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Noheria A, Shahab A, Andrews C, Cuculich PS, Rudy Y. Pilot study to evaluate left-to-right ventricular offset in biventricular pacing-comparison of electrocardiographic imaging and ECG. J Cardiovasc Electrophysiol 2024; 35:1185-1195. [PMID: 38591763 DOI: 10.1111/jce.16272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/14/2024] [Accepted: 03/23/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Biventricular pacing (BiVp) improves outcomes in systolic heart failure patients with electrical dyssynchrony. BiVp is delivered from epicardial left ventricular (LV) and endocardial right ventricular (RV) electrodes. Acute electrical activation changes with different LV-RV stimulation offsets can help guide individually optimized BiVp programming. We sought to study the BiVp ventricular activation with different LV-RV offsets and compare with 12-lead ECG. METHODS In five patients with BiVp (63 ± 17-year-old, 80% male, LV ejection fraction 27 ± 6%), we evaluated acute ventricular epicardial activation, varying LV-RV offsets in 20 ms increments from -40 to 80 ms, using electrocardiographic imaging (ECGI) to obtain absolute ventricular electrical uncoupling (VEUabs, absolute difference in average LV and average RV activation time) and total activation time (TAT). For each patient, we calculated the correlation between ECGI and corresponding ECG (3D-QRS-area and QRS duration) with different LV-RV offsets. RESULTS The LV-RV offset to attain minimum VEUabs in individual patients ranged 20-60 ms. In all patients, a larger LV-RV offset was required to achieve minimum VEUabs (36 ± 17 ms) or 3D-QRS-area (40 ± 14 ms) than that for minimum TAT (-4 ± 9 ms) or QRS duration (-8 ± 11 ms). In individual patients, 3D-QRS-area correlated with VEUabs (r 0.65 ± 0.24) and QRS duration correlated with TAT (r 0.95 ± 0.02). Minimum VEUabs and minimum 3D-QRS-area were obtained by LV-RV offset within 20 ms of each other in all five patients. CONCLUSIONS LV-RV electrical uncoupling, as assessed by ECGI, can be minimized by optimizing LV-RV stimulation offset. 3D-QRS-area is a surrogate to identify LV-RV offset that minimizes LV-RV uncoupling.
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Affiliation(s)
- Amit Noheria
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ahmed Shahab
- Department of Cardiovascular Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Christopher Andrews
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Phillip S Cuculich
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yoram Rudy
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, Missouri, USA
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Miyazaki Y, Ishibashi K, Ueda N, Oka S, Wakamiya A, Shimamoto K, Nakajima K, Kamakura T, Wada M, Inoue Y, Miyamoto K, Nagase S, Aiba T, Kusano K. Evaluation of synchronized left ventricular pacing rate over biventricular pacing in cardiac resynchronization therapy. J Cardiol 2024:S0914-5087(24)00080-7. [PMID: 38679318 DOI: 10.1016/j.jjcc.2024.04.007] [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: 01/09/2024] [Revised: 03/13/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND The adaptive cardiac resynchronization therapy (aCRT) algorithm enables synchronized left ventricular pacing (sLVP) to achieve fusion with intrinsic right ventricular activation. Although sLVP presents benefits over biventricular pacing, the adequate sLVP rate for better clinical outcomes remains unclear. We aimed to assess the association between sLVP rates and clinical outcomes. METHODS Our study cohort included 271 consecutive patients, who underwent CRT implantation between April 2016 and August 2021. RESULTS We evaluated 63 patients on whom we applied the aCRT algorithm [48 men, mean age: 64 ± 14 years; median follow-up period: 316 days (interquartile range: 212-809 days)]. At the 6-month follow-up after CRT implantation, the frequency of CRT responders was 71 % (n = 45). The sLVP rate was significantly higher in responders than in non-responders (75 ± 30 % vs. 47 ± 40 %, p = 0.003). Receiver operating characteristics curve analysis revealed that the optimal cut-off value during the sLVP rate was 59.4 % for the prediction of CRT responders (area under the curve, 0.70; sensitivity, 80 %; specificity, 61 %; positive predictive value, 84 %; and negative predictive value, 55 %). Kaplan-Meier analysis demonstrated that the higher-sLVP group (sLVP ≧59.4 %, n = 43) had a better prognosis (cardiac death and heart failure hospitalization) than the lower-sLVP group (sLVP <59.4 %, n = 20) (log-rank p < 0.001). Multivariate Cox hazard analysis revealed that a higher sLVP rate was associated with a good prognosis (p < 0.001). CONCLUSIONS sLVP was associated with CRT response, and a higher sLVP rate (≧59.4 %) was important for good prognosis in patients with aCRT.
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Affiliation(s)
- Yuichiro Miyazaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Oka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Akinori Wakamiya
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Keiko Shimamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenzaburo Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuko Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Miyazaki Y, Ishibashi K, Ueda N, Nakamura T, Oka S, Wakamiya A, Nakajima K, Wada M, Aiba T, Kusano K. Right Atrial Septal Lead Enhances the Favorable Effects of the Adaptive Cardiac Resynchronization Therapy Algorithm. JACC. ASIA 2024; 4:335-338. [PMID: 38660108 PMCID: PMC11035932 DOI: 10.1016/j.jacasi.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/10/2024] [Accepted: 01/26/2024] [Indexed: 04/26/2024]
Abstract
The adaptive cardiac resynchronization therapy (CRT) algorithm provides synchronized left ventricular pacing (sLVP). However, ensuring a high sLVP rate is challenging. We assessed the association between the sLVP rate and pacing sites in the right atrium. We evaluated 71 patients who underwent CRT and in whom the adaptive CRT algorithm was applied (53 men; mean age, 66 ± 14 years; median follow-up period, 301 days; IQR: 212-596 days). The atrial pacing leads were positioned in the right atrial (RA) septum in 17 patients (septal group) and in the RA appendage in 54 patients (RA appendage group), with significantly higher sLVP rates in the septal group compared with the RA appendage group (81% ± 30% vs 63% ± 37%; P = 0.045). In patients with first-degree atrioventricular blocks, the sLVP rates tended to be higher in the septal group. Therefore, RA septal pacing increased sLVP rates in patients undergoing CRT.
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Affiliation(s)
- Yuichiro Miyazaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toshihiro Nakamura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Oka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Akinori Wakamiya
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenzaburo Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
- Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Bank AJ, Brown CD, Burns KV, Johnson KM. Determination of sensed and paced atrial-ventricular delay in cardiac resynchronization therapy. Pacing Clin Electrophysiol 2024; 47:533-541. [PMID: 38477034 DOI: 10.1111/pace.14963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 02/08/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Optimization of atrial-ventricular delay (AVD) during atrial sensing (SAVD) and pacing (PAVD) provides the most effective cardiac resynchronization therapy (CRT). We demonstrate a novel electrocardiographic methodology for quantifying electrical synchrony and optimizing SAVD/PAVD. METHODS We studied 40 CRT patients with LV activation delay. Atrial-sensed to RV-sensed (As-RVs) and atrial-paced to RV-sensed (Ap-RVs) intervals were measured from intracardiac electrograms (IEGM). LV-only pacing was performed over a range of SAVD/PAVD settings. Electrical dyssynchrony (cardiac resynchronization index; CRI) was measured at each setting using a multilead ECG system placed over the anterior and posterior torso. Biventricular pacing, which included multiple interventricular delays, was also conducted in a subset of 10 patients. RESULTS When paced LV-only, peak CRI was similar (93 ± 5% vs. 92 ± 5%) during atrial sensing or pacing but optimal PAVD was 61 ± 31 ms greater than optimal SAVD. The difference between As-RVs and Ap-RVs intervals on IEGMs (62 ± 31 ms) was nearly identical. The slope of the correlation line (0.98) and the correlation coefficient r (0.99) comparing the 2 methods of assessing SAVD-PAVD offset were nearly 1 and the y-intercept (0.63 ms) was near 0. During simultaneous biventricular (BiV) pacing at short AVD, SAVD and PAVD programming did not affect CRI, but CRI was significantly (p < .05) lower during atrial sensing at long AVD. CONCLUSIONS A novel methodology for measuring electrical dyssynchrony was used to determine electrically optimal SAVD/PAVD during LV-only pacing. When BiV pacing, shorter AVDs produce better electrical synchrony.
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Affiliation(s)
- Alan J Bank
- Research Department, Minneapolis Heart Institute East at United Hospital, St. Paul, Minnesota, USA
- Heart Rhythm Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Christopher D Brown
- Research Department, Minneapolis Heart Institute East at United Hospital, St. Paul, Minnesota, USA
| | - Kevin V Burns
- Research Department, Minneapolis Heart Institute East at United Hospital, St. Paul, Minnesota, USA
- Heart Rhythm Science Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota, USA
| | - Katie M Johnson
- Research Department, Minneapolis Heart Institute East at United Hospital, St. Paul, Minnesota, USA
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Niu H, Yu Y, Ravikumar V, Gold MR. The impact of chronotropic incompetence on atrioventricular conduction times in heart failure patients. J Interv Card Electrophysiol 2023; 66:2055-2062. [PMID: 37036553 DOI: 10.1007/s10840-023-01545-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/03/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Intrinsic atrioventricular (AV) conduction is used to optimize AV intervals with cardiac resynchronization therapy (CRT) in most device algorithms. Atrial pacing and heart rate affect conduction times, but little is known regarding differeces among chronotropic incompetent(CI) and competent(CC) patients to guide programming. METHODS RAVE was a multicenter prospective trial of CRT patients. Heart rate was increased with incremental atrial pacing and with submaximal exercise. According to the maximal heart rate achieved during exercise, patients were classified as either CI or CC. For CI patients, an additional symptom-limited exercise with rate-adaptive pacing activated was performed. Intracardiac intervals were measured from the implantable lead electrograms in multiple postures. RESULTS There were 12 subjects with CI and 24 with CC. With atrial pacing, AV interval immediately increased and gradually increased with incremental atrial pacing in all patients. However, the changes in the atrial to right ventricular (ARV) and atrial to left ventricular (ALV) intervals with increasing atrial pacing rates were about threefold greater in CI patients compared to CC patients (24.3 ± 28.9 vs. 7.2 ± 5.5 ms/10 bpm for ARV and 22.7 ± 25.6 vs. 7.1 ± 5.7 ms/10 bpm for ALV in the standing position, p < 0.05). In CI pacing with rate-adaptive pacing during exercise, AV interval changes with paced heart rate were variable. CONCLUSIONS The AV response to overdrive atrial pacing at rest may provide a simple means of identifying chronotropic competence in CRT patients. For patients with CI, who often require rate-adaptive atrial pacing, rate-adaptive AV algorithms should be adjusted individually.
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Affiliation(s)
- Hongxia Niu
- Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | | | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, 30 Courtenay Drive, MSC 592, Charleston, SC, 29425, USA.
