 ms, p < .001). Non-lateral lead location was associated with a higher risk for all-cause mortality (HR 1.34 [1.09-1.67], p = .007) and heart failure hospitalization (HR 1.25 [1.03-1.52], p = .03). This association was strongest for patients with native left or right bundle branch block, and not significant for patients with prior paced QRS or nonspecific intraventricular conduction delay. CONCLUSIONS In patients treated with CRT, non-lateral LV lead positions (including apical, anterior, and inferior positions) were associated with worse clinical outcome and less reduction of QRS duration. This association was strongest for patients with native LBBB or RBBB.
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Affiliation(s)
- Tove Olsson Brandtvig
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Sofia Marinko
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Maiwand Farouq
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Johan Brandt
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - David Mörtsell
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Lingwei Wang
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Uzma Chaudhry
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Arrhythmia Section, Skane University Hospital, Lund, Sweden
| | - Samir Saba
- Department of Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania, USA
| | - Rasmus Borgquist
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Cardiology, Arrhythmia Section, Skane University Hospital, Lund, Sweden
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Clark HI, Pearson MJ, Smart NA. Rate adaptive pacing in people with chronic heart failure increases peak heart rate but not peak exercise capacity: a systematic review. Heart Fail Rev 2023; 28:21-34. [PMID: 35138522 PMCID: PMC9902309 DOI: 10.1007/s10741-022-10217-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 02/07/2023]
Abstract
Rate adaptive cardiac pacing (RAP) allows increased heart rate (HR) in response to metabolic demand in people with implantable electronic cardiac devices (IECD). The aim of this work was to conduct a systematic review to determine if RAP increases peak exercise capacity (peak VO2) in line with peak HR in people with chronic heart failure. We conducted a systematic literature search from 1980, when IECD and RAP were first introduced, until 31 July 2021. Databases searched include PubMed, Medline, EMBASE, EBSCO, and the Clinical Trials Register. A comprehensive search of the literature produced a total of 246 possible studies; of these, 14 studies were included. Studies and subsequent analyses were segregated according to comparison, specifically standard RAP (RAPON) vs fixed rate pacing (RAPOFF), and tailored RAP (TLD RAPON) vs standard RAP (RAPON). Pooled analyses were conducted for peak VO2 and peak HR for RAPON vs RAPOFF. Peak HR significantly increased by 15 bpm with RAPON compared to RAPOFF (95%CI, 7.98-21.97, P < 0.0001). There was no significant difference between pacing mode for peak VO2 0.45 ml kg-1 min-1 (95%CI, - 0.55-1.47, P = 0.38). This systematic review revealed RAP increased peak HR in people with CHF; however, there was no concomitant improvement in peak VO2. Rather RAP may provide benefits at submaximal intensities by controlling the rise in HR to optimise cardiac output at lower workloads. HR may be an important outcome of CHF management, reflecting myocardial efficiency.
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Affiliation(s)
- H. I. Clark
- grid.1020.30000 0004 1936 7371School of Science & Technology, Exercise & Sports Science, University of New England, Armidale, NSW Australia
| | - M. J. Pearson
- grid.1020.30000 0004 1936 7371School of Science & Technology, Exercise & Sports Science, University of New England, Armidale, NSW Australia
| | - N. A. Smart
- grid.1020.30000 0004 1936 7371School of Science & Technology, Exercise & Sports Science, University of New England, Armidale, NSW Australia
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Bank AJ, Brown CD, Burns KV, Espinosa EA, Harbin MM. Electrical dyssynchrony mapping and cardiac resynchronization therapy. J Electrocardiol 2022; 74:73-81. [PMID: 36055070 DOI: 10.1016/j.jelectrocard.2022.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/12/2022] [Accepted: 08/16/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE There is no clinical methodology for quantification or display of electrical dyssynchrony over a wide range of atrial-ventricular delays (AVD) and ventricular-ventricular delays (VVD) in patients with cardiac resynchronization therapy (CRT). This study aimed to develop a new methodology, based on wavefront fusion, for mapping electrical synchrony. METHODS A cardiac resynchronization index (CRI) was measured at multiple device settings in 90 patients. Electrical dyssynchrony maps (EDM) were constructed for each patient to display CRI at any combination of AVD and VVD. An optimal synchrony line (OSL) depicted the AVD/VVD combinations producing the highest CRIs. Fusion of right ventricular paced (RVp), left ventricular paced (LVp), and native wavefront offsets were calculated. RESULTS CRI significantly increased (p < 0.0001) from 58.0 ± 28.1% at baseline to 98.3 ± 1.7% at optimized settings. EDMs in patients with high-grade heart block (n = 20) had an OSL parallel to the simultaneous biventricular pacing (BiVPVV-SIM) line with leftward shift across all AVDs (RVp-LVpOFFSET = 50.5 ± 29.8 ms). EDMs in patients with intact AV node conduction (n = 64) had an OSL parallel to the BiVPVV-SIM line with leftward shift at short AVDs (RVp-LVpOFFSET = 33.4 ± 23.3 ms), curvilinear at intermediate AVDs (triple fusion), and vertical at long AVDs (native-LVpOFFSET = 85.2 ± 22.8 ms) in all patients except those with poor LV lead position (n = 6). CONCLUSION A new methodology is described for quantifying and graphing electrical dyssynchrony over a physiologic range of AVDs/VVDs. This methodology offers a noninvasive, practical, clinical approach for measuring electrical synchrony that could be applied to optimization of CRT devices.
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Affiliation(s)
- Alan J Bank
- Minneapolis Heart Institute East, Allina Health, St. Paul, MN, USA; Cardiology Division, Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Heart Rhythm Science Center, Minneapolis Heart Institute Foundation, Minneapolis, MN, USA.
| | | | - Kevin V Burns
- Minneapolis Heart Institute East, Allina Health, St. Paul, MN, USA
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Vergara C, Stella S, Maines M, Africa PC, Catanzariti D, Demattè C, Centonze M, Nobile F, Quarteroni A, Del Greco M. Computational electrophysiology of the coronary sinus branches based on electro-anatomical mapping for the prediction of the latest activated region. Med Biol Eng Comput 2022; 60:2307-2319. [PMID: 35729476 PMCID: PMC9293833 DOI: 10.1007/s11517-022-02610-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 06/07/2022] [Indexed: 01/18/2023]
Abstract
This work dealt with the assessment of a computational tool to estimate the electrical activation in the left ventricle focusing on the latest electrically activated segment (LEAS) in patients with left bundle branch block and possible myocardial fibrosis. We considered the Eikonal-diffusion equation and to recover the electrical activation maps in the myocardium. The model was calibrated by using activation times acquired in the coronary sinus (CS) branches or in the CS solely with an electroanatomic mapping system (EAMS) during cardiac resynchronization therapy (CRT). We applied our computational tool to ten patients founding an excellent accordance with EAMS measures; in particular, the error for LEAS location was less than 4 mm. We also calibrated our model using only information in the CS, still obtaining an excellent agreement with the measured LEAS. The proposed tool was able to accurately reproduce the electrical activation maps and in particular LEAS location in the CS branches, with an almost real-time computational effort, regardless of the presence of myocardial fibrosis, even when information only at CS was used to calibrate the model. This could be useful in the clinical practice since LEAS is often used as a target site for the left lead placement during CRT.
