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Gerra L, Bonini N, Mei DA, Imberti JF, Vitolo M, Bucci T, Boriani G, Lip GYH. Cardiac resynchronization therapy (CRT) non-responders in the contemporary era: A State-of-the-Art review. Heart Rhythm 2024:S1547-5271(24)02670-5. [PMID: 38848860 DOI: 10.1016/j.hrthm.2024.05.057] [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: 04/29/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024]
Abstract
Since 2000s CRT became a revolutionary therapy for heart failure with reduced left ventricular ejection fraction (HFrEF) and wide QRS. However, about one third of CRT recipients do not show a favorable response. This review of current literature aims to better define the concept of CRT response/non-response. The diagnosis of CRT non-responder should be viewed as a continuum, and it cannot rely solely on a single parameter. Moreover, several patients' baseline features might predict an unfavorable response. A strong collaboration between HF specialists and electrophysiologists is key to overcoming this challenge with multiple strategies. In the contemporary era, new pacing modalities, such as His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) represent a promising alternative to CRT. Observational studies demonstrated their potential; however, several limitations should be addressed. Large randomized controlled trials are needed to prove their efficacy in HFrEF with electromechanical dyssynchrony.
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Affiliation(s)
- Luigi Gerra
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Niccolò Bonini
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Davide Antonio Mei
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Jacopo Francesco Imberti
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Marco Vitolo
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of General and Specialized Surgery, Sapienza University of Rome, Italy
| | - Giuseppe Boriani
- Cardiology Division Department of Biomedical Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Kuschyk J, Sattler K, Fastenrath F, Rudic B, Akin I. [Treatment with cardiac electronic implantable devices]. Herz 2024; 49:233-246. [PMID: 38709278 DOI: 10.1007/s00059-024-05246-1] [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] [Accepted: 03/19/2024] [Indexed: 05/07/2024]
Abstract
Cardiac device therapy provides not only treatment options for bradyarrhythmia but also advanced treatment for heart failure and preventive measures against sudden cardiac death. In heart failure treatment it enables synergistic reverse remodelling and reduces pharmacological side effects. Cardiac resynchronization therapy (CRT) has revolutionized the treatment of reduced left ventricular ejection fraction (LVEF) and left bundle branch block by decreasing the mortality and morbidity with improvement of the quality of life and resilience. Conduction system pacing (CSP) as an alternative method of physiological stimulation can improve heart function and reduce the risk of pacemaker-induced cardiomyopathy. Leadless pacers and subcutaneous/extravascular defibrillators offer less invasive options with lower complication rates. The prevention of infections through preoperative and postoperative strategies enhances the safety of these therapies.
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Affiliation(s)
- Jürgen Kuschyk
- I. Medizinische Klinik, Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Katherine Sattler
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Fabian Fastenrath
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Boris Rudic
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - Ibrahim Akin
- I. Medizinische Klinik, Sektion für Invasive Kardiologie und Elektrophysiologie, Universitätsmedizin Mannheim, Mannheim, Deutschland
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3
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Bray JJH, Coronelli M, Scott SGC, Henry JA, Couch LS, Ahmad M, Ormerod J, Gamble J, Betts TR, Lewis A, Rider OJ, Green PG, Herring N. The effect of sodium-glucose co-transporter 2 inhibitors on outcomes after cardiac resynchronization therapy. ESC Heart Fail 2024. [PMID: 38649305 DOI: 10.1002/ehf2.14784] [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: 12/08/2023] [Revised: 02/14/2024] [Accepted: 03/10/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS The trials upon which recommendations for the use of cardiac resynchronization therapy (CRT) in heart failure used optimal medical therapy (OMT) before sodium-glucose co-transporter 2 inhibitors (SGLT2i). Moreover, the SGLT2i heart failure trials included only a small proportion of participants with CRT, and therefore, it remains uncertain whether SGLT2i should be considered part of OMT prior to CRT. METHODS AND RESULTS We compared electrocardiogram (ECG) and echocardiographic responses to CRT as well as hospitalization and mortality rates in consecutive patients undergoing implantation at a large tertiary centre between January 2019 to June 2022 with and without SGLT2i treatment. Three hundred seventy-four participants were included aged 74.0 ± 11.5 years (mean ± standard deviation), with a left ventricular ejection fraction (LVEF) of 31.8 ± 9.9% and QRS duration of 161 ± 29 ms. The majority had non-ischaemic cardiomyopathy (58%) and were in NYHA Class II/III (83.6%). These characteristics were similar between patients with (n = 66) and without (n = 308) prior SGLT2i treatment. Both groups demonstrated similar evidence of response to CRT in terms of QRS duration shortening, and improvements in LVEF, left ventricular end-diastolic inner-dimension (LVIDd) and diastolic function (E/A and e/e'). While there was no difference in rates of hospitalization (for heart failure or overall), mortality was significantly lower in patients treated with SGLT2i compared with those who were not (6.5 vs. 16.6%, P = 0.049). CONCLUSIONS We observed an improvement in mortality in patients undergoing CRT prescribed SGLT2i compared with those not prescribed SGLT2i, despite similar degrees of reverse remodelling. The authors recommend starting SGLT2i prior to CRT implantation, where it does not delay implantation.