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Akhtar Z, Gallagher MM, Kontogiannis C, Leung LWM, Spartalis M, Jouhra F, Sohal M, Shanmugam N. Progress in Cardiac Resynchronisation Therapy and Optimisation. J Cardiovasc Dev Dis 2023; 10:428. [PMID: 37887875 PMCID: PMC10607614 DOI: 10.3390/jcdd10100428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 10/28/2023] Open
Abstract
Cardiac resynchronisation therapy (CRT) has become the cornerstone of heart failure (HF) treatment. Despite the obvious benefit from this therapy, an estimated 30% of CRT patients do not respond ("non-responders"). The cause of "non-response" is multi-factorial and includes suboptimal device settings. To optimise CRT settings, echocardiography has been considered the gold standard but has limitations: it is user dependent and consumes time and resources. CRT proprietary algorithms have been developed to perform device optimisation efficiently and with limited resources. In this review, we discuss CRT optimisation including the various adopted proprietary algorithms and conduction system pacing.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Mark M. Gallagher
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Christos Kontogiannis
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Lisa W. M. Leung
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Michael Spartalis
- Department of Cardiology, National and Kapodistrian University of Athens, 10679 Athens, Greece
| | - Fadi Jouhra
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Manav Sohal
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Nesan Shanmugam
- Department of Cardiology, St George’s University Hospital, Blackshaw Road, London SW17 0QT, UK
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7
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Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP, Lopez-Cabanillas N, Ellenbogen KA, Hua W, Ikeda T, Mackall JA, Mason PK, McLeod CJ, Mela T, Moore JP, Racenet LK. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. J Arrhythm 2023; 39:681-756. [PMID: 37799799 PMCID: PMC10549836 DOI: 10.1002/joa3.12872] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eugene H Chung
- University of Michigan Medical School Ann Arbor Michigan USA
| | | | | | | | | | - Anne M Dubin
- Stanford University, Pediatric Cardiology Palo Alto California USA
| | - Douglas P Ensch
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Taya V Glotzer
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
| | - Michael R Gold
- Medical University of South Carolina Charleston South Carolina USA
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
| | | | - Eiran Z Gorodeski
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
| | | | | | - Weijian Huang
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
| | - Peter B Imrey
- Cleveland Clinic Cleveland Ohio USA
- Case Western Reserve University Cleveland Ohio USA
| | - Julia H Indik
- University of Arizona, Sarver Heart Center Tucson Arizona USA
| | - Saima Karim
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
| | - Peter P Karpawich
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
| | - Yaariv Khaykin
- Southlake Regional Health Center Newmarket Ontario Canada
| | | | - Jordana Kron
- Virginia Commonwealth University Richmond Virginia USA
| | | | - Mark S Link
- University of Texas Southwestern Medical Center Dallas Texas USA
| | - Joseph E Marine
- Johns Hopkins University School of Medicine Baltimore Maryland USA
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
| | - Seung-Jung Park
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
| | | | | | - Rajeev Kumar Pathak
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
| | | | | | | | | | | | - Morio Shoda
- Tokyo Women's Medical University Tokyo Japan
| | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
| | - David J Slotwiner
- Weill Cornell Medicine Population Health Sciences New York New York USA
| | | | - Uma N Srivatsa
- University of California Davis Sacramento California USA
| | | | | | | | | | - Cynthia M Tracy
- George Washington University Washington District of Columbia USA
| | | | | | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
| | | | | | - Wojciech Zareba
- University of Rochester Medical Center Rochester New York USA
| | | | - Nestor Lopez-Cabanillas
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Kenneth A Ellenbogen
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Wei Hua
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Takanori Ikeda
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Judith A Mackall
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Pamela K Mason
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Christopher J McLeod
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Theofanie Mela
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Jeremy P Moore
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
| | - Laurel Kay Racenet
- Cleveland Clinic Cleveland Ohio USA
- University of Washington Seattle Washington USA
- University of Hong Kong Hong Kong China
- Hospital SOS Cárdio Florianópolis Brazil
- Duke University Medical Center Durham North Carolina USA
- Indraprastha Apollo Hospital New Delhi India
- University of California San Diego Health La Jolla California USA
- Mayo Clinic, Rochester Rochester Minnesota USA
- University of Michigan Medical School Ann Arbor Michigan USA
- Temple University Philadelphia Pennsylvania USA
- University at Buffalo Buffalo New York USA
- Medical University of Łódź, Łódź Poland
- Virginia Mason Franciscan Health Tacoma Washington USA
- Stanford University, Pediatric Cardiology Palo Alto California USA
- Hackensack Meridian School of Medicine Hackensack New Jersey USA
- Medical University of South Carolina Charleston South Carolina USA
- University of Wisconsin School of Medicine and Public Health Madison Wisconsin USA
- Kansas City Heart Rhythm Institute Overland Park Kansas USA
- University Hospitals and Case Western Reserve University School of Medicine Cleveland Ohio USA
- University of Minnesota Minneapolis Minnesota USA
- McMaster University Hamilton Ontario Canada
- First Affiliated Hospital of Wenzhou Medical University Wenzhou China
- Case Western Reserve University Cleveland Ohio USA
- University of Arizona, Sarver Heart Center Tucson Arizona USA
- MetroHealth Medical Center Case Western Reserve University Cleveland Ohio USA
- The Children's Hospital of Michigan Central Michigan University Detroit Michigan USA
- Southlake Regional Health Center Newmarket Ontario Canada
- Sentara Norfolk Virginia USA
- Virginia Commonwealth University Richmond Virginia USA
- University of Rochester Medical Center Rochester New York USA
- University of Texas Southwestern Medical Center Dallas Texas USA
- Johns Hopkins University School of Medicine Baltimore Maryland USA
- Ziekenhuis Oost-Limburg Genk Belgium and Hasselt University Hasselt Belgium
- Sungkyunkwan University School of Medicine, Samsung Medical Center Seoul Republic of Korea
- QEII Health Sciences Center Halifax Nova Scotia Canada
- Clinica Corazones Unidos Santo Domingo Dominican Republic
- Australian National University, Canberra Hospital Garran Australian Capital Territory Australia
- Santojanni Hospital Buenos Aires Argentina
- Yale University School of Medicine New Haven Connecticut USA
- National University Hospital Singapore Singapore
- Mayo Clinic Phoenix Arizona USA
- Tokyo Women's Medical University Tokyo Japan
- Massachusetts General Hospital, Harvard Medical School Boston Massachusetts USA
- Weill Cornell Medicine Population Health Sciences New York New York USA
- University of California Davis Sacramento California USA
- Oregon Health & Science University Portland Oregon USA
- Indiana University Indianapolis Indiana USA
- Fundación Cardioinfantil Instituto de Cardiologia Bogotá Colombia
- George Washington University Washington District of Columbia USA
- University of Chicago Medicine Chicago Illinois USA
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center Maastricht The Netherlands
- Geisinger Health System Wilkes-Barre Pennsylvania USA
- Dartmouth Hitchcock Medical Center New Hampshire Lebanon
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Knijnik L, Wang B, Cardoso R, Shanafelt C, Lloyd MS. Clinical outcomes of automatic algorithms in cardiac resynchronization therapy: Systematic review and meta-analysis. Heart Rhythm O2 2023; 4:618-624. [PMID: 37936674 PMCID: PMC10626183 DOI: 10.1016/j.hroo.2023.09.001] [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: 11/09/2023] Open
Abstract
Background Algorithms to automatically adjust atrioventricular (AV) and interventricular (VV) intervals in cardiac resynchronization therapy (CRT) devices are common, but their clinical efficacy is unknown. Objective The purpose of this study was to evaluate automatic CRT algorithms in patients with heart failure for the reduction of mortality, heart failure hospitalizations, and clinical improvement. Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) in patients with CRT using automatic algorithms that change AV and VV intervals dynamically without manual input, on a beat-to-beat basis. We performed a subgroup analysis including intracardiac electrogram-based (EGM) algorithms and contractility-based algorithms. Results Nine RCTs with 8531 participants were included, of whom 4275 (50.1%) were randomized to automatic algorithm. Seven of the 9 trials used EGM-based algorithms, and 2 used contractility sensors. There was no difference in all-cause mortality (10.3% vs 11.3%; odds ratio [OR] 0.90; 95% confidence interval [CI] 0.71-1.03; P = .13; I2 = 0%) or heart failure hospitalizations (15.0% vs 16.1%; OR 0.924; 95% CI 0.81-1.04; P = .194; I2 = 0%) between the automatic algorithm group and the control group. Study-defined clinical improvement was also not significantly different between groups (66.6% vs 63.3%; risk ratio 1.01; 95% CI 0.95-1.06; P = .82; I2 = 50%). In the contractility-based subgroup, there was a trend toward greater clinical improvement with the use of the automatic algorithm (75% vs 68.3%; OR 1.45; 95% CI 0.97-2.18; P = .07; I2 = 40%), which did not reach statistical significance. The overall risk of bias was low. Conclusion Automatic algorithms that change AV or VV intervals did not improve mortality, heart failure hospitalizations, or cardiovascular symptoms in patients with heart failure and CRT.
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Affiliation(s)
- Leonardo Knijnik
- Emory University Adult Congenital Heart Center, Atlanta, Georgia
| | - Bo Wang
- Emory University Adult Congenital Heart Center, Atlanta, Georgia
| | - Rhanderson Cardoso
- Heart and Vascular Center, Brigham and Women’s Hospital, Boston Massachusetts
| | - Colby Shanafelt
- Emory University Adult Congenital Heart Center, Atlanta, Georgia
| | - Michael S. Lloyd
- Emory University Adult Congenital Heart Center, Atlanta, Georgia
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9
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Wilkoff BL, Filippatos G, Leclercq C, Gold MR, Hersi AS, Kusano K, Mullens W, Felker GM, Kantipudi C, El-Chami MF, Essebag V, Pierre B, Philippon F, Perez-Gil F, Chung ES, Sotomonte J, Tung S, Singh B, Bozorgnia B, Goel S, Ebert HH, Varma N, Quan KJ, Salerno F, Gerritse B, van Wel J, Schaber DE, Fagan DH, Birnie D. Adaptive versus conventional cardiac resynchronisation therapy in patients with heart failure (AdaptResponse): a global, prospective, randomised controlled trial. Lancet 2023; 402:1147-1157. [PMID: 37634520 DOI: 10.1016/s0140-6736(23)00912-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Continuous automatic optimisation of cardiac resynchronisation therapy (CRT), stimulating only the left ventricle to fuse with intrinsic right bundle conduction (synchronised left ventricular stimulation), might offer better outcomes than conventional CRT in patients with heart failure, left bundle branch block, and normal atrioventricular conduction. This study aimed to compare clinical outcomes of adaptive CRT versus conventional CRT in patients with heart failure with intact atrioventricular conduction and left bundle branch block. METHODS This global, prospective, randomised controlled trial was done in 227 hospitals in 27 countries across Asia, Australia, Europe, and North America. Eligible patients were aged 18 years or older with class 2-4 heart failure, an ejection fraction of 35% or less, left bundle branch block with QRS duration of 140 ms or more (male patients) or 130 ms or more (female patients), and a baseline PR interval 200 ms or less. Patients were randomly assigned (1:1) via block permutation to adaptive CRT (an algorithm providing synchronised left ventricular stimulation) or conventional biventricular CRT using a device programmer. All patients received device programming but were masked until procedures were completed. Site staff were not masked to group assignment. The primary outcome was a composite of all-cause death or intervention for heart failure decompensation and was assessed in the intention-to-treat population. Safety events were collected and reported in the intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT02205359, and is closed to accrual. FINDINGS Between Aug 5, 2014, and Jan 31, 2019, of 3797 patients enrolled, 3617 (95·3%) were randomly assigned (1810 to adaptive CRT and 1807 to conventional CRT). The futility boundary was crossed at the third interim analysis on June 23, 2022, when the decision was made to stop the trial early. 1568 (43·4%) of 3617 patients were female and 2049 (56·6%) were male. Median follow-up was 59·0 months (IQR 45-72). A primary outcome event occurred in 430 of 1810 patients (Kaplan-Meier occurrence rate 23·5% [95% CI 21·3-25·5] at 60 months) in the adaptive CRT group and in 470 of 1807 patients (25·7% [23·5-27·8] at 60 months) in the conventional CRT group (hazard ratio 0·89, 95% CI 0·78-1·01; p=0·077). System-related adverse events were reported in 452 (25·0%) of 1810 patients in the adaptive CRT group and 440 (24·3%) of 1807 patients in the conventional CRT group. INTERPRETATION Compared with conventional CRT, adaptive CRT did not significantly reduce the incidence of all-cause death or intervention for heart failure decompensation in the included population of patients with heart failure, left bundle branch block, and intact AV conduction. Death and heart failure decompensation rates were low with both CRT therapies, suggesting a greater response to CRT occurred in this population than in patients in previous trials. FUNDING Medtronic.