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Affiliation(s)
- Christian Vergara
- LABS, Dipartimento Di Chimica, Materiali E Ingegneria Chimica “Giulio Natta”, Politecnico Di Milano, Piazza Leonardo da Vinci 32, 20233 Milan, Italy
| | - Simone Stella
- Dipartimento Di Matematica, MOX, Politecnico Di Milano, Piazza Leonardo da Vinci 32, 20233 Milan, Italy
| | - Massimiliano Maines
- Department of Cardiology, S. Maria del Carmine Hospital, corso Verona 4, 38068 Rovereto, TN Italy
| | - Pasquale Claudio Africa
- Dipartimento Di Matematica, MOX, Politecnico Di Milano, Piazza Leonardo da Vinci 32, 20233 Milan, Italy
| | - Domenico Catanzariti
- Department of Cardiology, S. Maria del Carmine Hospital, corso Verona 4, 38068 Rovereto, TN Italy
| | - Cristina Demattè
- Department of Cardiology, S. Maria del Carmine Hospital, corso Verona 4, 38068 Rovereto, TN Italy
| | - Maurizio Centonze
- U.O. Di Radiologia Di Borgo-Pergine, Borgo Valsugana Hospital, viale Vicenza 9, 38051 Borgo Valsugana, (TN) Italy
| | - Fabio Nobile
- Institute of Mathematics, CSQI, École Polytechnique Fédérale de Lausanne, Route Cantonale, 1015 Lausanne, Switzerland
| | - Alfio Quarteroni
- Dipartimento Di Matematica, MOX, Politecnico Di Milano, Piazza Leonardo da Vinci 32, 20233 Milan, Italy
- Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Maurizio Del Greco
- Department of Cardiology, S. Maria del Carmine Hospital, corso Verona 4, 38068 Rovereto, TN Italy
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Borgquist R, Barrington WR, Bakos Z, Werther-Evaldsson A, Saba S. Targeting the latest site of left ventricular mechanical activation is associated with improved long-term outcomes for recipients of Cardiac Resynchronization Therapy. Heart Rhythm O2 2022; 3:377-384. [PMID: 36097466 PMCID: PMC9463689 DOI: 10.1016/j.hroo.2022.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Previous studies have suggested that targeting the site of latest mechanical activation of the left ventricle (LV) results in improved cardiac resynchronization therapy (CRT) outcomes. It is not known whether these benefits are sustained over medium-term follow-up. Objective To assess the clinical outcome of imaging-guided LV lead position. Methods We sought to assess the medium-term clinical outcome by performing a patient-level meta-analysis of 2 previously published randomized controlled trials (the “STARTER” trial and the “CRT Clinic” trial). These 2 trials compared imaging-guided LV lead placement in the latest activated scar-free segment (intervention group) to standard of care (control). Mortality and heart failure hospitalization outcomes over extended follow-up were gathered from the medical records and merged. Results were stratified for native electrocardiogram (ECG) morphology. Results A total of 289 patients were followed for a median of 6.3 years. Seven years post implant, 47 (28%) in the intervention group had died, vs 47 (38%) in the control group (P = .13); 49 (30%) vs 53 (42%) had been hospitalized for heart failure (P = .035); and 47% vs 59% (P = .057) had reached the combined endpoint. In Kaplan-Meier analysis, patients in the intervention group had better survival free of heart failure hospitalization (P = .045) and lower risk of heart failure hospitalization (P = .019). Conclusion Targeting the latest mechanically activated segment in CRT results in better medium-term clinical outcome, mainly driven by a reduced risk of hospitalization for heart failure. The effect was seen regardless of native ECG morphology.
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Affiliation(s)
- Rasmus Borgquist
- Arrhythmia Section, Department of Cardiology, Lund University, Skane University Hospital, Lund, Sweden
- Address reprint requests and correspondence: Dr Rasmus Borgquist, Arrhythmia Section, Skane University Hospital, 221 85, Lund, Sweden.
| | - William R. Barrington
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Zoltan Bakos
- Department of Cardiology, Kristianstad Hospital, Kristianstad, Sweden
| | - Anna Werther-Evaldsson
- Heart Failure and Transplant Section, Department of Cardiology, Lund University, Skane University Hospital, Lund, Sweden
| | - Samir Saba
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Abu-Alrub S, Strik M, Huntjens P, Ramirez FD, Potse M, Cochet H, Marchand H, Buliard S, Eschalier R, Haïssaguerre M, Bordachar P, Ploux S. Left-axis deviation in patients with nonischemic heart failure and left bundle branch block is a purely electrical phenomenon. Heart Rhythm 2021; 18:1352-1360. [PMID: 33831543 DOI: 10.1016/j.hrthm.2021.03.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/19/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Possible mechanisms of left-axis deviation (LAD) in the setting of left bundle branch block (LBBB) include differences in cardiac electrophysiology, structure, or anatomic axis. OBJECTIVE The purpose of this study was to clarify the mechanism(s) responsible for LAD in patients with LBBB. METHODS Twenty-nine patients with nonischemic cardiomyopathies and LBBB underwent noninvasive electrocardiographic imaging (ECGi), cardiac computed tomography, and magnetic resonance imaging in order to define ventricular electrical activation, characterize cardiac structure, and determine the cardiac anatomic axis. RESULTS Sixteen patients had a normal QRS axis (NA) (mean axis 8° ± 23°), whereas 13 patients had LAD (mean axis -48° ± 13°; P <.001). Total activation times were longer in the LAD group (112 ± 25 ms vs 91 ± 14 ms; P = .01) due to delayed activation of the basal anterolateral region (107 ± 10 ms vs 81 ± 17 ms; P <.001). Left ventricular (LV) activation in patients with LAD was from apex to base, in contrast to a circumferential pattern of activation in patients with NA. Apex-to-base delay was longer in the LA group (95 ± 13 ms vs 64 ± 21 ms; P <.001) and correlated with QRS frontal axis (R2 = 0.67; P <.001). Both groups were comparable with regard to LV end-diastolic volume (295 ± 84 mL vs LAD 310 ± 91 mL; P = .69), LV mass (177 ± 33 g vs LAD 180 ± 37 g; P = .83), and anatomic axis. CONCLUSION LAD in LBBB appears to be due to electrophysiological abnormalities rather than structural factors or cardiac anatomic axis.
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Affiliation(s)
- Saer Abu-Alrub
- Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France; Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France.
| | - Marc Strik
- Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France
| | - Peter Huntjens
- Division of Cardiology, Washington University, St. Louis, Missouri
| | - F Daniel Ramirez
- Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France
| | - Mark Potse
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France
| | - Hubert Cochet
- Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France
| | - Hugo Marchand
- Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Samuel Buliard
- Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France
| | - Romain Eschalier
- Cardiology Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Michel Haïssaguerre
- Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France
| | - Pierre Bordachar
- Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France
| | - Sylvain Ploux
- Cardio-Thoracic Unit, Bordeaux University Hospital (CHU), Pessac-Bordeaux, France; IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France
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Shatla IM, Sammour Y, El Iskandarani M, López-Candales A. Fragmentation of Ventricular Extrasystoles: A Potential New Electrocardiographic Window to Uncover Patients at Risk. Cureus 2021; 13:e13748. [PMID: 33842125 PMCID: PMC8022737 DOI: 10.7759/cureus.13748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Fragmented QRS (fQRS) is a marker of conduction block due to myocardial scar that presents in electrocardiography (ECG) as an additional one or more R wave (R’) or notching in the S wave nadir in contiguous leads. However, fQRS description on premature ventricular contractions (PVCs) has not been previously described. We describe a case of a 67-year-old male with a past medical history of prediabetes, hypertension and coronary artery disease who presented after an ophthalmic procedure with asymptomatic PVCs and episodes of bigeminy. Initial ECG showed an isolated fQRS in V2. However, during PVCs significant extrasystoles fragmentation was seen in other coronary territories. Upon reviewing his most recent cardiac catheterization, it showed a 40% ostial and 70% distal left anterior descending stenosis with a mid-segment patent stent, 95% first diagonal stenosis and totally occluded proximal right coronary artery. Identification of diffuse fQRS known to be associated with myocardial scar, sustained arrhythmic events and sudden cardiac death, particularly when seen in the inferior leads, became extremely relevant in our patient. We noted that ejection fraction reduction from 52% to 34% on his last coronary intervention was crucial to decide if an implantable cardioverter-defibrillator would be needed. PVC fragmentation might be a new ECG marker that could uncover both scar and arrhythmia potential in patients at risk of adverse cardiac events.
