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Suchodolski A, Jędrzejczyk-Patej E, Kowalska W, Mazurek M, Lenarczyk R, Kowalski O, Kalarus Z, Szulik M. Echocardiographic imaging in patients with conduction system pacing. Cardiovasc Ultrasound 2025; 23:14. [PMID: 40382643 PMCID: PMC12085811 DOI: 10.1186/s12947-025-00349-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Accepted: 04/30/2025] [Indexed: 05/20/2025] Open
Abstract
Conduction system pacing (CSP), encompassing His-bundle pacing (HBP) and left bundle branch area pacing (LBBAP), revolutionizes cardiac pacing, allowing a more physiological left ventricular activation than conventional right ventricular (RV) pacing through electrode placed in RV apex, interventricular septum or right ventricular outflow tract. Echocardiography plays a pivotal role in patient assessment, primarily by measuring left ventricular ejection fraction (LVEF) to determine the pacing strategy in alignment with current guidelines. Clinical data, simulations and ongoing trials on CSP explore CSP viability across various LVEF conditions. CSP is supposed to defer pacing-induced cardiomyopathy (PiCM) associated with conventional right ventricular pacing (RVP). This paper aims to review the current literature regarding the use of echocardiography in CSP. Images from our experience in the echocardiographic lab were used throughout this document to show our proposals of imaging in CSP. Echocardiography may help to determine lead localization within the interventricular septum (IVS), customizing pacing to individual anatomy and electromechanical indices (like atro-ventricular delay) and evaluates often-overlooked valvular function, a potential PiCM contributor. Three-dimensional (3-D) echocardiography widens the knowledge of lead localization and valvular dysfunction, as well as dyssynchrony assessment. Dyssynchrony, crucial both to resynchronization per se and physiological stimulation is quantified via echocardiography, especially using speckle-tracking imaging. Baseline LVEF and follow-up observation of CSP effects: early in Global Longitudinal Strain (GLS), afterwards in LV volumes and LVEF may improve the future proper qualification of patients. Limited left atrial (LA) and right atrial (RA) strain assessments hold potential in the CSP qualification and response assessment context. Echocardiography complements other imaging modalities for comprehensive patient evaluation. Echocardiography is integral in the CSP clinical use, from patient selection (by showing subtle changes in myocardial function) to post-procedure follow-up (tricuspid regurgitation, LV and RV function, leads and synchrony assessment). GLS, assessed by speckle tracking imaging and profound 2D and 3D (lead placement, septum morphology and global heart function under CSP) analyses show promise in CSP outcome assessment, though standardization is needed.
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Affiliation(s)
- Alexander Suchodolski
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences, Silesian Center for Heart Diseases, Medical University of Silesia, ZabrzeKatowice, Poland.
- Doctoral School of the, Medical University of Silesia, Katowice, Katowice, Poland.
- Silesian Center for Heart Diseases, Marii Skłodowskiej-Curie 9, 41-800, Zabrze, Poland.
| | - Ewa Jędrzejczyk-Patej
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences, Silesian Center for Heart Diseases, Medical University of Silesia, ZabrzeKatowice, Poland
| | - Wiktoria Kowalska
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences, Silesian Center for Heart Diseases, Medical University of Silesia, ZabrzeKatowice, Poland
- Doctoral School of the, Medical University of Silesia, Katowice, Katowice, Poland
| | - Michał Mazurek
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences, Silesian Center for Heart Diseases, Medical University of Silesia, ZabrzeKatowice, Poland
| | - Radosław Lenarczyk
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences, Silesian Center for Heart Diseases, Medical University of Silesia, ZabrzeKatowice, Poland
| | - Oskar Kowalski
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences, Silesian Center for Heart Diseases, Medical University of Silesia, ZabrzeKatowice, Poland
| | - Zbigniew Kalarus
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences, Silesian Center for Heart Diseases, Medical University of Silesia, ZabrzeKatowice, Poland
| | - Mariola Szulik
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences, Silesian Center for Heart Diseases, Medical University of Silesia, ZabrzeKatowice, Poland
- Collegium Medicum - Faculty of Medicine, Department of Medical and Health Sciences, Faculty of Applied Sciences, WSB University, Dąbrowa Górnicza, Poland
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Strocchi M, Samways JW, Naraen A, Ali N, Shun-Shin MJ, Gillette K, Rinaldi CA, Arnold AD, Plank G, Vigmond EJ, Whinnett ZI, Niederer SA. An in silico guide for ventriculo-ventricular delay programming for left bundle branch-optimized cardiac resynchronization therapy. Europace 2025; 27:euaf089. [PMID: 40394990 DOI: 10.1093/europace/euaf089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2024] [Accepted: 04/16/2025] [Indexed: 05/22/2025] Open
Abstract