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Affiliation(s)
- Jonathan J H Bray
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Marco Coronelli
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Sam G C Scott
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - John A Henry
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Liam S Couch
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Mahmood Ahmad
- UCL Medical School, University College London, London, UK
| | - Julian Ormerod
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - James Gamble
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Timothy R Betts
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Andrew Lewis
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Oliver J Rider
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Peregrine G Green
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
| | - Neil Herring
- Oxford Heart Centre, Oxford University Hospitals, NHS Trust, Oxford, UK
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
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Gold MR, Auricchio A, Leclercq C, Wold N, Stein KM, Ellenbogen KA. Atrioventricular optimization improves cardiac resynchronization response in patients with long interventricular electrical delays: A pooled analysis of the SMART-AV and SMART-CRT trials. Heart Rhythm 2024:S1547-5271(24)02277-X. [PMID: 38604592 DOI: 10.1016/j.hrthm.2024.03.1783] [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: 03/07/2024] [Revised: 03/21/2024] [Accepted: 03/24/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND The utility of atrioventricular (AV) optimization (AVO) algorithms remains in question. A substudy of the SMART-AV trial found that patients with prolonged interventricular delays ≥70 ms were more likely to benefit from cardiac resynchronization therapy (CRT) with AVO. The SMART-CRT trial evaluated AVO on the basis of these results, but the study was underpowered. OBJECTIVE To increase statistical power, data from SMART-AV patients meeting the inclusion criterion of interventricular delay ≥70 ms were pooled with data from SMART-CRT to reassess AVO. METHODS SMART-CRT and SMART-AV were prospective, randomized, multicenter clinical trials. Patients in both studies were randomized to be programmed with an AVO algorithm (SmartDelay) or fixed AV delay (120 ms). Paired echocardiograms obtained at baseline and 6 months were compared, with CRT response defined as ≥15% reduction in left ventricular end-systolic volume. RESULTS A total of 451 complete patient data sets were pooled and analyzed. The baseline demographics between studies did not differ statistically in terms of age, sex, left ventricular ejection fraction, or left ventricular end-systolic volume. The AVO group had a greater proportion of CRT responders (SmartDelay, 73.9%; fixed, 63.1%; P = .014) and greater changes in measures of reverse remodeling. SmartDelay patients with a recommended sensed AV delay outside the nominal range (100-120 ms) had 2.3 greater odds of CRT response than fixed AV delay patients. CONCLUSION Greater CRT response and measures of reverse remodeling were observed in patients with SmartDelay enabled vs a fixed AV delay. This study supports the use of SmartDelay in patients with a CRT indication and interventricular delay ≥70 ms. CLINICALTRIALS GOV REGISTRATION NCT00677014 and NCT03089281.
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Affiliation(s)
- Michael R Gold
- Medical University of South Carolina, Charleston, South Carolina.