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Affiliation(s)
- Islam M Shatla
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
| | - Yasser Sammour
- Internal Medicine, University of Missouri Kansas City School of Medicine, Kansas City, USA
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Dural M, van Stipdonk AMW, Salden FCWM, Ter Horst I, Crijns HJGM, Meine M, Maass AH, Kloosterman M, Vernooy K. Association of ECG characteristics with clinical and echocardiographic outcome to CRT in a non-LBBB patient population. J Interv Card Electrophysiol 2020; 62:9-19. [PMID: 32918666 DOI: 10.1007/s10840-020-00866-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/04/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE Effectiveness of cardiac resynchronization therapy (CRT) in patients without left bundle branch block (non-LBBB) QRS morphology is limited. Additional selection criteria are needed to identify these patients. METHODS Seven hundred ninety consecutive patients with non-LBBB morphology, who received a CRT-device in 3 university centers in the Netherlands, were selected. Pre-implantation 12-lead ECGs were evaluated on morphology, duration, and area of the QRS complex, as well as on PR interval, left ventricular activation time (LVAT), and the presence of fragmented QRS (fQRS). Association of these ECG features with the primary endpoint: a combination of left ventricular assist device (LVAD) implantation, cardiac transplantation and all-cause mortality, and secondary endpoint-echocardiographic reduction of left ventricular end-systolic volume (LVESV)-were evaluated. RESULTS The primary endpoint occurred more often in non-LBBB patients with with PR interval ≥ 230ms, QRS area < 109μVs, and with fQRS. Multivariable regression analysis showed independent associations of QRS area (HR 2.33 [1.44, 3.77], p = 0.001) and PR interval (HR 2.03 [1.51, 2.74], p < 0.001) only. Mean LVESV reduction was significantly lower in patients with baseline RBBB, QRS duration < 150 ms, PR interval ≥ 230 ms, and in QRS area < 109 μVs. Multivariable regression analyses only showed significant associations between QRS area ≥ 109 μVs (OR 2.00 [1.09, 3.66] p = 0.025) and probability of echocardiographic response to CRT. CONCLUSIONS In the heterogeneous non-LBBB patient population, QRS area and PR prolongation rather than traditional QRS duration and morphology are associated to both clinical and echocardiographic outcomes of CRT.
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Affiliation(s)
- Muhammet Dural
- Department of Cardiology, Eskişehir Osmangazi University Faculty of Medicine, 26040, Odunpazarı, Eskişehir, Turkey.
| | - Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Floor C W M Salden
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Iris Ter Horst
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Alexander H Maass
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Mariëlle Kloosterman
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht, the Netherlands.,Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
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11
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Kronborg MB, Stephansen C, Kristensen J, Gerdes C, Nielsen JC. Reproducibility and repeatability of identifying the latest electrical activation during mapping of coronary sinus branches in CRT recipients. J Cardiovasc Electrophysiol 2020; 31:2940-2947. [PMID: 32852869 DOI: 10.1111/jce.14729] [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] [Received: 06/16/2020] [Revised: 08/11/2020] [Accepted: 08/19/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Studies have shown an association between the outcome in cardiac resynchronization therapy (CRT) and longer interventricular delay at the site of the left ventricular (LV) lead. Targeted LV lead placement at the latest electrically activated segment increases LV function further as compared with standard treatment. We aimed to determine reproducibility and repeatability of identifying the latest electrically activated segment during mapping of all available coronary sinus (CS) branches in patients receiving CRT. METHODS We included 35 patients who underwent CRT implantation with protocolled mapping guided LV lead implantation aiming for the site of the latest electrical activation. Three different doctors experienced in electrophysiology and implantation of CRT devices independently measured time interval from the local bipolar right ventricular (RV) electrogram (EGM) to the local unipolar LV EGM at all mapped sites (RV-LV). The segment with the latest electrical activation was defined as the target segment (TS) and the CS tributary containing TS was defined as the target vein (TV). Weighted κ statistics with 95% confidence intervals were computed to assess intra- and interobserver agreement for TS and TV. RESULTS We mapped 258 segments within 131 veins. Weighted κ values for repeatability were 0.85 (0.81-0.89) for TS and 0.92 (0.89-0.93) for TV, and weighted κ values of interobserver agreement ranged from 0.70 (0.61-0.73) to 0.80 (0.76-0.83) for TS and 0.73 (0.64-0.78) to 0.86 (0.83-0.89) for TV among all three observers. CONCLUSION The reproducibility and repeatability of identifying the latest electrically activated segment during mapping of all available CS branches in patients receiving CRT range from good to very good.
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Affiliation(s)
- Mads B Kronborg
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Jens Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Gerdes
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens C Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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12
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Strocchi M, Augustin CM, Gsell MAF, Karabelas E, Neic A, Gillette K, Razeghi O, Prassl AJ, Vigmond EJ, Behar JM, Gould J, Sidhu B, Rinaldi CA, Bishop MJ, Plank G, Niederer SA. A publicly available virtual cohort of four-chamber heart meshes for cardiac electro-mechanics simulations. PLoS One 2020; 15:e0235145. [PMID: 32589679 PMCID: PMC7319311 DOI: 10.1371/journal.pone.0235145] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/09/2020] [Indexed: 12/12/2022] Open
Abstract
Computational models of the heart are increasingly being used in the development of devices, patient diagnosis and therapy guidance. While software techniques have been developed for simulating single hearts, there remain significant challenges in simulating cohorts of virtual hearts from multiple patients. To facilitate the development of new simulation and model analysis techniques by groups without direct access to medical data, image analysis techniques and meshing tools, we have created the first publicly available virtual cohort of twenty-four four-chamber hearts. Our cohort was built from heart failure patients, age 67±14 years. We segmented four-chamber heart geometries from end-diastolic (ED) CT images and generated linear tetrahedral meshes with an average edge length of 1.1±0.2mm. Ventricular fibres were added in the ventricles with a rule-based method with an orientation of -60° and 80° at the epicardium and endocardium, respectively. We additionally refined the meshes to an average edge length of 0.39±0.10mm to show that all given meshes can be resampled to achieve an arbitrary desired resolution. We ran simulations for ventricular electrical activation and free mechanical contraction on all 1.1mm-resolution meshes to ensure that our meshes are suitable for electro-mechanical simulations. Simulations for electrical activation resulted in a total activation time of 149±16ms. Free mechanical contractions gave an average left ventricular (LV) and right ventricular (RV) ejection fraction (EF) of 35±1% and 30±2%, respectively, and a LV and RV stroke volume (SV) of 95±28mL and 65±11mL, respectively. By making the cohort publicly available, we hope to facilitate large cohort computational studies and to promote the development of cardiac computational electro-mechanics for clinical applications.