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Affiliation(s)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece.
| | | | - Michael R Gold
- Medical University of South Carolina, Charleston, SC, USA
| | - Ahmad S Hersi
- King Saud University, Faculty of Medicine, Riyadh, Saudi Arabia
| | - Kengo Kusano
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; Hasselt University, Hasselt, Belgium
| | | | | | | | - Vidal Essebag
- McGill University Health Centre, Montreal, QC, Canada; Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada
| | - Bertrand Pierre
- Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université de Tours, Tours, France
| | - Francois Philippon
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, QC, Canada
| | | | - Eugene S Chung
- The Lindner Research Center at The Christ Hospital, Cincinnati, OH, USA
| | - Juan Sotomonte
- Cardiovascular Center of Puerto Rico and the Caribbean, San Juan, Puerto Rico
| | - Stanley Tung
- St Paul's Hospital, University of British Columbia, Vancouver, BC, Canada; Royal Columbian Hospital, New Westminster, BC, Canada
| | - Balbir Singh
- Medanta-The Medicity Hospital, Gurugram, Haryana, India
| | | | - Satish Goel
- First Coast Cardiovascular Institute, Jacksonville, FL, USA
| | | | | | - Kara J Quan
- Harrington Heart and Vascular Institute, University Hospitals of Cleveland, Cleveland, OH, USA
| | | | - Bart Gerritse
- Medtronic Bakken Research Center, Maastricht, Netherlands
| | | | | | | | - David Birnie
- University of Ottawa Heart Institute, Ottawa, ON, Canada
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10
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Chung MK, Patton KK, Lau CP, Dal Forno ARJ, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha YM, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Imrey PB, Indik JH, Karim S, Karpawich PP, Khaykin Y, Kiehl EL, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park SJ, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow SC, Shen WK, Shoda M, Singh JP, Slotwiner DJ, Sridhar ARM, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WHW, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm 2023; 20:e17-e91. [PMID: 37283271 PMCID: PMC11062890 DOI: 10.1016/j.hrthm.2023.03.1538] [Citation(s) in RCA: 85] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 06/08/2023]
Abstract
Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Eugene H Chung
- University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | | | | | - Anne M Dubin
- Stanford University, Pediatric Cardiology, Palo Alto, California
| | | | - Taya V Glotzer
- Hackensack Meridian School of Medicine, Hackensack, New Jersey
| | - Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina
| | - Zachary D Goldberger
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - Eiran Z Gorodeski
- University Hospitals and Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Weijian Huang
- First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Peter B Imrey
- Cleveland Clinic, Cleveland, Ohio; Case Western Reserve University, Cleveland, Ohio
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Saima Karim
- MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Peter P Karpawich
- The Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - Yaariv Khaykin
- Southlake Regional Health Center, Newmarket, Ontario, Canada
| | | | - Jordana Kron
- Virginia Commonwealth University, Richmond, Virginia
| | | | - Mark S Link
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joseph E Marine
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg Genk, Belgium and Hasselt University, Hasselt, Belgium
| | - Seung-Jung Park
- Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Ratika Parkash
- QEII Health Sciences Center, Halifax, Nova Scotia, Canada
| | | | - Rajeev Kumar Pathak
- Australian National University, Canberra Hospital, Garran, Australian Capital Territory, Australia
| | | | | | | | | | | | - Morio Shoda
- Tokyo Women's Medical University, Tokyo, Japan
| | - Jagmeet P Singh
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Slotwiner
- Weill Cornell Medicine Population Health Sciences, New York, New York
| | | | | | | | | | | | | | - Cynthia M Tracy
- George Washington University, Washington, District of Columbia
| | | | | | - Kevin Vernooy
- Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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11
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Oka S, Ueda N, Ishibashi K, Noda T, Miyazaki Y, Wakamiya A, Shimamoto K, Nakajima K, Kamakura T, Wada M, Inoue Y, Miyamoto K, Nagase S, Aiba T, Kanzaki H, Izumi C, Kusano K. Significance of effective cardiac resynchronization therapy pacing for clinical responses: An analysis based on the effective cardiac resynchronization therapy algorithm. Heart Rhythm 2023; 20:1289-1296. [PMID: 37307884 DOI: 10.1016/j.hrthm.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND High percent ventricular pacing maximizes cardiac resynchronization therapy (CRT) response. An effective CRT algorithm classifies each left ventricular (LV) pace as effective or ineffective on the basis of the detection of QS or QS-r morphology on the electrogram; however, the relationship between percent effective CRT pacing (%e-CRT) and responses is unclear. OBJECTIVE We aimed to clarify the association between %e-CRT and clinical outcomes. METHODS Of the 136 consecutive CRT patients, 49 using the adaptive and effective CRT algorithm with percent ventricular pacing > 90% were evaluated. The primary and secondary outcomes were heart failure (HF) hospitalization and prevalence of CRT responders, defined as patients with an improvement in LV ejection fraction of ≥10% or a reduction in LV end-systolic volume of ≥15% after CRT device implantation, respectively. RESULTS We divided the patients into the effective group (n = 25) and the less effective group (n = 24) by the median value of %e-CRT (97.4% [93.7%-98.3%]). During the median follow-up period of 507 days (interquartile range 335-730 days), the effective group had a significantly lower risk of HF hospitalization than the less effective group as revealed by Kaplan-Meier analysis (log-rank, P = .016). Univariate analysis revealed %e-CRT ≥ 97.4% (hazard ratio 0.12; 95% confidence interval 0.01-0.95; P = .045) as a predictor of HF hospitalization. The effective group had a higher prevalence of CRT responders than the less effective group (23 [92%] vs 9 [38%]; P < .001). Univariate analysis revealed that %e-CRT ≥ 97.4% (odds ratio 19.20; 95% confidence interval 3.63-101.00; P < .001) was a predictor of CRT response. CONCLUSION High %e-CRT is associated with high CRT responder prevalence and low HF hospitalization risk.
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Affiliation(s)
- Satoshi Oka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuichiro Miyazaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Akinori Wakamiya
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Keiko Shimamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenzaburo Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuko Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan; Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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12
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Akhtar Z, Sohal M, Gallagher MM. Comment on 'Leadless Pacemakers: Current Achievements and Future Perspectives'. Eur Cardiol 2023; 18:e50. [PMID: 37655135 PMCID: PMC10466268 DOI: 10.15420/ecr.2022.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 11/14/2022] [Indexed: 09/02/2023] Open
Affiliation(s)
- Zaki Akhtar
- Cardiology Academic Group, St George's University Hospital London, UK
| | - Manav Sohal
- Cardiology Academic Group, St George's University Hospital London, UK
| | - Mark M Gallagher
- Cardiology Academic Group, St George's University Hospital London, UK
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13
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Malaty MM, Sivagangabalan G, Qian PC. Beyond Conventional Cardiac Resynchronisation Therapy: A Review of Electrophysiological Options in the Management of Chronic Heart Failure. Heart Lung Circ 2023; 32:905-913. [PMID: 37286460 DOI: 10.1016/j.hlc.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
The incidence of heart failure (HF) continues to grow and burden our health care system. Electrophysiological aberrations are common amongst patients with heart failure and can contribute to worsening symptoms and prognosis. Targeting these abnormalities with cardiac and extra-cardiac device therapies and catheter ablation procedures augments cardiac function. Newer technologies aimed to improvement procedural outcomes, address known procedural limitations and target newer anatomical sites have been trialled recently. We review the role and evidence base for conventional cardiac resynchronisation therapy (CRT) and its optimisation, catheter ablation therapies for atrial arrhythmias, cardiac contractility and autonomic modulation therapies.
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Affiliation(s)
- Michael M Malaty
- Department of Cardiology, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Gopal Sivagangabalan
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia; School of Medicine, Sydney Campus, University of Notre Dame, Sydney, NSW, Australia
| | - Pierre C Qian
- Department of Cardiology, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia.
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14
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Spitaler P, Pfeifer BE, Mayr A, Bachler R, Bilgeri V, Adukauskaite A, Bauer A, Stühlinger M, Barbieri F, Dichtl W. Visualization of the SyncAV ® Algorithm for CRT Optimization by Non-invasive Imaging of Cardiac Electrophysiology: NICE-CRT Trial. J Clin Med 2023; 12:4510. [PMID: 37445543 DOI: 10.3390/jcm12134510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
(1) Background: Periodic repetitive AV interval optimization using a device-based algorithm in cardiac resynchronization therapy (CRT) devices may improve clinical outcomes. There is an unmet need to successfully transform its application into clinical routine. (2) Methods: Non-invasive imaging of cardiac electrophysiology was performed in different device programming settings of the SyncAV® algorithm in 14 heart failure patients with left bundle branch block and a PR interval ≤ 250 milliseconds to determine the shortest ventricular activation time. (3) Results: the best offset time (to be manually programmed) permitting automatic dynamic adjustment of the paced atrioventricular interval after every 256 heart beats was found to be 30 and 50 milliseconds, decreasing mean native QRS duration from 181.6 ± 23.9 milliseconds to 130.7 ± 10.0 and 130.1 ± 10.5 milliseconds, respectively (p = 0.01); this was followed by an offset of 40 milliseconds (decreasing QRS duration to 130.1 ± 12.2 milliseconds; p = 0.08). (4) Conclusions: The herein presented NICE-CRT study supports the current recommendation to program an offset of 50 milliseconds as default in patients with left bundle branch block and preserved atrioventricular conduction after implantation of a CRT device capable of SyncAV® optimization. Alternatively, offset programming of 30 milliseconds may also be applied as default programming. In patients with no or poor CRT response, additional efforts should be spent to individualize best offset programming with electrocardiographic optimization techniques.
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Affiliation(s)
- Philipp Spitaler
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Bernhard Erich Pfeifer
- Institute of Clinical Epidemiology, Tirol Kliniken, 6020 Innsbruck, Austria
- Institute of Medical Informatics, UMIT TIROL, Eduart Wallnöfer Zentrum, 6600 Hall in Tirol, Austria
| | - Agnes Mayr
- Department of Radiology, Medical University Innsbruck, 6020 Innsbruck, Austria
| | | | - Valentin Bilgeri
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Agne Adukauskaite
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Axel Bauer
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Markus Stühlinger
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Fabian Barbieri
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Wolfgang Dichtl
- Department of Internal Medicine III, Medical University of Innsbruck, 6020 Innsbruck, Austria
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15
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Kloosterman M, Daniëls F, Roseboom E, Rienstra M, Maass AH. Cardiac Resynchronization Therapy beyond Nominal Settings: An IEGM-Based Approach for Paced and Sensed Atrioventricular Delay Offset Optimization in Daily Clinical Practice. J Clin Med 2023; 12:4138. [PMID: 37373831 PMCID: PMC10299691 DOI: 10.3390/jcm12124138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 05/19/2023] [Accepted: 06/13/2023] [Indexed: 06/29/2023] Open
Abstract
Optimization of the atrioventricular (AV) delay has been performed in several landmark trials in cardiac resynchronization therapy (CRT), although it is often not performed in daily practice. Our aim was to study optimal AV delays and investigate a simple intracardiac electrogram (IEGM)-based optimization approach. 328 CRT patients with paired IEGM and echocardiography optimization data were included in our single-center observational study. Sensed (sAV) and paced (pAV) AV delays were optimized using an iterative echocardiography method. The offset between sAV and pAV delays was calculated using the IEGM method. The mean age of the patients was 69 ± 12 years; 64% were men, 48% had ischemic etiology of heart failure. During echocardiographic optimization, an offset of 73 ± 18 ms was found, differing from nominal AV settings (p < 0.001). Based on the IEGM method, the optimal offset was 75 ± 25 ms. The echocardiographic and IEGM-generated AV offset delays showed good correlation (R2 = 0.62, p < 0.001) and good agreement according to Bland-Altman plot analysis. CRT responders had a near zero offset difference between IEGM and echo optimization (-0.2 ± 17 ms), while non-responders had an offset difference of 6 ± 17 ms, p = 0.006. In conclusion, optimal AV delays are patient-specific and differ from nominal settings. pAV delay can easily be calculated from IEGM after sAV delay optimization.
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Affiliation(s)
- Mariëlle Kloosterman
- University Medical Center Groningen, Department of Cardiology, University of Groningen, 9712 CP Groningen, The Netherlands; (M.K.); (F.D.); (E.R.); (M.R.)
| | - Fenna Daniëls
- University Medical Center Groningen, Department of Cardiology, University of Groningen, 9712 CP Groningen, The Netherlands; (M.K.); (F.D.); (E.R.); (M.R.)
- Department of Cardiology, Isala Hospital, 8025 AB Zwolle, The Netherlands
| | - Eva Roseboom
- University Medical Center Groningen, Department of Cardiology, University of Groningen, 9712 CP Groningen, The Netherlands; (M.K.); (F.D.); (E.R.); (M.R.)
| | - Michiel Rienstra
- University Medical Center Groningen, Department of Cardiology, University of Groningen, 9712 CP Groningen, The Netherlands; (M.K.); (F.D.); (E.R.); (M.R.)
| | - Alexander H. Maass
- University Medical Center Groningen, Department of Cardiology, University of Groningen, 9712 CP Groningen, The Netherlands; (M.K.); (F.D.); (E.R.); (M.R.)