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Passafaro F, Rapacciuolo A, Ruocco A, Ammirati G, Crispo S, Pasceri E, Santarpia G, Mauro C, Esposito G, Indolfi C, Curcio A. COMPArison of Multi-Point Pacing and ConvenTional Cardiac Resynchronization Therapy Through Noninvasive Hemodynamics Measurement: Short- and Long-Term Results of the COMPACT-MPP Study. Am J Cardiol 2024; 215:42-49. [PMID: 38237796 DOI: 10.1016/j.amjcard.2023.12.057] [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: 10/15/2023] [Revised: 12/11/2023] [Accepted: 12/27/2023] [Indexed: 02/01/2024]
Abstract
Invasive hemodynamic studies have shown improved left ventricular (LV) performances when cardiac resynchronization therapy/defibrillator is delivered through multipoint pacing (MPP). Nowadays, strategies have become available that allow studying the same hemodynamic parameters at a noninvasive level. The aim of the present study was to evaluate the clinical implication of using a patient-tailored approach for cardiac resynchronization therapy programming based on noninvasively assessed LV hemodynamics to identify the best biventricular pacing modality between standard single-site pacing (STD) and MPP for each patient. Therefore, 51 patients with heart failure (age 69 ± 9 years, 35 men, 27% ischemic etiology) implanted with cardiac resynchronization therapy/defibrillator underwent noninvasive LV function assessment through photoplethysmography before hospital discharge for addressing dP/dt and stroke volume in both pacing modalities (STD and MPP). The modality that performed better in terms of hemodynamic improvement was permanently programmed. Global longitudinal strain (GLS) was also assessed, and repeated at 3 months. Compared with intrinsic rhythm (928 ± 486 mm Hg/s), dP/dtmax showed a trend to increase in both biventricular pacing modes (1,000 ± 577 mm Hg/s in STD, 1,036 ± 530 mm Hg/s in MPP, p = NS). MPP was associated with a wider hemodynamic improvement than was STD and was the modality of choice in 34 of 51 patients (67%). GLS at predischarge did not differ between groups (-10.3 ± 3.8% vs -10.2 ± 3.5%), but significant improvement of ejection fraction at 1 month (34.4 ± 5.3%, p <0.001) and of GLS at 3 months (-12.9 ± 2.9%, p <0.005) was observed across the entire cohort. At 3 months, 77% of patients were classified as responders. Interestingly, long-term (3 years) follow-up unveiled a reduction in all-cause mortality in the MPP group compared with the STD group. In conclusion, cardiac resynchronization therapy programming guided by acute noninvasive hemodynamics favored MPP modality and caused short-term LV positive remodeling and improved long-term outcomes. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT04299360.
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Affiliation(s)
- Francesco Passafaro
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Antonio Rapacciuolo
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Antonio Ruocco
- Division of Cardiology, Emergency Department, AORN Cardarelli, Naples, Italy
| | - Giuseppe Ammirati
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Salvatore Crispo
- Division of Cardiology, Emergency Department, AORN Cardarelli, Naples, Italy
| | - Eugenia Pasceri
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Santarpia
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Ciro Mauro
- Division of Cardiology, Emergency Department, AORN Cardarelli, Naples, Italy
| | - Giovanni Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Ciro Indolfi
- Division of Cardiology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Antonio Curcio
- Division of Cardiology, Department of Pharmacy, Health Sciences and Nutrition, University of Calabria, Cosenza, Italy.
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6
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Linde C. Electrical therapies in heart failure: Evolving technologies and indications. Presse Med 2024; 53:104192. [PMID: 37898311 DOI: 10.1016/j.lpm.2023.104192] [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: 06/06/2023] [Accepted: 10/06/2023] [Indexed: 10/30/2023] Open
Abstract
Device therapy for heart failure has rapidly evolved over 2 decades. The knowledge of indications, assessment lead and device technology has expanded to include CRT, leadless pacing and conduction system pacing such as His bundle and left bundle branch area pacing. But there is still a lack of evidence for these new technologies as well as for common indications such as atrial fibrillation and upgrading from a previous device. The role of personalized medicine will become increasingly important when selecting candidates for CRT, primary preventive ICD ablation procedures and emerging new devices such as cardiac contractility modulation (CCM). Rapidity of therapy is associated with outcome which will be a challenge. If properly implemented devices and drugs will have a large positive affect of HF outcomes.
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Affiliation(s)
- Cecilia Linde
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Karolinska Universitetssjukhuset, Stockholm, Sweden.