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Affiliation(s)
- Marina Strocchi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, City of London, United Kingdom
| | | | | | - Elias Karabelas
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, City of London, United Kingdom
| | | | - Karli Gillette
- Institute of Biophysics, Medical University of Graz, Graz, Steiermark, Austria
| | - Orod Razeghi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, City of London, United Kingdom
| | - Anton J. Prassl
- Institute of Biophysics, Medical University of Graz, Graz, Steiermark, Austria
| | - Edward J. Vigmond
- IHU Liryc, Electrophysiology and Heart Modeling Institute, fondation Bordeaux Université, F-33600 Pessac- Bordeaux, France
- University of Bordeaux, IMB, UMR 5251, F-33400 Talence, France
| | - Jonathan M. Behar
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, City of London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, City of London, United Kingdom
| | - Justin Gould
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, City of London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, City of London, United Kingdom
| | - Baldeep Sidhu
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, City of London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, City of London, United Kingdom
| | - Christopher A. Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, City of London, United Kingdom
- Guy’s and St Thomas’ NHS Foundation Trust, London, City of London, United Kingdom
| | - Martin J. Bishop
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, City of London, United Kingdom
| | - Gernot Plank
- Institute of Biophysics, Medical University of Graz, Graz, Steiermark, Austria
| | - Steven A. Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, City of London, United Kingdom
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13
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Chang S, He Y, Wang H, Guo F, Lv Q, Kang J, Bai R, Liu X, Du X, Ma C, Dong J. The Temporal Relation between Cardiomyopathy and LBBB and Response to Cardiac Resynchronization Therapy: Case Series and Literature Review. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2020. [DOI: 10.15212/cvia.2019.0560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Left bundle branch block (LBBB)-induced cardiomyopathy has been proposed, but the association between LBBB and cardiac resynchronization therapy (CRT) response remains unclear and practical criteria for selecting CRT candidates are needed.Methods: One hundred
and seventeen consecutive heart failure patients were reviewed, 24 of whom received CRT. Only two patients had a clear temporal relation between cardiomyopathy and LBBB.Results: Compared with the patient with “cardiomyopathy-induced LBBB,” the patient with “LBBB-induced
cardiomyopathy” had higher left ventricular (LV) wall thickness, higher LV wall thickening rate, higher peak circumferential strain, and longer peak circumferential strain delay. The LV deformation patterns in the two patients were obviously distinct on cardiovascular magnetic resonance
tissue tracking. During follow-up, the patient with LBBB-induced cardiomyopathy had a good response to CRT (LV ejection fraction 23 before CRT vs. 30% at 6 months vs. 29 at 12 months vs. 32% at 18 months; LV end-diastolic diameter 77 mm before CRT vs. 66 mm at 6 months vs. 62 mm at 12 months
vs. 63 mm at 18 months), and the other patient had no response to CRT (LV ejection fraction 29 before CRT vs. 29% at 6 months vs. 26 at 12 months vs. 22% at 24 months; LV end-diastolic diameter 85 mm before CRT vs. 88 mm at 6 months vs. 85 mm at 12 months vs. 84 mm at 24 months).Conclusion:
The temporal relation between cardiomyopathy and LBBB could be a determinant for CRT response. Cardiovascular magnetic resonance tissue tracking may be a useful tool to identify the chronological order and a principal consideration for selecting candidates for CRT. Larger prospective clinical
trials are needed to study the prevalence of, time course of, and risk factors for LBBB-induced cardiomyopathy.
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Affiliation(s)
- Sanshuai Chang
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Yi He
- Department of Radiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Hui Wang
- Department of Radiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Fei Guo
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Qiang Lv
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Junping Kang
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Rong Bai
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Xiaohui Liu
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Xin Du
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Changsheng Ma
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing AnZhen Hospital, Capital Medical University, National Clinical Research Centre for Cardiovascular Diseases, Beijing, China
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14
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Yamin M, Yuniadi Y, Alwi I, Setiati S, Munawar M. Endocardial biventricular pacing for chronic heart failure patients: Effect on transmural dispersion of repolarization. J Arrhythm 2019; 35:664-669. [PMID: 31410237 PMCID: PMC6686357 DOI: 10.1002/joa3.12205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 04/15/2019] [Accepted: 05/08/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIM Conventional epicardial cardiac resynchronization therapy (CRT) can cause fatal arrhythmia associated with increased transmural dispersion of repolarization (TDR). It is unknown whether endocardial biventricular pacing in various locations will decrease TDR and hence the occurrence of fatal arrhythmia. This study aimed to find out the most effective location of endocardial biventricular pacing resulting in the shortest homogenous TDR. METHODS A before-and-after study on adult chronic heart failure (CHF) patients undergoing endocardial biventricular pacing in several defined locations. The changes in TDR from baseline were compared among various pacing locations. RESULTS Fourteen subjects were included with age ranged 36-74 years old, of which 10 were males. Location revealed the highest post biventricular pacing TDR (113.4 (SD 13.8) ms) was the outlet septum of right ventricle in combination with lateral wall of left ventricle (RVOTseptum-LVlateral) while the lowest one (106.1 (SD 11.6) ms) was of the right ventricular apex and posterolateral left ventricle (RVapex-LVposterolateral). Two CRT locations resulted in the most homogenous TDR, that is the right ventricular apex - left ventricular lateral wall (RVapex-LVlateral, mean difference -9.43; 95% CI (-19.72;0.87) ms, P = 0.07) and right ventricular apex - left ventricle posterolateral wall (RVapex-LVposterolateral, mean difference -6.85; 95% CI (-13.93;0.22) ms, P = 0.056). CONCLUSION Endocardial biventricular pacing on right ventricular apex and left ventricular lateral/posterolateral walls results in the most homogenous TDR.
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Affiliation(s)
- Muhammad Yamin
- Department of Internal Medicine, Faculty of MedicineUniversitas Indonesia – Cipto Mangunkusumo HospitalJakartaIndonesia
| | - Yoga Yuniadi
- Department of CardiologyUniversitas IndonesiaJakartaIndonesia
| | - Idrus Alwi
- Department of Internal Medicine, Faculty of MedicineUniversitas Indonesia – Cipto Mangunkusumo HospitalJakartaIndonesia
| | - Siti Setiati
- Department of Internal Medicine, Faculty of MedicineUniversitas Indonesia – Cipto Mangunkusumo HospitalJakartaIndonesia
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15
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Celikyurt U, Açar B, Karauzum I, Karauzum K, Ural D, Agir A, Vural A. Shorter time to begin of QRS fragmentation predicts non-response to cardiac resynchronization therapy in non-ischemic heart failure patients. Rev Clin Esp 2019. [DOI: 10.1016/j.rceng.2019.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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16
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Celikyurt U, Açar B, Karauzum I, Karauzum K, Ural D, Agir A, Vural A. El inicio rápido de la fragmentación del QRS predice la no respuesta a la terapia de resincronización cardíaca en pacientes con insuficiencia cardíaca no isquémica. Rev Clin Esp 2019; 219:243-250. [DOI: 10.1016/j.rce.2018.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/24/2018] [Accepted: 11/26/2018] [Indexed: 11/30/2022]
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17
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Das A, Chatterjee S. Feasibility of RA-LV pacing in patients with symptomatic left bundle branch block: a pilot study. Heart Vessels 2019; 34:1552-1558. [PMID: 30963301 DOI: 10.1007/s00380-019-01390-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/22/2019] [Indexed: 11/29/2022]
Abstract
Several studies have reported the adverse effects of right ventricular apical pacing. Permanent His bundle pacing is proved to be the most physiological. But it can be technically difficult sometimes. One recent large multicenter randomized trial showed that pacing from left ventricular apex or mid-lateral wall has the greatest potential to prevent pacing-induced reduction of cardiac pump function (by maintaining left ventricular mechanical synchrony) and, therefore, can be considered as physiological site. In our study, we have wanted to see the outcome of left ventricular pacing through coronary sinus branch with active fixation bipolar lead as a routine pacing technique in patients with symptomatic left bundle branch block. In our study we have recruited 27 patients for left ventricular pacing through coronary sinus branch (as done in cardiac resynchronization therapy) with active fixation bipolar lead and 33 patients for right ventricular apical pacing (control) and compared left ventricular pacing with right ventricular apical pacing in patients with history of syncope with left bundle branch block in baseline electrocardiography who presented with atrio-ventricular block or prolonged HV interval (≥ 70 ms) on electrophysiology study in term of procedure and fluoroscopy time and short-term lead performance and left ventricular function. The results of our study showed that left ventricular pacing through a tributary of coronary sinus is associated with shortened QRS duration (21.10 ± 3.92 ms) and better LV function (higher left ventricular ejection fraction 64.00 ± 3.03 vs. 59.73 ± 6.73 and lower left ventricular diastolic internal diameter 4.58 ± 0.32 vs. 5.23 ± 0.40 cm) in comparison to right ventricular apical pacing. However, the total procedure time and fluoroscopy time was significantly higher (73.75 ± 11.02 vs. 63.32 ± 6.06 min and 7.08 ± 1.48 vs. 5.02 ± 1.39 min, respectively) in left ventricular pacing group. The results of this study indicate that transvenous left ventricular epicardial pacing may be an option for physiological pacing in patients with symptomatic left bundle branch block.