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16
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Ballantyne BA, Chew DS, Vandenberk B. Paradigm Shifts in Cardiac Pacing: Where Have We Been and What Lies Ahead? J Clin Med 2023; 12:jcm12082938. [PMID: 37109274 PMCID: PMC10146747 DOI: 10.3390/jcm12082938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/07/2023] [Accepted: 04/09/2023] [Indexed: 04/29/2023] Open
Abstract
The history of cardiac pacing dates back to the 1930s with externalized pacing and has evolved to incorporate transvenous, multi-lead, or even leadless devices. Annual implantation rates of cardiac implantable electronic devices have increased since the introduction of the implantable system, likely related to expanding indications, and increasing global life expectancy and aging demographics. Here, we summarize the relevant literature on cardiac pacing to demonstrate the enormous impact it has had within the field of cardiology. Further, we look forward to the future of cardiac pacing, including conduction system pacing and leadless pacing strategies.
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Affiliation(s)
- Brennan A Ballantyne
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Bert Vandenberk
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
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17
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Impact of long-term optimizing atrioventricular delay using device-based algorithms on cardiac resynchronization therapy. Heart Vessels 2023; 38:216-227. [PMID: 36173447 PMCID: PMC9816250 DOI: 10.1007/s00380-022-02162-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 08/18/2022] [Indexed: 01/10/2023]
Abstract
Sub-optimal atrioventricular delay (AVD) is one of the main causes of non-responder for cardiac resynchronization therapy (CRT). Recently, device-based algorithms (DBAs) that provide optimal AVD based on intracardiac electrograms, have been developed. However, their long-term effectiveness is still unknown. This study aims to investigate the effect of optimizing AVD using DBAs over a long period, on the prognosis of patients undergoing CRT. A total of 118 patients who underwent CRT at our hospital between April 2008 and March 2018, were retrospectively reviewed; 61 of them with optimizing AVD using DBAs were classified into the treated group (group 1), and the remaining 57 were classified into the control group (group 2). The median follow-up period was 46.0 months. The responder and survival rate in group 1 were significantly better than those in group 2 (group 1 vs. group 2: responder rate = 64% vs. 46%, p = 0.046; survival rate: 85.2% vs. 64.9%, p = 0.02). Moreover, investigating only the non-responder population showed that group 1 had an improved survival rate compared to group 2 (group 1 vs. group 2 = 72.7% vs. 45.1%, p = 0.02). Optimizing AVD using DBAs was a significant contributor to the improved survival rate in CRT non-responders in multivariate analysis (HR 3.6, p = 0.01). In conclusion, the long-term optimizing AVD using DBAs improved the survival rate in CRT and the prognosis of CRT non-responders, as well.
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18
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Ikeda Y, Kato R. Clinical implication of device-based algorithm that optimize atrioventricular delay during cardiac resynchronization therapy: author’s reply. Heart Vessels 2022; 38:998-999. [DOI: 10.1007/s00380-022-02205-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 11/28/2022]
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19
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Rickard J, Jackson K, Gold M, Biffi M, Ziacchi M, Silverstein J, Ramza B, Metzl M, Grubman E, Abben R, Varma N, Tabbal G, Jensen C, Wouters G, Ghosh S, Vernooy K. Electrocardiogram Belt guidance for left ventricular lead placement and biventricular pacing optimization. Heart Rhythm 2022; 20:537-544. [PMID: 36442824 DOI: 10.1016/j.hrthm.2022.11.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/07/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Patients with ischemic cardiomyopathy, non-left bundle branch block, or QRS duration <150 ms have a lower response rate to cardiac resynchronization therapy (CRT) than did other indicated patients. The ECG Belt system (EBS) is a novel surface mapping system designed to measure electrical dyssynchrony via the standard deviation of the activation times of the left ventricle. OBJECTIVES The objectives of this study were to evaluate the efficacy of the EBS in patients less likely to respond to CRT and to determine whether EBS use in lead placement guidance and device programming was superior to standard CRT care. METHODS This was a prospective randomized trial of patients with heart failure and EBS-guided CRT implantation and programming vs standard CRT care. The primary end point was relative change in left ventricular end-systolic volume from baseline to 6 months postimplantation. RESULTS A total of 408 patients from centers in Europe and North America were randomized. Although both patients with EBS and control patients had a mean improvement in left ventricular end-systolic volume, there was no significant difference in relative change from baseline (P = .26). While patients with a higher baseline standard deviation of the activation times derived greater left ventricular reverse remodeling, improvement in electrical dyssynchrony did not correlate with the extent of reverse remodeling. CONCLUSION The findings of the present study do not support EBS-guided therapy for CRT management of heart failure with reduced ejection fraction.
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Affiliation(s)
- John Rickard
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Kevin Jackson
- Section of Cardiac Electrophysiology, Division of Cardiovascular Disease, Duke University Medical Center, Durham, North Carolina
| | - Michael Gold
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Mauro Biffi
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Matteo Ziacchi
- Department of Experimental, Diagnostic and Specialty Medicine, Institute of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Brian Ramza
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Mark Metzl
- Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois
| | - Eric Grubman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Richard Abben
- Cardiac Interventions and Cardiac Arrythmia Center, Cardiovascular Institute of the South, Houma, Louisiana
| | - Niraj Varma
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ghiyath Tabbal
- Cardiac Interventions and Cardiac Arrythmia Center, Cardiovascular Institute of the South, Houma, Louisiana
| | - Cory Jensen
- Department of Cardiac Electrophysiology, Heartland Cardiology, Wichita, Kansas
| | - Griet Wouters
- Department of Cardiac Rhythm Management, Medtronic Inc., Mounds View, Minnesota
| | - Subham Ghosh
- Department of Cardiac Rhythm Management, Medtronic Inc., Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
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20
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Hua J, Kong Q, Chen Q. Alternative pacing strategies for optimal cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:923394. [PMID: 36237907 PMCID: PMC9551024 DOI: 10.3389/fcvm.2022.923394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 09/06/2022] [Indexed: 12/02/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) via biventricular pacing (BVP) improves morbidity, mortality, and quality of life, especially in subsets of patients with impaired cardiac function and wide QRS. However, the rate of unsuccessful or complicated left ventricular (LV) lead placement through coronary sinus is 5–7%, and the rate of “CRT non-response” is approximately 30%. These reasons have pushed physicians and engineers to collaborate to overcome the challenges of LV lead implantation. Thus, various alternatives to BVP have been proposed to improve CRT effectiveness. His bundle pacing (HBP) has been increasingly used by activating the His–Purkinje system but is constrained by challenging implantation, low success rates, high and often unstable thresholds, and low perception. Therefore, the concept of pacing a specialized conduction system distal to the His bundle to bypass the block region was proposed. Multiple clinical studies have demonstrated that left bundle branch area pacing (LBBAP) has comparable electrical resynchronization with HBP but is superior in terms of simpler operation, higher success rates, lower and stable capture thresholds, and higher perception. Despite their well-demonstrated effectiveness, the transvenous lead-related complications remain major limitations. Recently, leadless LV pacing has been developed and demonstrated effective for these challenging patient cohorts. This article focuses on the current state and latest progress in HBP, LBBAP, and leadless LV pacing as alternatives for failed or non-responsive conventional CRT as well as their limits and prospects.
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21
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The Interplay of PR Interval and AV Pacing Delays Used for Cardiac Resynchronization Therapy in Heart Failure Patients: Association with Clinical Response in a Retrospective Analysis of a Large Observational Study. J Pers Med 2022; 12:jpm12091512. [PMID: 36143297 PMCID: PMC9501597 DOI: 10.3390/jpm12091512] [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: 08/08/2022] [Revised: 09/07/2022] [Accepted: 09/08/2022] [Indexed: 11/17/2022] Open
Abstract
Background. Cardiac resynchronization therapy (CRT) is a treatment for heart failure (HF) patients with prolonged QRS and impaired left ventricular (LV) systolic function. We aim to evaluate how the baseline PR interval is associated with outcomes (all-cause death or HF hospitalizations) and LV reverse remodeling (>15% relative reduction in LV end-systolic volume). Methods. Among 2224 patients with CRT defibrillators, 1718 (77.2%) had a device programmed at out-of-the-box settings (sensed AV delay: 100 ms and paced AV delay: 130 ms). Results. In this cohort of 1718 patients (78.7% men, mean age 66 years, 71.6% in NYHA class III/IV, LVEF = 27 ± 6%), echocardiographic assessment at 6-month follow-up showed that LV reverse remodeling was not constant as a function of the PR interval; in detail, it occurred in 56.4% of all patients but was more frequent (76.6%) in patients with a PR interval of 160 ms. In a median follow-up of 20 months, the endpoint of death or HF hospitalizations occurred in 304/1718 (17.7%) patients; in the multivariable regression analysis it was significantly less frequent when the PR interval was between 150 and 170 ms (hazard ratio = 0.79, 95% confidence interval (CI): 0.63−0.99, p = 0.046). The same PR range was associated with higher probability of CRT response (odds ratio = 2.51, 95% CI: 1.41−4.47, p = 0.002). Conclusions. In a large population of CRT patients, with fixed AV pacing delays, specific PR intervals are associated with significant benefits in terms of LV reverse remodeling and lower morbidity. These observational data suggest the importance of optimizing pacing programming as a function of the PR interval to maximize CRT response and patient outcome.
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22
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Chung ES, Rickard J, Lu X, DerSarkissian M, Zichlin ML, Cheung HC, Swartz N, Greatsinger A, Duh MS. Real-world clinical burden among patients with and without heart failure worsening after cardiac resynchronization therapy. Curr Med Res Opin 2022; 38:1489-1498. [PMID: 35727103 DOI: 10.1080/03007995.2022.2092374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Cardiac resynchronization therapy (CRT) can improve cardiac function in patients with heart failure (HF); however, in some patients, HF worsens despite CRT. This study characterized the long-term clinical burden of patients with and without HF worsening (HFW) within 6 months post CRT implantation. METHODS A claims database (2007-2018) was used to identify two cohorts of adults: those with HFW within 180 days post-CRT and those with no HFW (NHFW). The evaluated clinical outcomes were cardiovascular events/complications, HF-related interventions, hospice enrollment, and all-cause mortality. Inverse probability of treatment weighting (IPTW) was used to adjust for confounders; adjusted comparisons were assessed using weighted Cox proportional hazard ratios (HRs). RESULTS Among the 12,753 adults analyzed (HFW: N = 4,785; NHFW: N = 7,968), the mean age was 72 years and the mean duration of follow-up was approximately 2 years. The clinical burden was greater for HFW than for NHFW in terms of all-cause mortality (19.7% vs. 12.1%) and occurrence of atrial fibrillation (57.4% vs. 51.2%). In the IPTW-adjusted Cox proportional hazard analyses, patients with HFW had a 54% higher average hazard of experiencing all-cause mortality compared to NHFW (adjusted average HR = 1.54, 95% confidence interval [CI]: 1.41-1.70; p < .001). Of the clinical events experienced by ≥5% of patients, the greatest differences in average hazard were for HF decompensation (adjusted average HR = 1.83, 95% CI: 1.60-2.09) and HF decompensation or death (HR = 1.63, 95%CI: 1.50-1.77). CONCLUSION Patients with early HFW post-CRT experienced a significantly higher clinical burden than those without HFW. Vigilance for signs of worsening HF in the first 6 months post-CRT is warranted.