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7
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Tsurumi N, Inden Y, Yanagisawa S, Hiramatsu K, Yamauchi R, Watanabe R, Suzuki N, Shimojo M, Suga K, Tsuji Y, Murohara T. Clinical outcomes and predictors of delayed echocardiographic response to cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2024; 35:97-110. [PMID: 37897084 DOI: 10.1111/jce.16125] [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: 05/09/2023] [Revised: 10/17/2023] [Accepted: 10/26/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION The clinical outcomes and mechanisms of delayed responses to cardiac resynchronization therapy (CRT) remain unclear. We aimed to investigate the differences in outcomes and gain insight into the mechanisms of early and delayed responses to CRT. METHODS This retrospective study included 110 patients who underwent CRT implantation. Positive response to CRT was defined as ≥15% reduction of left ventricular (LV) end-systolic volume on echocardiography at 1 year (early phase) and 3 years (delayed phase) after implantation. The latest mechanical activation site (LMAS) of the LV was identified using two-dimensional speckle-tracking radial strain analysis. RESULTS Seventy-eight (71%) patients exhibited an early response 1 year after CRT implantation. Of 32 non-responders in the early phase, 12 (38%) demonstrated a delayed response, and 20 (62%) were classified as non-responders after 3 years. During the follow-up time of 10.3 ± 0.5 years, the delayed and early responders had a similar prognosis of mortality and heart failure (HF) hospitalization. In contrast, non-responders had a worse prognosis. Multivariate analysis revealed that a longer duration (months) between initial HF hospitalization and CRT (odds ratio [OR]: 1.126; 95% confidence interval [CI]: 1.036-1.222; p = .005), non-exact concordance of LV lead location with LMAS (OR: 32.744; 95% CI: 1.101-973.518; p = .044), and pre-QRS duration (OR: 0.901; 95% CI: 0.827-0.981; p = .016) were independent predictors of delayed response to CRT compared with early response. CONCLUSION The prognoses were similar regardless of the response time after CRT. A longer history of HF, suboptimal LV lead position, and shorter pre-QRS duration were related to delayed response than early response.
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Affiliation(s)
- Naoki Tsurumi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Satoshi Yanagisawa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kei Hiramatsu
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Ryota Yamauchi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Ryo Watanabe
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Noriyuki Suzuki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masafumi Shimojo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kazumasa Suga
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yukiomi Tsuji
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Dural M, Ghossein MA, Gerrits W, Daniels F, Meine M, Maass AH, Rienstra M, Prinzen FW, Vernooy K, van Stipdonk AMW. Association of vectorcardiographic T-wave area with clinical and echocardiographic outcomes in cardiac resynchronization therapy. Europace 2023; 26:euad370. [PMID: 38146837 PMCID: PMC10766142 DOI: 10.1093/europace/euad370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023] Open
Abstract
AIMS Data on repolarization parameters in cardiac resynchronization therapy (CRT) are scarce. We investigated the association of baseline T-wave area, with both clinical and echocardiographic outcomes of CRT in a large, multi-centre cohort of CRT recipients. Also, we evaluated the association between the baseline T-wave area and QRS area. METHODS AND RESULTS In this retrospective study, 1355 consecutive CRT recipients were evaluated. Pre-implantation T-wave and QRS area were calculated from vectorcardiograms. Echocardiographic response was defined as a reduction of ≥15% in left ventricular end-systolic volume between 3 and 12 months after implantation. The clinical outcome was a combination of all-cause mortality, heart transplantation, and left ventricular assist device implantation. Left ventricular end-systolic volume reduction was largest in patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs compared with QRS area ≥ 109 μVs and T-wave area < 66 μVs (P = 0.004), QRS area < 109 μVs and T-wave area ≥ 66 μVs (P < 0.001) and QRS area < 109 μVs and T-wave area < 66 μVs (P < 0.001). Event-free survival rate was higher in the subgroup of patients with QRS area ≥ 109 μVs and T-wave area ≥ 66 μVs (n = 616, P < 0.001) and QRS area ≥ 109 μVs and T-wave area < 66 μVs (n = 100, P < 0.001) than the other subgroups. In the multivariate analysis, T-wave area remained associated with echocardiographic response (P = 0.008), but not with the clinical outcome (P = 0.143), when QRS area was included in the model. CONCLUSION Baseline T-wave area has a significant association with both clinical and echocardiographic outcomes after CRT. The association of T-wave area with echocardiographic response is independent from QRS area; the association with clinical outcome, however, is not.