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Affiliation(s)
- Asit Das
- Department of Cardiology, IPGME&R and SSKM Hospital, Flat-B1, GB-43, Narayantala (west), DB Nagar, Kolkata, West Bengal, 700059, India.
| | - Suman Chatterjee
- Department of Cardiology, IPGME&R and SSKM Hospital, Flat-B1, GB-43, Narayantala (west), DB Nagar, Kolkata, West Bengal, 700059, India
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18
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MacIver DH, Partridge JB, Agger P, Stephenson RS, Boukens BJD, Omann C, Jarvis JC, Zhang H. The end of the unique myocardial band: Part II. Clinical and functional considerations. Eur J Cardiothorac Surg 2018; 53:120-128. [PMID: 29029119 DOI: 10.1093/ejcts/ezx335] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/20/2017] [Indexed: 12/25/2022] Open
Abstract
Two of the leading concepts of mural ventricular architecture are the unique myocardial band and the myocardial mesh model. We have described, in an accompanying article published in this journal, how the anatomical, histological and high-resolution computed tomographic studies strongly favour the latter concept. We now extend the argument to describe the linkage between mural architecture and ventricular function in both health and disease. We show that clinical imaging by echocardiography and magnetic resonance imaging, and electrophysiological studies, all support the myocardial mesh model. We also provide evidence that the unique myocardial band model is not compatible with much of scientific research.
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Affiliation(s)
- David H MacIver
- Department of Cardiology, Taunton and Somerset Hospital, Musgrove Park, Taunton, UK.,Medical Education, University of Bristol, Senate House, Bristol, UK.,Biological Physics Group, School of Physics and Astronomy, University of Manchester, Manchester, UK
| | - John B Partridge
- Eurobodalla Unit, Rural Clinical School of the ANU College of Medicine, Biology & Environment, Batemans Bay, NSW, Australia
| | - Peter Agger
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark.,Comparative Medicine Lab, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Robert S Stephenson
- Comparative Medicine Lab, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bastiaan J D Boukens
- Department of Medical Biology, Academic Medical Centre, Amsterdam University, Amsterdam, Netherlands
| | - Camilla Omann
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jonathan C Jarvis
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Henggui Zhang
- Biological Physics Group, School of Physics and Astronomy, University of Manchester, Manchester, UK
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19
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Wang Y, Li G, Ma C, Guan Z, Jin X, Li Y, Liu S, Yang J. Predictive Value of Septal Flash for Reduction of Left Ventricular Systolic Function as Reflected by Global Longitudinal Strain Using Echocardiography in Patients With Isolated Complete Left Bundle-Branch Block. Circ J 2018; 82:2111-2118. [PMID: 29925741 DOI: 10.1253/circj.cj-17-1422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Septal leftward motion followed by a counter motion during early systole is known as septal flash (SF) in patients with isolated complete left bundle-branch block (cLBBB). This study aimed to determine the predictive value of SF for reduction of left ventricular (LV) global systolic function using 2D speckle-tracking echocardiography (2D STE) in cLBBB patients.Methods and Results:The study group of 41 patients with isolated cLBBB and preserved LV ejection fraction and 41 age- and sex-matched control subjects were studied. The presence of SF and LV global longitudinal strain (GLS) were defined and measured using 2D STE. Multivariate logistic regression analysis identified the presence of SF as an independent factor predicting LV GLS >-20% in isolated cLBBB patients (odds ratio, 1.38; 95% confidence interval, 1.10-1.72; P=0.005). LV GLS in cLBBB patients with SF further decreased over time, whereas LV GLS did not decrease in patients without SF. The presence of SF was shown to be an independent factor predicting the reduction of LV global systolic function (relative reduction in LV GLS >15% from baseline to 2-year follow-up) (odds ratio, 1.27; 95% confidence interval, 1.06-1.50; P=0.008). CONCLUSIONS Assessment of SF by 2D STE may be an easy and effective method of predicting the reduction in LV global systolic function in isolated cLBBB patients.
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Affiliation(s)
- Yonghuai Wang
- Department of Cardiovascular Ultrasound, First Hospital of China Medical University
| | - Guangyuan Li
- Department of Cardiovascular Ultrasound, First Hospital of China Medical University
| | - Chunyan Ma
- Department of Cardiovascular Ultrasound, First Hospital of China Medical University
| | - Zhengyu Guan
- Department of Cardiovascular Ultrasound, First Hospital of China Medical University
| | | | - Yang Li
- Department of Cardiovascular Ultrasound, First Hospital of China Medical University
| | - Shuang Liu
- Department of Cardiovascular Ultrasound, First Hospital of China Medical University
| | - Jun Yang
- Department of Cardiovascular Ultrasound, First Hospital of China Medical University
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20
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Saporito S, Houthuizen P, Aben JPMM, Westenberg JJM, van Den Bosch HCM, van Assen HC, Mischi M. Endocardial center motion for quantification of left ventricular discoordination in heart failure using cine MRI. Physiol Meas 2018; 39:025009. [PMID: 29369050 DOI: 10.1088/1361-6579/aaaaa0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare a novel cardiovascular magnetic resonance technique for the assessment of left ventricular (LV) mechanical discoordination by characterizing the endocardial center motion (ECM) in short-axis cine MRI in healthy volunteers and heart failure patients with left bundle branch block (HF-LBBB). APPROACH To evaluate ECM analysis as mechanical discoordination measure, we retrospectively compared spatial and temporal features of the ECM between a group of healthy volunteers (n = 14) and conduction defect patients (HF-LBBB, n = 31). We tracked the center of the endocardial borders on short-axis view MRI cine loops during the cardiac cycle. From the ECM trajectory we calculated the overall traveled distance, the enclosed area, the eccentricity of the trajectory, and the maximum traveled distance. The ECM can be visualized in spatial coordinates as well as by its temporal behavior. We evaluated the classification performance of these measures for LBBB detection. We also quantified the coherence of the ECM on the longitudinal direction by considering the variability of the ECM measures between different short-axis slices. MAIN RESULTS Patients with LBBB showed significantly higher traveled distance (p < 0.0001), enclosed area (p < 0.002), eccentricity (p < 0.02), and peak displacement (p < 0.02) of the endocardial center. Patients with positive late gadolinium enhancement showed a higher variability of ECM measures across different slices (p < 0.05). SIGNIFICANCE ECM analysis is feasible and it allows the assessment of left ventricular mechanical discoordination. Differences in ECM measures permit one to distinguish between LBBB and healthy volunteers.