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Affiliation(s)
- Eugene S Chung
- The Lindner Clinical Research Center at The Christ Hospital, Cincinnati, OH, USA
| | | | - Xiaoxiao Lu
- Medtronic Global CRHF Headquarters, Mounds View, MN, USA
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Goanță EV, Luca CT, Vacarescu C, Crișan S, Petrescu L, Vatasescu R, Lazăr MA, Gurgu A, Turi VR, Cozma D. Nonischemic Super-Responders in Fusion CRT Pacing with Normal Atrioventricular Conduction. Diagnostics (Basel) 2022; 12:diagnostics12092032. [PMID: 36140434 PMCID: PMC9497644 DOI: 10.3390/diagnostics12092032] [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] [Received: 06/15/2022] [Revised: 07/29/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Fusion CRT pacing (FCRT) is noninferior to biventricular pacing, according to the current data. The aim of this study is to assess the response to FCRT and to identify predictors of super-responders (SRs) in a nonischemic population with normal AV conduction. Methods: LV-only CRT patients (pts) with a right atrium/left ventricle pacing system implanted in two CRT centers in Romania were included. Device interrogation, exercise tests, echocardiography, and individualized drug optimization were performed every 6 months during close follow-up. SRs pts were defined as those with left ventricular end-systolic volume (LVESV) improvement ≥30% and stable ejection fraction (LVEF) ≥45%. Results: A total of 25 out of 83 pts (31%) were SRs, with nonischemic LBBB low EF cardiomyopathy (50 male, 62 ± 9 y.o.) initially included. Mean follow-up was 5 years ± 27 months. Patients were divided in two groups: SRs and non-SRs (52 responders/6 hypo-responders). Two predictors were found in the SRs group: a higher baseline LVEF (SRs 29 ± 5% vs. non-SRs 26 ± 5%, p = 0.02) and a lower pulmonary arterial systolic pressure (SRs 38 ± 11 mm Hg vs. non-SRs 50 ± 15 mmHg, p = 0.003). Baseline severe mitral regurgitation was found in 11% of SRs vs. 64% in the non-SRs group. Conclusions: SRs in the selected NICM-FCRT group are significative high. Higher baseline LVEF and mild pulmonary arterial hypertension were independently associated with super-response.
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Affiliation(s)
- Emilia-Violeta Goanță
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Constantin-Tudor Luca
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Cristina Vacarescu
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Correspondence: (C.V.); (S.C.)
| | - Simina Crișan
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Correspondence: (C.V.); (S.C.)
| | - Lucian Petrescu
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
| | - Radu Vatasescu
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 014451 Bucharest, Romania
- Clinical Emergency Hospital, 014451 Bucharest, Romania
| | - Mihai-Andrei Lazăr
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Andra Gurgu
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Vladiana-Romina Turi
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
| | - Dragos Cozma
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Sq., 300041 Timisoara, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
- Institute of Cardiovascular Diseases Timisoara, 13A Gheorghe Adam Street, 300310 Timisoara, Romania
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Feng XF, Yang LC, Zhao Y, Yu YC, Liu B, Li YG. Effects of adaptive left bundle branch-optimized cardiac resynchronization therapy: a single centre experience. BMC Cardiovasc Disord 2022; 22:360. [PMID: 35933334 PMCID: PMC9357303 DOI: 10.1186/s12872-022-02742-2] [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: 03/26/2022] [Accepted: 06/30/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Adaptive cardiac resynchronization therapy (aCRT) is associated with improved clinical outcomes. Left bundle branch area pacing (LBBAP) has shown encouraging results as an alternative option for aCRT. A technique that can be accomplished effectively using LBBAP combined with coronary venous pacing (LOT-aCRT). We aimed to assess the feasibility and outcomes of LOT-aCRT. METHODS LOT-aCRT, capable of providing two pacing modes, LBBAP alone or LBBAP combined with LV pacing, was attempted in patients with CRT indications. Patients were divided into two groups: those with LBBAP and LV pacing (LOT-aCRT) and those with conventional biventricular pacing (BVP-aCRT). RESULTS A total of 21 patients were enrolled in the study (10 in the LOT-aCRT group, 11 in the BVP-aCRT group). In the LOT-aCRT group, the QRS duration (QRSd) via BVP was narrowed from 158.0 ± 13.0 ms at baseline to 132.0 ± 4.5 ms (P = 0.019) during the procedure, and further narrowed to 123.0 ± 5.7 ms (P < 0.01) via LBBAP. After the procedure, when LOT-aCRT implanted and worked, QRSd was further changed to 121.0 ± 3.8 ms, but the change was not significant (P > 0.05). In the BVP-aCRT group, BVP resulted in a significant reduction in the QRSd from 176.7 ± 19.7 ms at baseline to 133.3 ± 8.2 ms (P = 0.011). However, compared with LOT-aCRT, BVP has no advantage in reducing QRSd and the difference was statistically significant (P < 0.01). During 9 months of follow-up, patients in both groups showed improvements in the LVEF and NT-proBNP levels (all P < 0.01). However, compared with BVP-aCRT, LOT-aCRT showed more significant changes in these parameters (P < 0.01). CONCLUSIONS The study demonstrates that LOT-aCRT is clinically feasible in patients with systolic heart failure and LBBB. LOT-aCRT was associated with significant narrowing of the QRSd and improvement in LV function.
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Affiliation(s)
- Xiang-Fei Feng
- grid.16821.3c0000 0004 0368 8293Department of Cardiology, School of Medicine, Xinhua Hospital, Shanghai Jiao Tong University, #1665, KongJiang Road, Shanghai, 200092 China
| | - Ling-Chao Yang
- grid.16821.3c0000 0004 0368 8293Department of Cardiology, School of Medicine, Xinhua Hospital, Shanghai Jiao Tong University, #1665, KongJiang Road, Shanghai, 200092 China
| | - Yan Zhao
- grid.16821.3c0000 0004 0368 8293Department of Cardiology, School of Medicine, Xinhua Hospital, Shanghai Jiao Tong University, #1665, KongJiang Road, Shanghai, 200092 China
| | - Yi-Chi Yu
- grid.16821.3c0000 0004 0368 8293Department of Cardiology, School of Medicine, Xinhua Hospital, Shanghai Jiao Tong University, #1665, KongJiang Road, Shanghai, 200092 China
| | - Bo Liu
- grid.16821.3c0000 0004 0368 8293Department of Cardiology, School of Medicine, Xinhua Hospital, Shanghai Jiao Tong University, #1665, KongJiang Road, Shanghai, 200092 China
| | - Yi-Gang Li
- grid.16821.3c0000 0004 0368 8293Department of Cardiology, School of Medicine, Xinhua Hospital, Shanghai Jiao Tong University, #1665, KongJiang Road, Shanghai, 200092 China
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25
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Varrias D, De La Hoz MA, Zhao M, Pujol M, Orencole M, Venkata VS, Zordok MA, Luong K, Rana F, Lau E, Ibrahim N, Newton-Cheh C, Heist K, Singh J, Das S. Sex-Specific Differences in Ventricular Remodeling and Response After Cardiac Resynchronization Therapy. Am J Cardiol 2022; 174:68-75. [PMID: 35473782 DOI: 10.1016/j.amjcard.2022.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 01/18/2023]
Abstract
In this study, we investigated the baseline characteristics and "trajectories" of clinical response in men and women after cardiac resynchronization therapy (CRT) implantation. Although women enjoy improved echocardiographic response after CRT compared with men, the kinetics of this response and its relation to functional performance and outcomes are less clear. We identified 592 patients who underwent CRT implantation at our center between 2004 and 2017 and were serially followed in a multidisciplinary clinic. Longitudinal linear mixed effects regression for cardiac response was specified, including interaction terms between time after CRT and sex , and Cox regression models were used to assess differences in all-cause mortality by gender after CRT. Women in our cohort were younger than men, had less frequent ischemic etiology of heart failure (24% vs 60% in men), a shorter QRS (151 vs 161 ms) and more frequent left bundle branch block (77% vs 52%) at baseline. Women had a greater improvement in left ventricular ejection fraction that was evident starting at approximately 1-month after CRT. We did not observe effect modification by gender in New York Heart Association class or 6-minute walk distance after CRT. Although women had improved mortality after CRT, after adjustment for potential confounders, gender was not associated with mortality after CRT. In conclusion, women were more likely to have CRT implantation for left bundle branch block and exhibited improved echocardiographic but not functional response within the first year after CRT. Clinical outcomes after CRT were not associated with gender in adjusted analysis.
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26
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Moulin T, Hamon D, Djouadi K, D'Humières T, Elbaz N, Boukantar M, Zerbib C, Rouffiac S, Dhanjal TS, Ernande L, Derumeaux G, Teiger E, Damy T, Lellouche N. Impact of cardiac resynchronization therapy optimization inside a heart failure programme: a real-world experience. ESC Heart Fail 2022; 9:3101-3112. [PMID: 35748123 DOI: 10.1002/ehf2.14043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/16/2022] [Accepted: 06/03/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS This study sought to describe and evaluate the impact of a routine in-hospital cardiac resynchronization therapy (CRT) programme, including comprehensive heart failure (HF) evaluation and systematic echo-guided CRT optimization. METHODS AND RESULTS CRT implanted patients were referred for optimization programme at 3 to 12 months from implantation. The program included clinical and biological status, standardized screening for potential cause of CRT non-response and systematic echo-guided atrioventricular and interventricular delays (AVd and VVd) optimization. Initial CRT-response and improvement at 6 months post-optimization were assessed with a clinical composite score (CCS). Major HF events were tracked during 1 year after optimization. A total of 227 patients were referred for CRT optimization and enrolled (71 ± 11 years old, 77% male, LVEF 30.6 ± 7.9%), of whom 111 (48.9%) were classified as initial non-responders. Left ventricular lead dislodgement was noted in 4 patients (1.8%), and loss or ≤90% biventricular capture in 22 (9.7%), mostly due to arrhythmias. Of the 196 patients (86%) who could undergo echo-guided CRT optimization, 71 (36.2%) required VVd modification and 50/144 (34.7%) AVd modification. At 6 months post-optimization, 34.3% of the initial non-responders were improved according to the CCS, but neither AVd nor VVd echo-guided modification was significantly associated with CCS-improvement. After one-year follow-up, initial non-responders maintained a higher rate of major HF events than initial responders, with no significant difference between AVd/VVd modified or not. CONCLUSIONS Our study supports the necessity of a close, comprehensive and multidisciplinary follow-up of CRT patients, without arguing for routine use of echo-guided CRT optimization.
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Affiliation(s)
- Thibaut Moulin
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - David Hamon
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - Kamila Djouadi
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - Thomas D'Humières
- Department of Physiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France.,INSERM U955, Université Paris-Est Créteil (UPEC), EUR LIVE, Créteil, France
| | - Nathalie Elbaz
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - Madjid Boukantar
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - Céline Zerbib
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - Ségolène Rouffiac
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - Tarvinder S Dhanjal
- Department of Cardiac Electrophysiology, University of Warwick, Coventry, UK
| | - Laura Ernande
- Department of Physiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - Geneviève Derumeaux
- Department of Physiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France.,INSERM U955, Université Paris-Est Créteil (UPEC), EUR LIVE, Créteil, France
| | - Emmanuel Teiger
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - Thibaud Damy
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
| | - Nicolas Lellouche
- Department of Cardiology, FHU SENEC, AP-HP, University Hospital Henri Mondor, Créteil, France
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Programming Algorithms for Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2022; 14:243-252. [PMID: 35715082 DOI: 10.1016/j.ccep.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Current cardiac resynchronization therapy (CRT) implant guidelines emphasize the presence of electrical dyssynchrony (left bundle branch block (LBBB) and QRS > 150 ms) yet have modest predictive value for response and have not reduced the 30% nonresponse rate. Optimized programming to optimize CRT delivery has promised much but to date has largely been ineffective. What is missing is the understanding of LV paced effects (which are unpredictable) and optimal paced AV interval (that can be conserved during physiologic variations) that then can be incorporated into an individualized programming prescription. Automatic device-based algorithms that deliver electrical optimization and maintain this during ambulatory fluctuations in AV interval are discussed.
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28
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Zweerink A, Burri H. His-Optimized and Left Bundle Branch-Optimized Cardiac Resynchronization Therapy: In Control of Fusion Pacing. Card Electrophysiol Clin 2022; 14:311-321. [PMID: 35715088 DOI: 10.1016/j.ccep.2021.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Fusion pacing, which exploits conduction via the intrinsic His-Purkinje system, forms the basis of recent cardiac resynchronization therapy (CRT) optimization algorithms. However, settings need to be constantly adjusted to accommodate for changes in AV conduction, and the algorithms are not always available (eg, depending on the device, in case of AV block or with atrial fibrillation). His-optimized cardiac resynchronization therapy (HOT-CRT), and left-bundle branch optimized cardiac resynchronization therapy (LOT-CRT) which combines conduction system pacing with ventricular fusion pacing, provide constant fusion with ventricular activation (irrespective of intrinsic AV conduction). These modalities provide promising treatment strategies for patients with heart failure, especially in those with chronic atrial fibrillation who require CRT (in whom the atrial port is usually plugged and can be used to connect the conduction system pacing lead).