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Affiliation(s)
- Muhammet Dural
- Department of Cardiology, Eskişehir Osmangazi University Faculty of Medicine, Odunpazarı, Eskişehir 26040, Turkey
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
| | - Mohammed A Ghossein
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Willem Gerrits
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Fenna Daniels
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mathias Meine
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alexander H Maass
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
| | - Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre+, Maastricht 6202, The Netherlands
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Veres B, Fehérvári P, Engh MA, Hegyi P, Gharehdaghi S, Zima E, Duray G, Merkely B, Kosztin A. Time-trend treatment effect of cardiac resynchronization therapy with or without defibrillator on mortality: a systematic review and meta-analysis. Europace 2023; 25:euad289. [PMID: 37766466 PMCID: PMC10585357 DOI: 10.1093/europace/euad289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
AIMS This study aimed to investigate the impact of cardiac resynchronization therapy with a defibrillator (CRT-D) on mortality, comparing it with CRT with a pacemaker (CRT-P). Additionally, the study sought to identify subgroups, evaluate the time trend in treatment effects, and analyze patient characteristics, considering the changing indications over the past decades. METHODS AND RESULTS PubMed, CENTRAL, and Embase up to October 2021 were screened for studies comparing CRT-P and CRT-D, focusing on mortality. Altogether 26 observational studies were selected comprising 128 030 CRT patients, including 55 469 with CRT-P and 72 561 with CRT-D device. Cardiac resynchronization therapy with defibrillator was able to reduce all-cause mortality by almost 20% over CRT-P [adjusted hazard ratio (HR): 0.85; 95% confidence interval (CI): 0.76-0.94; P < 0.01] even in propensity-matched studies (HR: 0.83; 95% CI: 0.80-0.87; P < 0.001) but not in those with non-ischaemic aetiology (HR: 0.95; 95% CI: 0.79-1.15; P = 0.19) or over 75 years (HR: 1.08; 95% CI 0.96-1.21; P = 0.17). When treatment effect on mortality was investigated by the median year of inclusion, there was a difference between studies released before 2015 and those thereafter. Time-trend effects could be also observed in patients' characteristics: CRT-P candidates were getting older and the prevalence of ischaemic aetiology was increasing over time. CONCLUSION The results of this systematic review of observational studies, mostly retrospective with meta-analysis, suggest that patients with CRT-D had a lower risk of mortality compared with CRT-P. However, subgroups could be identified, where CRT-D was not superior such as non-ischaemic and older patients. An improved treatment effect of CRT-D on mortality could be observed between the early and late studies partly related to the changed characteristics of CRT candidates.
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Affiliation(s)
- Boglárka Veres
- Heart and Vascular Center, Semmelweis University, Városmajor Str. 68, 1122 Budapest, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Fehérvári
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biostatistics, University of Veterinary Medicine, Budapest, Hungary
| | - Marie Anne Engh
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Sara Gharehdaghi
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Gottsegen György National Cardiovascular Institute, Budapest, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, Városmajor Str. 68, 1122 Budapest, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Gábor Duray
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Central Hospital of Northern Pest-Military Hospital, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Városmajor Str. 68, 1122 Budapest, Hungary
| | - Annamária Kosztin
- Heart and Vascular Center, Semmelweis University, Városmajor Str. 68, 1122 Budapest, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
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10
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Linde C. Will the results from the AdaptResponse trial boost CRT use? Lancet 2023; 402:1110-1112. [PMID: 37634522 DOI: 10.1016/s0140-6736(23)01313-2] [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: 05/19/2023] [Accepted: 06/22/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Cecilia Linde
- Heart, Vascular and Neurology Theme, Karolinska University Hospital, Stockholm, Sweden; Karolinska Institutet, 171 77 Stockholm, Sweden.