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Affiliation(s)
- Salvatore Saporito
- Department of Electrical Engineering, Eindhoven University of Technology, Den Dolech 2, 5612 AZ Eindhoven, Netherlands
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21
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Zhao L, Zhao L, Pu L, Hua B, Wang Y, Li S, Li Q, Guo T. Left Univentricular Pacing by Rate-Adaptive Atrioventricular Delay in Treatment of Chronic Heart Failure. Med Sci Monit 2017; 23:3971-3980. [PMID: 28814710 PMCID: PMC5572785 DOI: 10.12659/msm.904348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is efficacious in the treatment of chronic heart failure (CHF); however, because it is non-physiological, some patients are unresponsive. The present study used rate-adaptive atrioventricular delay (RAAVD) to track the physiological atrioventricular delay and investigated the effects of left univentricular pacing on CRT. Material/Methods Patients with CHF fulfilling the indication of CRT Class I were categorized into a left univentricular pacing by RAAVD group and a standard biventricular pacing group. Preoperative and postoperative electrocardiography QRS duration, echocardiographic indicators, quality of life, cardiac function, and annual treatment cost were estimated. The standard deviation (RS/R-SD5) of the S/R ratio in lead V1 at 5 heart rate segments in the left univentricular pacing by RAAVD was calculated, and the accuracy of RAAVD in tracking the physiological AV delay was evaluated. Results The comparison between the left univentricular pacing by RAAVD group and the standard biventricular pacing group after operation showed a significantly reduced QRS duration (137±11 vs. 144±11 ms, P<0.05), increased AVVTI (21.84±2.25 vs. 20.45±2.12 cm, P<0.05), reduced IVMD (64.27±12.29 vs. 71.39±13.64 ms, P<0.05), decreased MRA (3.09±1.12 vs. 3.73±1.19 cm2, P<0.05), and reduced average annual treatment cost (1.30±0.1 vs. 2.20±0.2 million Yuan, P<0.05). The RS/R-SD5 in the left univentricular pacing by RAAVD group was negatively correlated with improvements in cardiac function (r=−0.394, P=0.031). Conclusions Left univentricular pacing by RAAVD has treatment effects similar to those of standard biventricular pacing, and is an economically and physiologically effective method for biventricular systolic resynchronization in the treatment of CHF.
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Affiliation(s)
- Lulu Zhao
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Ling Zhao
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Lijin Pu
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Baotong Hua
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Yu Wang
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Shumin Li
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Qing Li
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
| | - Tao Guo
- Department of Cardiology, The First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China (mainland)
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Effect of septal flash on right ventricular systolic function in left bundle-branch block patients with preserved left ventricular ejection fraction. Sci Rep 2017; 7:5936. [PMID: 28724945 PMCID: PMC5517639 DOI: 10.1038/s41598-017-06362-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 06/05/2017] [Indexed: 11/24/2022] Open
Abstract
A leftward motion of the ventricular septum prior to ejection, known as the septal flash (SF), is frequently observed in patients with left bundle-branch block (LBBB). We investigated whether the abnormal motion of the ventricular septum affects right ventricle (RV) contractile performance in LBBB patients with preserved left ventricular ejection fraction (LVEF). Forty-four patients with complete LBBB were selected using standard 12-lead electrocardiograms (ECGs), with 30 healthy individuals serving as controls. According to the presence of SF, patients with LBBB were allocated to two subgroups: those with SF (LBBB-SF, n = 24) and those without SF (LBBB-NSF, n = 20). RV longitudinal strain (LS) decreased in LBBB patients with preserved LVEF compared to control subjects (p = 0.002). And RV LS decreased significantly in LBBB-SF patients compared to NSF-LBBB patients (p = 0.04). RV LS correlated negatively with involved septal myocardial segments of SF (r = −0.36, p = 0.02), but did not correlate with the magnitude of SF. RV contractile performance deceased in LBBB patients with preserved LVEF. SF, particularly the extent of this phenomenon, may further affect RV contractile performance.
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Left univentricular pacing for cardiac resynchronization therapy using rate-adaptive atrioventricular delay. J Geriatr Cardiol 2017; 14:118-126. [PMID: 28491086 PMCID: PMC5409353 DOI: 10.11909/j.issn.1671-5411.2017.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate left univentricular (LUV) pacing for cardiac resynchronization therapy (CRT) using a rate-adaptive atrioventricular delay (RAAVD) algorithm to track physiological atrioventricular delay (AVD). METHODS A total of 72 patients with congestive heart failure (CHF) were randomized to RAAVD LUV pacing versus standard biventricular (BiV) pacing in a 1: 1 ratio. Echocardiography was used to optimize AVD for both groups. The effects of sequential BiV pacing and LUV pacing with optimized A-V (right atrio-LV) delay using an RAAVD algorithm were compared. The standard deviation (SD) of the S/R ratio in lead V1 at five heart rate (HR) segments (RS/R-SD5), defined as the "tracking index," was used to evaluate the accuracy of the RAAVD algorithm for tracking physiological AVD. RESULTS The QRS complex duration (132 ± 9.8 vs. 138 ± 10 ms, P < 0.05), the time required for optimization (21 ± 5 vs. 50 ± 8 min, P < 0.001), the mitral regurgitant area (1.9 ± 1.1 vs. 2.5 ± 1.3 cm2, P < 0.05), the interventricular mechanical delay time (60.7 ± 13.3 ms vs. 68.3 ± 14.2 ms, P < 0.05), and the average annual cost (13,200 ± 1000 vs. 21,600 ± 2000 RMB, P < 0.001) in the RAAVD LUV pacing group were significantly less than those in the standard BiV pacing group. The aortic valve velocity-time integral in the RAAVD LUV pacing group was greater than that in the standard BiV pacing group (22.7 ± 2.2 vs. 21.4 ± 2.1 cm, P < 0.05). The RS/R-SD5 was 4.08 ± 1.91 in the RAAVD LUV pacing group, and was significantly negatively correlated with improved left ventricular ejection fraction (LVEF) (ΔLVEF, Pearson's r = -0.427, P = 0.009), and positively correlated with New York Heart Association class (Spearman's r = 0.348, P = 0.037). CONCLUSIONS RAAVD LUV pacing is as effective as standard BiV pacing, can be more physiological than standard BiV pacing, and can decrease the average annual cost of CRT.
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Left bundle-branch block contraction patterns identified from radial-strain analysis predicts outcomes following cardiac resynchronization therapy. Int J Cardiovasc Imaging 2017; 33:869-877. [PMID: 28150083 DOI: 10.1007/s10554-017-1083-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 01/24/2017] [Indexed: 10/20/2022]
Abstract
A left bundle-branch block (LBBB) contraction pattern identified from longitudinal-strain analysis predicts outcomes following cardiac resynchronization therapy (CRT). We investigated the use of an LBBB-contraction pattern identified from radial- or circumferential-strain analysis in the prediction of CRT benefits. Eighty CRT candidates were prospectively enrolled. Before CRT implantation, speckle-tracking analyses in three deformation directions were performed to determine whether an LBBB-contraction pattern was present. The study endpoints were reverse remodeling at 6 months, and adverse outcomes including death or heart failure hospitalization. At 6 months, 49 (61%) patients had reverse remodeling. An LBBB-contraction pattern identified from the radial strain in the mid-ventricular short-axis view or longitudinal strain in the four-chamber view provided excellent true-positive (86%) and false-negative (8%) rates for predicting reverse remodeling. During a median follow-up of 30 months, 31 patients (39%) had adverse outcomes. Absence of an LBBB-contraction pattern in radial (hazard ratio 3.74; 95% confidence interval 1.83-7.62) or longitudinal strain (hazard ratio 3.49; 95% confidence interval 1.71-7.13) was significantly associated with an increased risk of adverse outcomes. Adding the LBBB-pattern assessment by radial-(model χ2 from 8.2 to 18.5, p = 0.005), or longitudinal-strain analysis (model χ2 from 8.2 to 16.9, p = 0.011) to a risk model significantly improved the model, including QRS duration and ischemic etiology. In conclusion, an LBBB-contraction pattern identified from radial-strain analysis in the mid-ventricular short-axis view predicted reverse remodeling and outcome following CRT, similarly to the longitudinal-strain analysis.