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Affiliation(s)
- Alwin Zweerink
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland; Department of Cardiology and Amsterdam Cardiovascular Sciences (ACS), Amsterdam University Medical Centers (AUMC), Location VU Medical Center, Amsterdam, The Netherlands
| | - Haran Burri
- Department of Cardiology, University Hospital of Geneva, Geneva, Switzerland.
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29
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Kusano K, Park S, Johar S, Lim TW, Gerritse B, Hidaka K, Aonuma K. Design of
Mid‐Q
Response: A prospective, randomized trial of adaptive cardiac resynchronization therapy in Asian patients. J Arrhythm 2022; 38:608-614. [PMID: 35936040 PMCID: PMC9347206 DOI: 10.1002/joa3.12731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022] Open
Abstract
Aims The aim of the Mid‐Q Response study is to test the hypothesis that adaptive preferential left ventricular‐only pacing with the AdaptivCRT algorithm has superior clinical outcomes compared to conventional cardiac resynchronization therapy (CRT) in heart failure (HF) patients with moderately wide QRS duration (≥120 ms and <150 ms), left bundle branch block (LBBB), and normal atrioventricular (AV) conduction (PR interval ≤200 ms). Methods This prospective, multi‐center, randomized, controlled, clinical study is being conducted at approximately 60 centers in Asia. Following enrollment and baseline assessment, eligible patients are implanted with a CRT system equipped with the AdaptivCRT algorithm and are randomly assigned in a 1:1 ratio to have AdaptivCRT ON (Adaptive Bi‐V and LV pacing) or AdaptivCRT OFF (Nonadaptive CRT). A minimum of 220 randomized patients are required for analysis of the primary endpoint, clinical composite score (CCS) at 6 months post‐implant. The secondary and ancillary endpoints are all‐cause and cardiovascular death, hospitalizations for worsening HF, New York Heart Association (NYHA) class, Kansas City Cardiomyopathy Questionnaire (KCCQ), atrial fibrillation (AF), and cardiovascular adverse events at 6 or 12 months. Conclusion The Mid‐Q Response study is expected to provide additional evidence on the incremental benefit of the AdaptivCRT algorithm among Asian HF patients with normal AV conduction, moderately wide QRS, and LBBB undergoing CRT implant.
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Affiliation(s)
- Kengo Kusano
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Seung‐Jung Park
- Sungkyunkwan University School of Medicine Samsung Medical Center Seoul South Korea
| | - Sofian Johar
- Gleneagles Jerudong Park Medical Centre and Institute of Health Sciences Universiti Brunei Darussalam Bandar Seri Begawan Brunei Darussalam
| | - Toon Wei Lim
- National University Hospital Singapore Singapore
| | - Bart Gerritse
- Medtronic Bakken Research Center Maastricht The Netherlands
| | | | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine University of Tsukuba Tsukuba Japan
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30
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Ono S, Janoušek J, Ikegawa T, Kawai S, Saito N, Sakaguchi H, Ueda H. Cardiac Resynchronization Therapy Using Single Site Left Ventricular Pacing in a Tricuspid Atresia Patient With Left Bundle Branch Block. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:94-97. [PMID: 37969241 PMCID: PMC10642151 DOI: 10.1016/j.cjcpc.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/31/2022] [Indexed: 11/17/2023]
Abstract
Cardiac resynchronization therapy (CRT) is typically achieved by pacing both ventricles. However, left ventricular-only pacing has been shown to be noninferior to biventricular pacing in patients with left bundle branch block and normal atrioventricular conduction. However, there is no evidence in favour of CRT with single-site pacing for patients with single-ventricle physiology. In this case, we performed CRT with single-site pacing in a patient with tricuspid atresia and left bundle branch block, enabling successful Fontan completion.
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Affiliation(s)
- Shin Ono
- Department of Pediatric Cardiology, Kanagawa Children’s Medical Center, Yokohama, Japan
| | - Jan Janoušek
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Takeshi Ikegawa
- Department of Pediatric Cardiology, Kanagawa Children’s Medical Center, Yokohama, Japan
| | - Shun Kawai
- Department of Pediatric Cardiology, Kanagawa Children’s Medical Center, Yokohama, Japan
| | - Naka Saito
- Department of Pediatric Cardiology, Kanagawa Children’s Medical Center, Yokohama, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideaki Ueda
- Department of Pediatric Cardiology, Kanagawa Children’s Medical Center, Yokohama, Japan
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31
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Harbin MM, Brown CD, Espinoza EA, Burns KV, Bank AJ. Relationship between QRS duration and resynchronization window for CRT optimization: Implications for CRT in narrow QRS patients. J Electrocardiol 2022; 72:72-78. [DOI: 10.1016/j.jelectrocard.2022.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 03/14/2022] [Indexed: 12/28/2022]
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32
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Cost-effective analysis of automated programming optimization in cardiac resynchronization therapy: Holistic Markov modelling. J Cardiol 2022; 79:734-739. [PMID: 35016809 DOI: 10.1016/j.jjcc.2021.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Automated optimization algorithm (AdaptivCRT; Medtronic, Mounds View, MN, USA) allowing automated optimization of cardiac resynchronization therapy (CRT), has been introduced. However, little is known concerning its cost-effectiveness. This study aims to evaluate the potential economic benefits of AdaptivCRT of CRT. METHODS Markov modelling was informed by empirical data sourced from the AdaptivCRT Clinical Trial. Published meta-analyses were used to derive the impact of increasing response to hospitalization and mortality risks. Response was assessed via the clinical composite score. RESULTS Deterministic results suggested a mean survival of 10.97 years with adaptive algorithms against 10.5 years without (+0.47 in favour of novel algorithms). Heart failure hospitalization costs were modelled to ¥1,382,753 (US $12,686) with novel devices against ¥1,524,747 (US $13,989) with previous technology models. Sensitivity analyses show CRT with Adaptive algorithm was projected to provide cost savings in all scenarios. CONCLUSIONS The use of AdaptivCRT was projected to improve average patient survival and avoid costs in a Japanese healthcare setting.
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Fukata M, Yamasaki H, Sai E, Ogawa K, Kuroki K, Igarashi M, Sekiguchi Y, Kimura K, Seo Y, Odashiro K, Akashi K, Nogami A, Aonuma K. Impact of adaptive cardiac resynchronization therapy in patients with systolic heart failure: Beyond QRS duration and morphology. J Cardiol 2021; 79:365-370. [PMID: 34937673 DOI: 10.1016/j.jjcc.2021.11.004] [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: 08/09/2021] [Revised: 10/10/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Mechanical and electrical restoration by cardiac resynchronization therapy (CRT) with adaptive pacing algorithm (aCRT) in heart failure patients with a moderately wide (120-149 ms) QRS has not been fully evaluated. The purpose of this study was to investigate the therapeutic effect of aCRT compared with conventional biventricular CRT (BiV-CRT) regardless of QRS morphology. METHODS Seventeen consecutive patients with a QRS ≥120 ms, regardless of morphology, underwent CRT device implantation with an aCRT pacing algorithm. Propensity score matched analysis was performed to evaluate the impact of aCRT on the improvement in mechanical and electrical parameters after CRT device implantation using historical controls (HC) from the clinical registry of BiV-CRT (START trial). RESULTS Left ventricular (LV) volume significantly decreased after CRT in all patients in both the aCRT and HC groups. The difference in relative reduction of LV end-systolic volume (LVESV) was not significantly different between the 2 arms. QRS shortening after CRT was significantly greater in the aCRT group than in the BiV-CRT group, and the difference was prominent in patients with a moderately wide QRS (120-149 ms). In patients with a moderately wide QRS, the relative reduction in LVESV [39 (29-47)% vs. 2 (-6-20)%, p = 0.04] and proportion of LV volume responders (90% vs. 38%, p = 0.04) were significantly greater in the aCRT group than in the HC group. The proportion of volume responders was not significantly different in patients with a wide QRS (≥150 ms). CONCLUSIONS The aCRT algorithm improved electrical and mechanical parameters in patients with a moderately wide QRS, regardless of QRS morphology.
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Affiliation(s)
- Mitsuhiro Fukata
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan.
| | - Eikou Sai
- Division of Cardiology, National Hospital Organization Kagoshima Medical Center, Kagoshima, Japan
| | - Kojiro Ogawa
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Kenji Kuroki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Miyako Igarashi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Yukio Sekiguchi
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Japan
| | | | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Keita Odashiro
- Division of Cardiology, Kyusyu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
| | - Koich Akashi
- Department of Hematology, Oncology and Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
| | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan
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The importance of early evaluation after cardiac resynchronization therapy to redefine response: Pooled individual patient analysis from 5 prospective studies. Heart Rhythm 2021; 19:595-603. [PMID: 34843964 DOI: 10.1016/j.hrthm.2021.11.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/09/2021] [Accepted: 11/21/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) reduces mortality and improves outcomes in appropriately selected patients with heart failure (HF); however, response may vary. OBJECTIVE We sought to correlate 6-month CRT response assessed by clinical composite score (CCS) and left ventricular end-systolic volume index (LVESVi) with longer-term mortality and HF hospitalizations. METHODS Individual patient data from 5 prospective CRT studies-MIRACLE, MIRACLE ICD, InSync III Marquis, PROSPECT, and Adaptive CRT-were pooled. Classification of CRT response status using CCS and LVESVi were made at 6 months. Kaplan-Meier analyses were used to assess time to mortality. Cox proportional hazards regression models were used to compute hazard ratios (HRs) for the 3 levels of CRT response: improved, stabilized, and worsened. Adjusted models controlled for baseline factors known to influence both CRT response and mortality. HF-related hospitalization was compared between CRT response categories using incidence rate ratios. RESULTS Among a total of 1603 patients, 1426 and 1165 were evaluated in the CCS and LVESVi outcome assessments, respectively. Mortality was significantly lower for patients in the improved (CCS: HR 0.22; 95% confidence interval [CI] 0.15-0.31; LVESVi: HR 0.40; 95% CI 0.27-0.60) and stabilized (CCS: HR 0.38; 95% CI 0.24-0.61; LVESVi: HR 0.41; 95% CI 0.25-0.68) groups than in the worsened group for both measures after adjusting for potential confounders. CONCLUSION Patients with a worsened CRT response status have a high mortality rate and HF hospitalizations. Stabilized patients have a more favorable prognosis than do worsened patients and thus should not be considered CRT nonresponders.
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Bosch R. [Patient with a defibrillator for cardiac resynchronization therapy (CRT-D) and progressive symptoms of heart failure]. Herzschrittmacherther Elektrophysiol 2021; 32:492-499. [PMID: 34748046 DOI: 10.1007/s00399-021-00825-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 10/12/2021] [Indexed: 11/25/2022]
Abstract
A 73-year-old woman with advanced heart failure experienced a deterioration of symptoms and left ventricular function despite treatment with cardiac resynchronization therapy (CRT). The cause was diagnosed by 12-lead ECG and corrected by reprogramming, which led to an improvement in symptoms and echocardiography.
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Affiliation(s)
- Ralph Bosch
- Cardio Centrum Ludwigsburg-Bietigheim (CCLB), Asperger Str. 48, 71634, Ludwigsburg, Deutschland.
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36
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Herweg B, Welter-Frost A, Vijayaraman P. The evolution of cardiac resynchronization therapy and an introduction to conduction system pacing: a conceptual review. Europace 2021; 23:496-510. [PMID: 33247913 DOI: 10.1093/europace/euaa264] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Indexed: 01/14/2023] Open
Abstract
In chronic systolic heart failure and conduction system disease, cardiac resynchronization therapy (CRT) is the only known non-pharmacologic heart failure therapy that improves cardiac function, functional capacity, and survival while decreasing cardiac workload and hospitalization rates. While conventional bi-ventricular pacing has been shown to benefit patients with heart failure and conduction system disease, there are limitations to its therapeutic success, resulting in widely variable clinical response. Limitations of conventional CRT evolve around myocardial scar, fibrosis, and inability to effectively simulate diseased tissue. Studies have shown endocardial stimulation in closer proximity to the specialized conduction system is more effective when compared with epicardial stimulation. Several observational and acute haemodynamic studies have demonstrated improved electrical resynchronization and echocardiographic response with conduction system pacing (CSP). Our objective is to provide a systematic review of the evolution of CRT, and an introduction to CSP as an intriguing, though experimental physiologic alternative to conventional CRT.