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11
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Ellenbogen KA, Auricchio A, Burri H, Gold MR, Leclercq C, Leyva F, Linde C, Jastrzebski M, Prinzen F, Vernooy K. The evolving state of cardiac resynchronization therapy and conduction system pacing: 25 years of research at EP Europace journal. Europace 2023; 25:euad168. [PMID: 37622580 PMCID: PMC10450796 DOI: 10.1093/europace/euad168] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 08/26/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) was proposed in the 1990s as a new therapy for patients with heart failure and wide QRS with depressed left ventricular ejection fraction despite optimal medical treatment. This review is aimed first to describe the rationale and the physiologic effects of CRT. The journey of the landmark randomized trials leading to the adoption of CRT in the guidelines since 2005 is also reported showing the high level of evidence for CRT. Different alternative pacing modalities of CRT to conventional left ventricular pacing through the coronary sinus have been proposed to increase the response rate to CRT such as multisite pacing and endocardial pacing. A new emerging alternative technique to conventional biventricular pacing, conduction system pacing (CSP), is a promising therapy. The different modalities of CSP are described (Hirs pacing and left bundle branch area pacing). This new technique has to be evaluated in clinical randomized trials before implementation in the guidelines with a high level of evidence.
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Affiliation(s)
- Kenneth A Ellenbogen
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Angelo Auricchio
- Division of Cardiology, Università della Svizzera Italiana and Istituto Cardiocentro Ticino, Lugano, Switzerland
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | | | - Francisco Leyva
- Aston University, Birmingham NHS Trust at Queen Elizabeth Hospital, Birmingham, UK
| | - Cecilia Linde
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Frits Prinzen
- Physiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC), Maastricht, the Netherlands
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12
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Boriani G, Bertini M, Manzo M, Calò L, Santini L, Savarese G, Dello Russo A, Santobuono VE, Lavalle C, Viscusi M, Amellone C, Calvanese R, Santoro A, Rapacciuolo A, Ziacchi M, Arena G, Imberti JF, Campari M, Valsecchi S, D’Onofrio A. Performance of a multi-sensor implantable defibrillator algorithm for heart failure monitoring in the presence of atrial fibrillation. Europace 2023; 25:euad261. [PMID: 37656991 PMCID: PMC10498140 DOI: 10.1093/europace/euad261] [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: 05/19/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023] Open
Abstract
AIMS The HeartLogic Index combines data from multiple implantable cardioverter defibrillators (ICDs) sensors and has been shown to accurately stratify patients at risk of heart failure (HF) events. We evaluated and compared the performance of this algorithm during sinus rhythm and during long-lasting atrial fibrillation (AF). METHODS AND RESULTS HeartLogic was activated in 568 ICD patients from 26 centres. We found periods of ≥30 consecutive days with an atrial high-rate episode (AHRE) burden <1 h/day and periods with an AHRE burden ≥20 h/day. We then identified patients who met both criteria during the follow-up (AHRE group, n = 53), to allow pairwise comparison of periods. For control purposes, we identified patients with an AHRE burden <1 h throughout their follow-up and implemented 2:1 propensity score matching vs. the AHRE group (matched non-AHRE group, n = 106). In the AHRE group, the rate of alerts was 1.2 [95% confidence interval (CI): 1.0-1.5]/patient-year during periods with an AHRE burden <1 h/day and 2.0 (95% CI: 1.5-2.6)/patient-year during periods with an AHRE-burden ≥20 h/day (P = 0.004). The rate of HF hospitalizations was 0.34 (95% CI: 0.15-0.69)/patient-year during IN-alert periods and 0.06 (95% CI: 0.02-0.14)/patient-year during OUT-of-alert periods (P < 0.001). The IN/OUT-of-alert state incidence rate ratio of HF hospitalizations was 8.59 (95% CI: 1.67-55.31) during periods with an AHRE burden <1 h/day and 2.70 (95% CI: 1.01-28.33) during periods with an AHRE burden ≥20 h/day. In the matched non-AHRE group, the rate of HF hospitalizations was 0.29 (95% CI: 0.12-0.60)/patient-year during IN-alert periods and 0.04 (95% CI: 0.02-0.08)/patient-year during OUT-of-alert periods (P < 0.001). The incidence rate ratio was 7.11 (95% CI: 2.19-22.44). CONCLUSION Patients received more alerts during periods of AF. The ability of the algorithm to identify increased risk of HF events was confirmed during AF, despite a lower IN/OUT-of-alert incidence rate ratio in comparison with non-AF periods and non-AF patients. CLINICAL TRIAL REGISTRATION http://clinicaltrials.gov/Identifier: NCT02275637.