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Friedberg MK, Schwartz SM, Zhang H, Chiu-Man C, Manlhiot C, Ilina MV, Arsdell GV, Kirsh JA, McCrindle BW, Stephenson EA. Hemodynamic effects of sustained postoperative cardiac resynchronization therapy in infants after repair of congenital heart disease: Results of a randomized clinical trial. Heart Rhythm 2017; 14:240-247. [DOI: 10.1016/j.hrthm.2016.09.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Indexed: 10/20/2022]
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26
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Auger DA, Bilchick KC, Gonzalez JA, Cui SX, Holmes JW, Kramer CM, Salerno M, Epstein FH. Imaging left-ventricular mechanical activation in heart failure patients using cine DENSE MRI: Validation and implications for cardiac resynchronization therapy. J Magn Reson Imaging 2017; 46:887-896. [PMID: 28067978 DOI: 10.1002/jmri.25613] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 12/09/2016] [Accepted: 12/10/2016] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To image late mechanical activation and identify effective left-ventricular (LV) pacing sites for cardiac resynchronization therapy (CRT). There is variability in defining mechanical activation time, with some studies using the time to peak strain (TPS) and some using the time to the onset of circumferential shortening (TOS). We developed improved methods for imaging mechanical activation and evaluated them in heart failure (HF) patients undergoing CRT. MATERIALS AND METHODS We applied active contours to cine displacement encoding with stimulated echoes (DENSE) strain images to detect TOS. Six healthy volunteers underwent magnetic resonance imaging (MRI) at 1.5T, and 50 patients underwent pre-CRT MRI (strain, scar, volumes) and echocardiography, assessment of the electrical activation time (Q-LV) at the LV pacing site, and echocardiography assessment of LV reverse remodeling 6 months after CRT. TPS at the LV pacing site was also measured by DENSE. RESULTS The latest TOS was greater in HF patients vs. healthy subjects (112 ± 28 msec vs. 61 ± 7 msec, P < 0.01). The correlation between TOS and Q-LV was strong (r > 0.75; P < 0.001) and better than between TPS and Q-LV (r < 0.62; P ≥ 0.006). Twenty-three of 50 patients had the latest activating segment in a region other than the mid-ventricular lateral wall, the most common site for the CRT LV lead. Using a multivariable model, TOS/QRS was significantly associated with LV reverse remodeling even after adjustment for overall dyssynchrony and scar (P < 0.05), whereas TPS was not (P = 0.49). CONCLUSION Late activation by cine DENSE TOS analysis is associated with improved LV reverse remodeling with CRT and deserves further study as a tool to achieve optimal LV lead placement in CRT. LEVEL OF EVIDENCE 1 Technical Efficacy: Stage 1 J. MAGN. RESON. IMAGING 2017;46:887-896.
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Affiliation(s)
- Daniel A Auger
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Kenneth C Bilchick
- Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jorge A Gonzalez
- Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sophia X Cui
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jeffrey W Holmes
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA.,Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christopher M Kramer
- Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA.,Radiology/Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael Salerno
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA.,Medicine/Cardiology/Electrophysiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Frederick H Epstein
- Department of Biomedical Engineering, University of Virginia Health System, Charlottesville, Virginia, USA.,Radiology/Medical Imaging, University of Virginia Health System, Charlottesville, Virginia, USA
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Schreurs R, Wiegerinck RF, Prinzen FW. Exploring the Electrophysiologic and Hemodynamic Effects of Cardiac Resynchronization Therapy: From Bench to Bedside and Vice Versa. Heart Fail Clin 2016; 13:43-52. [PMID: 27886931 DOI: 10.1016/j.hfc.2016.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Cardiac resynchronization therapy (CRT) is an important therapy for heart failure patients with prolonged QRS duration. In patients with left bundle branch block the altered left ventricular electrical activation results in dyssynchronous, inefficient contraction of the left ventricle. CRT aims to reverse these changes and to improve cardiac function. This article explores the electrophysiologic and hemodynamic changes that occur during CRT in patient and animal studies. It also addresses how novel techniques, such as multipoint and endocardial pacing, can further improve the electromechanical response.
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Affiliation(s)
- Rick Schreurs
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Rob F Wiegerinck
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
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Corteville B, De Pooter J, De Backer T, El Haddad M, Stroobandt R, Timmermans F. The electrocardiographic characteristics of septal flash in patients with left bundle branch block. Europace 2016; 19:103-109. [PMID: 26843575 DOI: 10.1093/europace/euv461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 12/29/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS In patients with systolic heart failure and left bundle branch block (LBBB), septal flash (SF) movement has been described by echocardiography. We evaluated the prevalence of SF in LBBB and non-LBBB patients and evaluated whether specific electrocardiographic (ECG) characteristics within LBBB are associated with the presence of SF on echocardiography. METHODS AND RESULTS One hundred and four patients with probable LBBB on standard 12-lead ECG were selected, 40 patients with non-LBBB served as controls. Left bundle branch block and non-LBBB were defined, according to the most recent guidelines. The presence of SF was assessed by echocardiography. Strict LBBB criteria were met in 93.3% of the patients. Septal flash was present in 45.2% of LBBB patients and was not present in non-LBBB patients. This was more prevalent in patients without anterior ischaemic cardiomyopathy (ICMP) compared with those with anterior ICMP (P = 0.008). The duration of QRS was longer in SF patients compared with that of non-SF patients (P < 0.05). The presence of a mid-QRS notching in more than two consecutive leads was a good predictor for the presence of SF (P = 0.01), and when combined with an absent R-wave in lead V1, the presence of SF is very likely (P = 0.001). CONCLUSION Our data show that SF is present in 45.2% of LBBB patients, whereas it was absent in patients with non-LBBB. Patients with SF fulfilled more LBBB criteria compared with LBBB patients without SF. Our findings raise the provocative question of whether the presence of SF identifies patients with 'true LBBB' and whether this echocardiographic finding might be considered as a selection parameter in cardiac resynchronization therapy.
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Affiliation(s)
- Ben Corteville
- Ghent University Hospital, Heart Center, Department of Cardiology, 8K12 IE, De Pintelaan 185, Ghent 9000, Belgium
| | - Jan De Pooter
- Ghent University Hospital, Heart Center, Department of Cardiology, 8K12 IE, De Pintelaan 185, Ghent 9000, Belgium
| | - Tine De Backer
- Ghent University Hospital, Heart Center, Department of Cardiology, 8K12 IE, De Pintelaan 185, Ghent 9000, Belgium
| | - Milad El Haddad
- Ghent University Hospital, Heart Center, Department of Cardiology, 8K12 IE, De Pintelaan 185, Ghent 9000, Belgium
| | - Roland Stroobandt
- Ghent University Hospital, Heart Center, Department of Cardiology, 8K12 IE, De Pintelaan 185, Ghent 9000, Belgium
| | - Frank Timmermans
- Ghent University Hospital, Heart Center, Department of Cardiology, 8K12 IE, De Pintelaan 185, Ghent 9000, Belgium
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Schreurs R, Wiegerinck RF, Prinzen FW. Exploring the Electrophysiologic and Hemodynamic Effects of Cardiac Resynchronization Therapy: From Bench to Bedside and Vice Versa. Card Electrophysiol Clin 2015; 7:599-608. [PMID: 26596805 DOI: 10.1016/j.ccep.2015.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Cardiac resynchronization therapy (CRT) is an important therapy for heart failure patients with prolonged QRS duration. In patients with left bundle branch block the altered left ventricular electrical activation results in dyssynchronous, inefficient contraction of the left ventricle. CRT aims to reverse these changes and to improve cardiac function. This article explores the electrophysiologic and hemodynamic changes that occur during CRT in patient and animal studies. It also addresses how novel techniques, such as multipoint and endocardial pacing, can further improve the electromechanical response.