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Affiliation(s)
- Bengt Herweg
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, South Tampa Center, 2 Tampa General Circle, Tampa, FL 33606, USA.,Tampa General Hospital, USF Health South Tampa Center, 1 Tampa General Circle, Tampa, FL 33606, USA
| | - Allan Welter-Frost
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, South Tampa Center, 2 Tampa General Circle, Tampa, FL 33606, USA.,Tampa General Hospital, USF Health South Tampa Center, 1 Tampa General Circle, Tampa, FL 33606, USA
| | - Pugazhendhi Vijayaraman
- Division of Cardiology, Geisinger Commonwealth School of Medicine, Geisinger Heart Institute, MC 36-10, 1000 E Mountain Blvd, Wilkes-Barre, PA 18711, USA
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Nielsen JC, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care. Europace 2021; 23:1324-1342. [PMID: 34037728 DOI: 10.1093/europace/euaa411] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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Su Y, Hua W, Shen F, Zou J, Tang B, Chen K, Liang Y, He L, Zhou X, Zhang X, Lu H, Zhang S. Left ventricular-only fusion pacing versus cardiac resynchronization therapy in heart failure patients: A randomized controlled trial. Clin Cardiol 2021; 44:1225-1232. [PMID: 34342026 PMCID: PMC8427977 DOI: 10.1002/clc.23616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/14/2021] [Accepted: 04/20/2021] [Indexed: 11/24/2022] Open
Abstract
Background It is unclear whether clinical benefits of cardiac resynchronization can be achieved by pacing only the left ventricle. Hypothesis We aimed to compare the effect of a novel adaptive left ventricular‐only fusion pacing (LVP) on ventricular function with conventional biventricular pacing (BVP) in cardiac resynchronization therapy (CRT) indicated patients. Methods This prospective, randomized, multicenter study enrolled CRT‐indicated patients with PR interval ≤ 200 ms who were randomized in the adaptive LVP group (using the AdaptivCRT™ algorithm with intentional non‐capture right ventricular pacing) or the echocardiography‐optimized BVP group. Cardiac function and echocardiography were evaluated at baseline and follow‐ups. CRT super response was defined as two‐fold or more increase of left ventricular ejection fraction (LVEF) or final LVEF >45%, and LV end‐systolic volume (LVESV) decrease >15%, and New York Heart Association (NYHA) class improved by at least one level. Results Sixty‐three patients were enrolled in the study (LVP = 34 vs. BVP = 29). At 6‐month follow‐up, significant improvements in LVEF, LVESV, and NYHA class were observed in both groups. The CRT super response rate was significantly higher in patients with high‐percentage adaptive LV‐only pacing in LVP group (68.4%) than in BVP group (36.4%, p = .04). Conclusions Adaptive LV‐only pacing was comparable to BVP in improving cardiac function and clinical condition in CRT‐indicated patients. This finding raises the possibility that an adaptive LVP algorithm with appropriate right ventricular sensing to fuse with intrinsic right ventricular activation in a two‐lead (right atrium and left ventricle) device may provide clinical benefit in a subset of CRT patients with intact atrioventricular conduction.
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Affiliation(s)
- Yangang Su
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, 200032, China
| | - Wei Hua
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Farong Shen
- Department of Cardiology, Zhejiang Greentown Cardiovascular Hospital, Hangzhou, China
| | - Jiangang Zou
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Baopeng Tang
- Department of Pacing and Electrophysiology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Keping Chen
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yixiu Liang
- Department of Cardiology, Zhongshan Hospital of Fudan University, Shanghai Institute of Cardiovascular Diseases, National Clinical Research Center for Interventional Medicine, Shanghai, 200032, China
| | - Lang He
- Department of Cardiology, Zhejiang Greentown Cardiovascular Hospital, Hangzhou, China
| | - Xiaohong Zhou
- Cardiac Rhythm Management, Medtronic plc, Mounds View, Minnesota, USA
| | - Xue Zhang
- Cardiac Rhythm Management, Medtronic Technology Center, Medtronic (Shanghai) Ltd, Shanghai, China
| | - Hongyang Lu
- Cardiac Rhythm Management, Medtronic Technology Center, Medtronic (Shanghai) Ltd, Shanghai, China
| | - Shu Zhang
- Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Haq KT, Rogovoy NM, Thomas JA, Hamilton C, Lutz KJ, Wirth A, Bender AB, German DM, Przybylowicz R, van Dam P, Dewland TA, Dalouk K, Stecker E, Nazer B, Jessel PM, MacMurdy KS, Zarraga IGE, Beitinjaneh B, Henrikson CA, Raitt M, Fuss C, Ferencik M, Tereshchenko LG. Adaptive Cardiac Resynchronization Therapy Effect on Electrical Dyssynchrony (aCRT-ELSYNC): A randomized controlled trial. Heart Rhythm O2 2021; 2:374-381. [PMID: 34430943 PMCID: PMC8369305 DOI: 10.1016/j.hroo.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Adaptive cardiac resynchronization therapy (aCRT) is known to have clinical benefits over conventional CRT, but the mechanisms are unclear. OBJECTIVE Compare effects of aCRT and conventional CRT on electrical dyssynchrony. METHODS A prospective, double-blind, 1:1 parallel-group assignment randomized controlled trial in patients receiving CRT for routine clinical indications. Participants underwent cardiac computed tomography and 128-electrode body surface mapping. The primary outcome was change in electrical dyssynchrony measured on the epicardial surface using noninvasive electrocardiographic imaging before and 6 months post-CRT. Ventricular electrical uncoupling (VEU) was calculated as the difference between the mean left ventricular (LV) and right ventricular (RV) activation times. An electrical dyssynchrony index (EDI) was computed as the standard deviation of local epicardial activation times. RESULTS We randomized 27 participants (aged 64 ± 12 years; 34% female; 53% ischemic cardiomyopathy; LV ejection fraction 28% ± 8%; QRS duration 155 ± 21 ms; typical left bundle branch block [LBBB] in 13%) to conventional CRT (n = 15) vs aCRT (n = 12). In atypical LBBB (n = 11; 41%) with S waves in V5-V6, conduction block occurred in the anterior RV, as opposed to the interventricular groove in strict LBBB. As compared to baseline, VEU reduced post-CRT in the aCRT (median reduction 18.9 [interquartile range 4.3-29.2 ms; P = .034]), but not in the conventional CRT (21.4 [-30.0 to 49.9 ms; P = .525]) group. There were no differences in the degree of change in VEU and EDI indices between treatment groups. CONCLUSION The effect of aCRT and conventional CRT on electrical dyssynchrony is largely similar, but only aCRT harmoniously reduced interventricular dyssynchrony by reducing RV uncoupling.
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Affiliation(s)
- Kazi T. Haq
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Nichole M. Rogovoy
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Jason A. Thomas
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- University of Washington, Seattle, Washington
| | - Christopher Hamilton
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Katherine J. Lutz
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Ashley Wirth
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Aron B. Bender
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- University of California Los Angeles, Los Angeles, California
| | - David M. German
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Ryle Przybylowicz
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | | | - Thomas A. Dewland
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- University of California San Francisco, San Francisco, California
| | - Khidir Dalouk
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Eric Stecker
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Peter M. Jessel
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Karen S. MacMurdy
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Ignatius Gerardo E. Zarraga
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Bassel Beitinjaneh
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Charles A. Henrikson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Merritt Raitt
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Cristina Fuss
- Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Oregon
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
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Su L, Cai M, Wu S, Wang S, Xu T, Vijayaraman P, Huang W. Long-term performance and risk factors analysis after permanent His-bundle pacing and atrioventricular node ablation in patients with atrial fibrillation and heart failure. Europace 2021; 22:ii19-ii26. [PMID: 33370800 DOI: 10.1093/europace/euaa306] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS His-bundle pacing (HBP) combined with atrioventricular node (AVN) ablation has been demonstrated to be effective in patients with atrial fibrillation (AF) and heart failure (HF) during medium-term follow-up and there are limited data on the risk analysis of adverse prognosis in this population. In this study, we aimed to evaluate the long-term performance of HBP following AVN ablation in AF and HF. METHODS AND RESULTS From August 2012 to December 2017, consecutive AF patients with HF and narrow QRS who underwent AVN ablation and HBP were enrolled. The clinical and echocardiographic data, pacing parameters, all-cause mortality, and heart failure hospitalization (HFH) were tracked. A total of 94 patients were enrolled (age 70.1 ± 10.5 years; male 57.4%). Acute HBP were achieved in 89 (94.7%) patients with successful permanent HBP combined with AVN ablation in 81 (86.2%) patients. Left ventricular ejection fraction (LVEF) improved from 44.9 ± 14.9% at baseline to 57.6 ± 12.5% during a median follow-up of 3.0 (IQR: 2.0-4.4) years (P < 0.001). Heart failure hospitalization or all-cause mortality occurred in 21 (25.9%) patients. The LVEF ≤ 40%, pulmonary artery systolic pressure (PASP) ≥40 mmHg, or serum creatinine (Scr) ≥97 μmol/L at baseline was significantly associated with higher composite endpoint of HFH or death (P < 0.05). The His capture threshold was 1.0 ± 0.7 V/0.5 ms at implant and remained stable during follow-up. CONCLUSION His-bundle pacing combined with AVN ablation was effective in patients with AF and drug-refectory HF. High PASP, high Scr, or low LVEF at baseline was independent predictors of composite endpoint of all-cause mortality or HFH.
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Affiliation(s)
- Lan Su
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Science and Technology of Wenzhou, Wenzhou, China
| | - Mengxing Cai
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Science and Technology of Wenzhou, Wenzhou, China
| | - Shengjie Wu
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Science and Technology of Wenzhou, Wenzhou, China
| | - Songjie Wang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Science and Technology of Wenzhou, Wenzhou, China
| | - Tiancheng Xu
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Science and Technology of Wenzhou, Wenzhou, China
| | - Pugazhendhi Vijayaraman
- Department of Cardiac Electrophysiology, Geisinger Commonwealth School of Medicine, Wilkes-Barre, PA, USA
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou 325000, China.,The Key Lab of Cardiovascular Disease of Wenzhou, Science and Technology of Wenzhou, Wenzhou, China
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Abstract
Despite constant breakthroughs in heart failure (HF) therapy, the population of HF patients resume to grow and is linked to increased mortality and morbidity. Ventricular arrhythmias (VA) are one of the leading causes of mortality in HF subjects. Implantable cardioverter-defibrillators (ICDs) are currently the gold standard in treatment, preventing arrhythmic sudden cardiac death (SCD) episodes. However, the death rates related to HF remain elevated, as not all HF subjects benefit equally. Cardiac resynchronization therapy (CRT) has emerged as a novel approach for HF patients. These devices have been thoroughly investigated in major randomized controlled studies but continue to be underutilized in various countries. This review discusses the use of ICD
in HF populations on top of treatments.
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Cosedis Nielsen J, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology. Eur J Heart Fail 2021; 22:2349-2369. [PMID: 33136300 DOI: 10.1002/ejhf.2046] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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Varma N. Fine-tuning delivery of cardiac resynchronization therapy: Optimization for "triple fusion". HeartRhythm Case Rep 2021; 7:425-428. [PMID: 34194995 PMCID: PMC8226313 DOI: 10.1016/j.hrcr.2021.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Cardiac resynchronization therapy (CRT) is an important and effective therapy for end-stage heart failure. Non-response to CRT is one of the main obstacles to its application in clinical practice. There is no uniform consensus or definition of CRT “response.” Clinical symptoms, ventricular remodeling indices, and cardiovascular events have been reported to be associated with non-responders. To prevent non-response to CRT, three aspects should be thoroughly considered: preoperative patient selection, electrode implantation, and postoperative management. Preoperative selection of appropriate patients for CRT treatment is an important step in preventing non-response. Currently, the CRT inclusion criteria are mainly based on the morphology of QRS waves in deciding ventricular dyssynchrony. Echocardiography and cardiac magnetic resonance are being explored to predict nonresponse to CRT. The location of left ventricular electrode implantation is a current hot spot of research; it is important to identify the location of the latest exciting ventricular segment and avoid scars. Cardiac magnetic resonance and ultrasonic spot tracking are being progressively developed in this field. Some new techniques such as His Bundle pacing, endocardial electrodes, and novel sensors are also being investigated. Postoperative management of patients is another essential step towards preventing non-response; it mainly focuses on the treatment of the disease itself and CRT program control optimization. CRT treatment is just one part of the overall treatment of heart failure, and multidisciplinary efforts are needed to improve the overall outcome.