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Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Matteo Bertini
- Cardiology Department, University of Ferrara, S. Anna University Hospital, Ferrara, Italy
| | - Michele Manzo
- Cardiology Department, OO.RR. San Giovanni di Dio Ruggi d'Aragona, Salerno, Italy
| | - Leonardo Calò
- Division of Cardiology, Policlinico Casilino, Rome, Italy
| | - Luca Santini
- Division of Cardiology, Giovan Battista Grassi’ Hospital, Rome, Italy
| | - Gianluca Savarese
- Division of Cardiology, ‘S. Giovanni Battista’ Hospital, Foligno, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, Ancona, Italy
| | - Vincenzo Ezio Santobuono
- University Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Policlinico di Bari, Bari, Italy
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Miguel Viscusi
- Cardiology Department, S. Anna e S. Sebastiano Hospital, Caserta, Italy
| | | | | | | | - Antonio Rapacciuolo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Matteo Ziacchi
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Giuseppe Arena
- Cardiology Department, Ospedale Civile Apuane, Massa (MS), Italy
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Monica Campari
- Rhythm Management Division, Boston Scientific, Milan, Italy
| | | | - Antonio D’Onofrio
- Unità Operativa di Elettrofisiologia, Studio e Terapia delle Aritmie, Monaldi Hospital, Naples, Italy
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13
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Salah HM, Fudim M, Burkhoff D. Device Interventions for Heart Failure. JACC. HEART FAILURE 2023; 11:1039-1054. [PMID: 37611987 DOI: 10.1016/j.jchf.2023.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 08/25/2023]
Abstract
Despite remarkable advances in drug therapy for heart failure (HF), the residual HF-related morbidity, mortality, and hospitalizations remain substantial across all HF phenotypes, and significant proportions of patients with HF remain symptomatic despite optimal drug therapy. Driven by these unmet clinical needs, the exponential growth of transcatheter interventions, and a recent shift in the regulatory landscape of device-based therapies, novel device-based interventions have emerged as a potential therapy for various phenotypes of HF. Device-based interventions can overcome some of the limitations of drug therapy (eg, intolerance, nonadherence, inconsistent delivery, and recurrent and long-term cost) and can target some HF-related pathophysiologic pathways more effectively than drug therapy. This paper reviews the current evolving landscape of device-based interventions in HF and highlights critical points related to implementation of these therapies in the current workflow of HF management.
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Affiliation(s)
- Husam M Salah
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York, New York, USA.
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14
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Gatti P, Lind S, Kristjánsdóttir I, Azari A, Savarese G, Anselmino M, Linde C, Gadler F. Prognosis of CRT-treated and CRT-untreated unselected population with LBBB in Stockholm County. Europace 2023; 25:euad192. [PMID: 37403689 PMCID: PMC10365846 DOI: 10.1093/europace/euad192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/23/2023] [Indexed: 07/06/2023] Open
Abstract
AIMS Left bundle branch block (LBBB) might be the first finding of cardiovascular diseases but also the prerequisite for cardiac resynchronization therapy (CRT) in heart failure (HF) with reduced ejection fraction (HFrEF). The prognosis for patients with LBBB and the implications of CRT in an unselected real-world setting are the focus of our study. METHODS AND RESULTS A central electrocardiogram (ECG) database and national registers have been screened to identify patients with LBBB. Predictors of HF and the use of CRT were identified with Cox models. The hazard ratios (HRs) of death, cardiovascular death (CVD), and HF hospitalization (HFH) were estimated according to CRT use. Of 5359 patients with LBBB and QRS > 150 ms, median age 76 years, 36% were female. At the time of index ECG, 41% had a previous history of HF and 27% developed HF. Among 1053 patients with a class I indication for CRT, only 60% received CRT with a median delay of 137 days, and it was associated with a lower risk of death [HR: 0.45, 95% confidence interval (CI): 0.36-0.57], CVD (HR: 0.47, 95% CI: 0.35-0.63), and HFH (HR: 0.56, 95% CI: 0.48-0.66). The age of over 75 years and the diagnosis of dementia and chronic obstructive pulmonary disease were predictors of CRT non-use, while having a pacing/defibrillator device independently predicted CRT use. CONCLUSION In an unselected LBBB population, CRT is underused but of great value for HF patients. Therefore, it is crucial to find ways of better implementing and understanding CRT utilization and characteristics that influence the management of our patients.