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Affiliation(s)
- Rick Schreurs
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Rob F Wiegerinck
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
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30
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Seo Y, Ishizu T, Kawamura R, Yamamoto M, Kuroki K, Igarashi M, Sekiguchi Y, Nogami A, Aonuma K. Three-Dimensional Propagation Imaging of Left Ventricular Activation by Speckle-Tracking Echocardiography to Predict Responses to Cardiac Resynchronization Therapy. J Am Soc Echocardiogr 2015; 28:606-14. [DOI: 10.1016/j.echo.2015.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Indexed: 11/30/2022]
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Bordachar P, Eschalier R, Lumens J, Ploux S. Optimal Strategies on Avoiding CRT Nonresponse. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:299. [PMID: 24633974 DOI: 10.1007/s11936-014-0299-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT The high rate of nonresponse to cardiac resynchronization therapy (CRT) has remained nearly unchanged since the treatment was introduced. We believe that this is directly related to the many persisting unknowns regarding the mechanical function of asynchronous hearts and the use of electrical stimulation to counteract the deleterious effects of that asynchrony. As a consequence, the key questions pertaining to the pre-implant, intra-implant, and postimplant phases remain unanswered or only partially answered. QRS duration is an imperfect selection criterion, as it does not discriminate the activation pattern. The inclusion of QRS morphology in the international professional practice guidelines is an important first step toward increasing the yield of this therapy. The invasive and the noninvasive electrical mapping techniques seem highly promising and need to be tested in large trials. The site of stimulation is a key element of the response to CRT; additional research must be pursued in this field.
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Sorgente A, Cappato R. A Critical Reappraisal of the Current Clinical Indications to Cardiac Resynchronisation Therapy. Arrhythm Electrophysiol Rev 2013; 2:91-4. [PMID: 26835046 DOI: 10.15420/aer.2013.2.2.91] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Cardiac resynchronisation therapy (CRT) is a well-established non-pharmacological treatment option for patients with refractory symptomatic heart failure (HF) already under optimal medical therapy. CRT is founded on the principle that interventricular conduction disturbances and more in particular left bundle branch block (LBBB) are deleterious to cardiac performance, and may contribute to the systolic and diastolic incompetency typical of patients with HF. Although CRT is associated with a not negligible percentage of non-response, all the international guidelines on chronic HF have extended their indications to CRT, also to patients with less symptomatic HF who are already showing signs of systolic dysfunction and interventricular dyssynchrony, without giving any substantial advice to reduce the number of failures of this therapy. This review seeks to point out the potential issues linked to CRT, with the aim of making a reappraisal of the clinical evidences supporting the current indications to CRT, and to figure out which type of research should be warranted in the field for the future to reduce the percentage of non-responders to this therapy.
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Affiliation(s)
- Antonio Sorgente
- Arrhythmia and Electrophysiology Department, Policlinico San Donato, Milan, Italy
| | - Riccardo Cappato
- Arrhythmia and Electrophysiology Department, Policlinico San Donato, Milan, Italy
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Strik M, van Middendorp LB, Houthuizen P, Ploux S, van Hunnik A, Kuiper M, Auricchio A, Prinzen FW. Interplay of electrical wavefronts as determinant of the response to cardiac resynchronization therapy in dyssynchronous canine hearts. Circ Arrhythm Electrophysiol 2013; 6:924-31. [PMID: 24047705 DOI: 10.1161/circep.113.000753] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The relative contribution of electromechanical synchronization and ventricular filling to the optimal hemodynamic effect in cardiac resynchronization therapy (CRT) during adjustment of stimulation-timings is incompletely understood. We investigated whether optimal hemodynamic effect in CRT requires collision of pacing-induced and intrinsic activation waves and optimal filling of the left ventricle (LV). METHODS AND RESULTS CRT was performed in dogs with chronic left bundle-branch block (n=8) or atrioventricular (AV) block (n=6) through atrial (A), right ventricular (RV) apex, and LV-basolateral pacing. A 100 randomized combinations of A-LV/A-RV intervals were tested. Total activation time (TAT) was calculated from >100 contact mapping electrodes. Mechanical interventricular dyssynchrony was determined as the time delay between upslopes of LV and RV pressure curves. Settings providing an increase in LVdP/dtmax (maximal rate of rise of left ventricular pressure) of ≥90% of the maximum LVdP/dtmax value were defined as optimal (CRTopt). Filling was assessed by changes in LV end-diastolic volume (EDV; conductance catheter technique). In all hearts, CRTopt was observed during multiple settings, providing an average LVdP/dtmax increase of ≈15%. In AV-block hearts, CRTopt exclusively depended on interventricular-interval and not on AV-interval. In left bundle-branch block hearts, CRTopt occurred at A-LV intervals that allowed fusion of LV-pacing-derived activation with right bundle-derived activation. In all animals, CRTopt occurred at settings resulting in the largest decrease in TAT and mechanical interventricular dyssynchrony, whereas LV EDV hardly changed. CONCLUSIONS In left bundle-branch block and AV-block hearts, optimal hemodynamic effect of CRT depends on optimal interplay between pacing-induced and intrinsic activation waves and the corresponding mechanical resynchronization rather than filling.
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Affiliation(s)
- Marc Strik
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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Strik M, van Deursen CJ, van Middendorp LB, van Hunnik A, Kuiper M, Auricchio A, Prinzen FW. Transseptal Conduction as an Important Determinant for Cardiac Resynchronization Therapy, as Revealed by Extensive Electrical Mapping in the Dyssynchronous Canine Heart. Circ Arrhythm Electrophysiol 2013; 6:682-9. [DOI: 10.1161/circep.111.000028] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marc Strik
- From the Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands (M.S., C.J.M.v.D., L.B.v.M., A.v.H., M.K., F.W.P.); and Department of Cardiology, Fondazione, Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Caroline J.M. van Deursen
- From the Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands (M.S., C.J.M.v.D., L.B.v.M., A.v.H., M.K., F.W.P.); and Department of Cardiology, Fondazione, Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Lars B. van Middendorp
- From the Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands (M.S., C.J.M.v.D., L.B.v.M., A.v.H., M.K., F.W.P.); and Department of Cardiology, Fondazione, Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Arne van Hunnik
- From the Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands (M.S., C.J.M.v.D., L.B.v.M., A.v.H., M.K., F.W.P.); and Department of Cardiology, Fondazione, Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Marion Kuiper
- From the Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands (M.S., C.J.M.v.D., L.B.v.M., A.v.H., M.K., F.W.P.); and Department of Cardiology, Fondazione, Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Angelo Auricchio
- From the Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands (M.S., C.J.M.v.D., L.B.v.M., A.v.H., M.K., F.W.P.); and Department of Cardiology, Fondazione, Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Frits W. Prinzen
- From the Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Limburg, The Netherlands (M.S., C.J.M.v.D., L.B.v.M., A.v.H., M.K., F.W.P.); and Department of Cardiology, Fondazione, Cardiocentro Ticino, Lugano, Switzerland (A.A.)
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Fadel BM, Al-Amro B, Al-Admawi M, Sergani H, Alsoufi B, Pergola V, Di Salvo G. A patient with recent chest discomfort-ischemia or no ischemia? Postsystolic shortening comes to the rescue. Echocardiography 2013; 30:E285-8. [PMID: 23822760 DOI: 10.1111/echo.12295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The diagnosis of myocardial ischemia in the emergency department can be challenging particularly in a patient in whom the chest discomfort has abated. Symptoms can be atypical, physical exam is often noncontributory, the electrocardiogram is usually nondiagnostic and cardiac enzymes remain normal. Thus, the decision for hospital admission or discharge can be quite difficult. Here, we describe such a patient in whom echocardiography with strain imaging identified the presence of postsystolic shortening (PSS) at the left ventricular apex. This suggested the likelihood of ischemic memory in the territory of the left anterior descending (LAD) artery. At coronary angiography a high grade stenosis was present in the proximal LAD artery. Our report highlights the role of echocardiography in the detection of myocardial ischemia and apical PSS as a marker of ischemic memory.
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Affiliation(s)
- Bahaa M Fadel
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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