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Gierula J, Paton MF, Witte KK. Advances in cardiac resynchronization and implantable cardioverter/defibrillator therapy: Medtronic Cobalt and Crome. Future Cardiol 2021; 17:609-618. [PMID: 33635121 DOI: 10.2217/fca-2020-0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cardiovascular implantable electronic devices have revolutionized the management of heart failure with reduced ejection fraction. New device generations tend to be launched every few years, with incremental improvements in performance and safety and with an expectation that these will improve patient management and outcomes while remaining cost-effective. As a result, today's cardiac resynchronization therapy (CRT) and implantable cardioverter defibrillator devices are quite different from the pioneering but often bulky devices of the late 20th century. This review discusses new and improved features developed to target specific needs in managing heart failure patients, some of which are especially pertinent to the current worldwide healthcare situation, with focus on the latest generation of CRTs with defibrillator (CRT-Ds) and implantable cardioverter defibrillators from Medtronic.
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Affiliation(s)
- John Gierula
- Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
| | - Maria F Paton
- Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular & Metabolic Medicine, University of Leeds, Leeds, UK
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Chung ES, Rickard J, Lu X, DerSarkissian M, Zichlin ML, Cheung HC, Swartz N, Greatsinger A, Duh MS. Real-World Economic Burden Among Patients With And Without Heart Failure Worsening After Cardiac Resynchronization Therapy. Adv Ther 2021; 38:441-467. [PMID: 33141415 DOI: 10.1007/s12325-020-01536-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/14/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Although cardiac resynchronization therapy (CRT) has the potential to improve cardiac function in patients with heart failure (HF), a considerable portion of patients do not respond to therapy. This study assessed the economic burden among patients with and without HF worsening after receiving CRT in real-world practice. METHODS In this retrospective claims-based study using Optum's de-identified Clinformatics® Data Mart Database (January 2007-December 2018), adults who received CRT were stratified into two cohorts based on whether they showed evidence of HF worsening within 180 days post-CRT implantation. Inverse probability of treatment weighting (IPTW) was used to adjust for confounding, accounting for demographics (e.g., age, sex), the Quan-Charlson Comorbidity Index, other clinical characteristics, healthcare resource utilization (HRU), and healthcare costs during the 180 days pre-CRT (baseline period). Annualized all-cause and congestive HF-related HRU and healthcare costs from payer and patient perspectives were assessed from day 181 post-CRT (follow-up period), and compared between cohorts using incidence rate ratios (IRRs) and cost ratios (CRs). RESULTS This study included 12,753 patients (n = 4785 with HF worsening; n = 7968 without). Mean age was 72 years and roughly two-thirds were male. Baseline characteristics were balanced between cohorts post-IPTW. During follow-up, patients with HF worsening had significantly greater annual all-cause inpatient [adjusted IRR (95% confidence interval) = 1.55 (1.44, 1.66), p < 0.001], outpatient [adjusted IRR = 1.46 (1.32, 1.61), p < 0.001], and emergency department [adjusted IRR = 1.31 (1.22, 1.41), p < 0.001] visits. Mean annual total per patient payer-paid amounts were significantly higher for patients with HF worsening versus without HF worsening [adjusted CR = 1.68 (1.56, 1.80), p < 0.001]. Annual patient-paid medical costs were also higher for patients with HF worsening [adjusted CR = 1.31 (1.25, 1.38), p < 0.001]. Results were similar for congestive HF-related HRU and costs. CONCLUSIONS The incremental economic burden among patients with HF worsening following CRT is substantial. Efforts aimed at CRT optimization may help reduce this burden.
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Filippatos G, Lu X, Tsintzos SI, Gold MR, Mullens W, Birnie D, Hersi AS, Kusano K, Leclercq C, Fagan DH, Wilkoff BL. Economic implications of adding a novel algorithm to optimize cardiac resynchronization therapy: rationale and design of economic analysis for the AdaptResponse trial. J Med Econ 2020; 23:1401-1408. [PMID: 33043737 DOI: 10.1080/13696998.2020.1835333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AIMS Although cardiac resynchronization therapy (CRT) has proven beneficial in several randomized trials, a subset of patients have limited clinical improvement. The AdaptivCRT algorithm provides automated selection between synchronized left ventricular or biventricular pacing with optimization of atrioventricular delays. The rationale and design of the economic analysis of the AdaptResponse clinical trial are described. RATIONALE The costs associated with HF hospitalization are substantial and are compounded by a high rate of readmission. HF hospitalization payments range from $1,001 for Greece to $12,235 for US private insurance. When examining the breakdown of HF-related costs, it is clear that approximately 55% of the hospitalization costs are directly attributable to length of stay. Notably, the mean costs of a CRT patient in need of a HF-related hospitalization are currently estimated to be an average of $10,679. METHODS The economic analysis of the AdaptResponse trial has two main objectives. The hospital provider objective seeks to test the hypothesis that AdaptivCRT reduces the incidence of all-cause re-admissions after a heart failure admission within 30 days of the index event. A negative binomial regression model will be used to estimate and compare the number of readmissions after an index HF hospitalization. The payer economic objective will assess cost-effectiveness of CRT devices with the AdaptivCRT algorithm relative to traditional CRT programming. This analysis will be conducted from a U.S. payer perspective. A decision analytic model comprised of a 6-month decision tree and a Markov model for long term extrapolation will be used to evaluate lifetime costs and benefits. CONCLUSION AdaptivCRT may offer improvements over traditional device programming in patient outcomes. How the data from AdaptResponse will be used to demonstrate if these clinical benefits translate into substantial economic gains is herein described.
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Affiliation(s)
- Gerasimos Filippatos
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Xiaoxiao Lu
- Cardiac Rhythm and Heart Failure (CRHF), Medtronic plc, Mounds View, MN, USA
| | - Stelios I Tsintzos
- Cardiac Rhythm and Heart Failure (CRHF), Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - Michael R Gold
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Wilfried Mullens
- Department of Cardiology, Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - David Birnie
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Canada
| | - Ahmad S Hersi
- Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Osaka, Japan
| | | | - Dedra H Fagan
- Cardiac Rhythm and Heart Failure (CRHF), Medtronic plc, Mounds View, MN, USA
| | - Bruce L Wilkoff
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA
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Covino G, Volpicelli M, Ciardiello C, Capogrosso P. Usefulness of Hemodynamic Device-Based Optimization in Heterogeneous Patients Implanted with Cardiac Resynchronization Therapy Defibrillator. J Cardiovasc Transl Res 2020; 13:938-943. [PMID: 32385806 DOI: 10.1007/s12265-020-10004-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
Optimization of the atrioventricular (AV) and interventricular (VV) timings of the CRT is the most supposed correctable variable to improve the rate of CRT responder. The aim of the present study has been to evaluate if there is a specific subgroup of patients who can actually benefit the most from a hemodynamic optimization of AV. This is a prospective, observational single-center study that enrolled consecutive patients with clinical indication for CRT; all patients were implanted with CRT-D devices with SonR technology, able to automatically adjust AV and VV delay on a weekly basis. Among 57 patients, 39 (69%) showed a LVESV reduction > 15%. The SonR was able to modify the pacing parameters, but an increase of left atrial diameter was associated to a reduced AV variability, suggesting that an impaired left atrial function could potentially reduce the ability of the SonR algorithm to adjust the correct timing of pacing. Graphical abstract Patients with respectively a high (A) and low (B) AV timing variability, among several parameters that could potentially influence the AV timing, only left atrial dimensions demonstrated a significant impact. In fact an increase of left atrial diameter was associated to a reduced AV variability, suggesting that an impaired left atrial function could potentially reduce the ability of the SonR algorithm to adjust the correct timing of pacing.
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Affiliation(s)
- Gregorio Covino
- Ospedale San Giovanni Bosco, Via Filippo Maria Briganti, 255, 80144, Naples, Italy
| | - Mario Volpicelli
- Ospedale San Giovanni Bosco, Via Filippo Maria Briganti, 255, 80144, Naples, Italy
| | | | - Paolo Capogrosso
- Ospedale San Giovanni Bosco, Via Filippo Maria Briganti, 255, 80144, Naples, Italy
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Wang Z, Wu Y, Zhang J. Cardiac resynchronization therapy in heart failure patients: tough road but clear future. Heart Fail Rev 2020; 26:735-745. [PMID: 33098491 DOI: 10.1007/s10741-020-10040-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/07/2020] [Indexed: 01/14/2023]
Abstract
Cardiac resynchronization therapy (CRT) based on biventricular pacing (BVP) is an invaluable intervention currently used in heart failure (HF) patients. The therapy involves electromechanical dyssynchrony, which can not only improve heart function and quality of life but also reduce hospitalization and mortality rates. However, approximately 30% to 40% of patients remain unresponsive to conventional BVP in clinical practice. In the recent years, extensive research has been employed to find a more physiological approach to cardiac resynchronization. The His-Purkinje system pacing (HPSP) including His bundle pacing (HBP) and left bundle branch area pacing (LBBaP) may potentially be the future of CRT. These technologies present various advantages including offering an almost real physiological pacing, less complicated procedures, and economic feasibility. Additionally, other methods, such as isolated left-ventricular pacing and multipoint pacing, may in the future be important but non-mainstream alternatives to CRT because currently, there is no strong evidence to support their effectiveness. This article reviews the current situation and latest progress in CRT, explores the existing technology, and highlights future prospects in the development of CRT.
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Affiliation(s)
- Ziyu Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China
| | - Yongquan Wu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.
| | - Junmeng Zhang
- Department of Cardiology, Heart Center, the First Hospital of Tsinghua University, No. 6 Jiuxianqiao 1st Street, Chaoyang District, Beijing, 100016, China.
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50
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Ogawa K, Igarashi M, Nogami A, Yamamoto M, Sugano A, Sekiguchi Y, Aonuma K, Ieda M. The Usefulness and Limitations of Impedance Cardiography for Cardiac Resynchronization Therapy Device Optimization. Int Heart J 2020; 61:896-904. [PMID: 32999195 DOI: 10.1536/ihj.19-620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Identifying the optimal atrioventricular (AV) or interventricular (VV) delay is beneficial for patients using cardiac resynchronization therapy (CRT) devices. Ultrasonic echocardiography (UCG) has been the most commonly used method; however, it requires high technical knowledge. Impedance cardiography (ICG) can calculate stroke volume by measuring changes in transthoracic electric impedance. This study sought to assess the clinical utility of ICG in comparison with that of UCG for the optimization of CRT devices.Patients who underwent CRT device implantation were retrospectively analyzed. One week after implantation, optimization of AV delay (AVD) was performed in every patient with ICG (AVD-ICG) and UCG (AVD-UCG). VV delay (VVD) was then determined according to the optimal AVD using these two methods.Forty-two patients were enrolled. Average AVD-ICG was significantly shorter than AVD-UCG (128 ± 49 versus 146 ± 41 milliseconds, P = 0.018). Five patients (12%) had the same optimized AVD with two methods, and the difference between AVD-ICG and AVD-UCG was ≤ 20 milliseconds in 19 patients (45%). In the multivariate analysis, the presence of postoperative mitral regurgitation (MR) was an independent predictor of AVD-ICG/AVD-UCG mismatch, defined as a difference over 20 milliseconds (odds ratio = 10.71; 95% confidence interval = 1.72 to 66.72; P = 0.018). The results of optimized VVD were similar using both methods.ICG might be a promising tool for the rapid optimization of CRT devices. However, in patients with moderate-to-severe MR, ICG may not be able to optimize AVD.
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Affiliation(s)
- Kojiro Ogawa
- Department of Cardiology, Faculty of Medicine, University of Tsukuba.,Department of Cardiology, Hitachi General Hospital
| | - Miyako Igarashi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Akinori Sugano
- Department of Cardiology, Faculty of Medicine, University of Tsukuba.,Department of Cardiology, Tsukuba Medical Center Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba.,Department of Internal Medicine (Cardiology), Kasumigaura Medical Center
| | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
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