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Affiliation(s)
- Paolo Gatti
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
| | - Stefan Lind
- Department of Cardiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Ingibjörg Kristjánsdóttir
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
| | - Ava Azari
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
- Department of Cardiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Cecilia Linde
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
- Department of Cardiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Fredrik Gadler
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
- Department of Cardiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
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15
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Leyva F, Zegard A, Patel P, Stegemann B, Marshall H, Ludman P, de Bono J, Boriani G, Qiu T. Improved prognosis after cardiac resynchronization therapy over a decade. Europace 2023; 25:euad141. [PMID: 37265253 PMCID: PMC10236714 DOI: 10.1093/europace/euad141] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/16/2023] [Indexed: 06/03/2023] Open
Abstract
AIMS The past decade has seen an increased delivery of cardiac resynchronization therapy (CRT) for patients with heart failure (HF). We explored whether clinical outcomes after CRT have changed from the perspective of an entire public healthcare system. METHODS AND RESULTS A national database covering the population of England (56.3 million in 2019) was used to explore clinical outcomes after CRT from 2010 to 2019. A total of 64 698 consecutive patients (age 71.4 ± 11.7 years; 74.8% male) underwent CRT-defibrillation [n = 32 313 (49.7%)] or CRT-pacing [n = 32 655 (50.3%)] implantation. From 2010-2011 to 2018-2019, there was a 76% increase in CRT implantations. During the same period, the proportion of patients with hypertension (59.6-73.4%), diabetes (26.5-30.8%), and chronic kidney disease (8.62-22.5%) increased, as did the Charlson comorbidity index (CCI ≥ 3 from 20.0% to 25.1%) (all P < 0.001). Total mortality decreased at 30 days (1.43-1.09%) and 1 year (9.51-8.13%) after implantation (both P < 0.001). At 2 years, total mortality [hazard ratio (HR): 0.72; 95% confidence interval (CI) 0.69-0.76] and total mortality or HF hospitalization (HR: 0.59; 95% CI 0.57-0.62) decreased from 2010-2011 to 2018-2019, after correction for age, race, sex, device type (CRT-defibrillation or pacing), comorbidities (hypertension, diabetes, chronic kidney disease, and myocardial infarction), or the CCI (HR: 0.81; 95% CI 0.77-0.85). CONCLUSIONS From the perspective of an entire public health system, survival has improved and HF hospitalizations have decreased after CRT implantation over the past decade. This prognostic improvement has occurred despite an increasing comorbidity burden.
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Affiliation(s)
- Francisco Leyva
- Aston Medical Reseach Insitute, Aston Medical School, Aston University, Aston Triangle, Birmingham B4 7ET, UK
| | - Abbasin Zegard
- Aston Medical Reseach Insitute, Aston Medical School, Aston University, Aston Triangle, Birmingham B4 7ET, UK
- Univeristy Hospitals Birmingham Queen Elizabeth, Mindelsohn Way, Birmingham B15 2WB, UK
| | - Peysh Patel
- Univeristy Hospitals Birmingham Queen Elizabeth, Mindelsohn Way, Birmingham B15 2WB, UK
| | - Berthold Stegemann
- Aston Medical Reseach Insitute, Aston Medical School, Aston University, Aston Triangle, Birmingham B4 7ET, UK
- Univeristy Hospitals Birmingham Queen Elizabeth, Mindelsohn Way, Birmingham B15 2WB, UK
| | - Howard Marshall
- Univeristy Hospitals Birmingham Queen Elizabeth, Mindelsohn Way, Birmingham B15 2WB, UK
| | - Peter Ludman
- Univeristy Hospitals Birmingham Queen Elizabeth, Mindelsohn Way, Birmingham B15 2WB, UK
| | - Joseph de Bono
- Univeristy Hospitals Birmingham Queen Elizabeth, Mindelsohn Way, Birmingham B15 2WB, UK
| | - Giuseppe Boriani
- Cardiology Division, Department of Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Via Universita 4, Modena 41100, Italy
| | - Tian Qiu
- Univeristy Hospitals Birmingham Queen Elizabeth, Mindelsohn Way, Birmingham B15 2WB, UK
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