AIMS Left bundle branch pacing (LBBP)-optimized cardiac resynchronization therapy (LOT-CRT) can improve left ventricular (LV) activation when LBBP alone or conventional biventricular pacing are ineffective. However, the optimal programming settings for ventriculo-ventricular delay (VVD) for LOT-CRT are unknown. We aim to investigate how to optimally program VVD for LOT-CRT in the presence of various LV conduction substrates using computational modelling. METHODS AND RESULTS We simulated ventricular activation on 24 anatomies and validated the model against clinical data. Diffuse LV conduction system and intra-myocardial delay were simulated by slowing the conduction velocity of the LV His-Purkinje system and myocardium, respectively, alone or in combination with proximal left bundle branch block (LBBB). We simulated LOT-CRT with selective or myocardial capture (LV septal pacing, LVSP) with VVD ranging between -100 ms (LBBP/LVSP ahead) and +100 ms [LV epicardial lead (LVepiP), ahead]. Response was quantified with 95% LV activation times (LVAT95). In the presence of diffuse LV conduction system delay, the optimal VVD for LOT-CRT was always negative (LBBB: -42.5 ± 6.6 ms; no LBBB: -36.2 ± 5.6 ms), as delivering LBBP ahead of LVepiP compensates for the slow LV His-Purkinje. In the presence of LV intra-myocardial disease, the shortest LVAT95 with LOT-CRT was achieved by pacing the coronary sinus LV first (optimal VVD for LBBB: 23.3 ± 8.5 ms; no LBBB: 79.2 ± 18.0 ms). The type of capture for LOT-CRT affected the optimal VVD, with myocardial capture favouring negative VVDs (LVSP ahead). CONCLUSION The optimal VVD for LOT-CRT depends on the mechanism of delayed LV activation and type of capture achieved, highlighting the importance of VVD optimization.
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Affiliation(s)
- Marina Strocchi
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, London W12 0NN, UK
| | - Jack W Samways
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, London W12 0NN, UK
| | - Akriti Naraen
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, London W12 0NN, UK
| | - Nadine Ali
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, London W12 0NN, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, London W12 0NN, UK
| | - Karli Gillette
- Gottfried Schatz Research Center, Division of Medical Physics and Biophysics, Medical University of Graz, Graz, Austria
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
- Scientific Computing and Imaging Institute, University of Utah, Salt Lake City, UT, USA
| | - Christopher Aldo Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Cardiovascular Department, Guys' and St Thomas' NHS Foundation Trust, London, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, London W12 0NN, UK
| | - Gernot Plank
- Gottfried Schatz Research Center, Division of Medical Physics and Biophysics, Medical University of Graz, Graz, Austria
- BioTechMed-Graz, Graz, Austria
| | - Edward J Vigmond
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation University Bordeaux, Pessac-Bordeaux, France
- Institute of Mathematics of Bordeaux, UMR 5251, University of Bordeaux, Bordeaux, Talence, France
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, London W12 0NN, UK
| | - Steven A Niederer
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, London W12 0NN, UK
- The Alan Turing Institute, London, UK
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Glikson M, Burri H, Abdin A, Cano O, Curila K, De Pooter J, Diaz JC, Drossart I, Huang W, Israel CW, Jastrzębski M, Joza J, Karvonen J, Keene D, Leclercq C, Mullens W, Pujol-Lopez M, Rao A, Vernooy K, Vijayaraman P, Zanon F, Michowitz Y. European Society of Cardiology (ESC) clinical consensus statement on indications for conduction system pacing, with special contribution of the European Heart Rhythm Association of the ESC and endorsed by the Asia Pacific Heart Rhythm Society, the Canadian Heart Rhythm Society, the Heart Rhythm Society, and the Latin American Heart Rhythm Society. Europace 2025; 27:euaf050. [PMID: 40159278 PMCID: PMC11957271 DOI: 10.1093/europace/euaf050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2025] [Revised: 03/09/2025] [Accepted: 03/10/2025] [Indexed: 04/02/2025] Open
Abstract
Conduction system pacing (CSP) is being increasingly adopted as a more physiological alternative to right ventricular and biventricular pacing. Since the 2021 European Society of Cardiology pacing guidelines, there has been growing evidence that this therapy is safe and effective. Furthermore, left bundle branch area pacing was not covered in these guidelines due to limited evidence at that time. This Clinical Consensus Statement provides advice on indications for CSP, taking into account the significant evolution in this domain.
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Affiliation(s)
- Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, 12 Shmuel Beit Street, 9103102, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Geneva, Switzerland
| | - Amr Abdin
- Internal Medicine Clinic III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Homburg/Saar, Germany
| | - Oscar Cano
- Unidad de Arritmias, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Karol Curila
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jan De Pooter
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Juan C Diaz
- Clínica Las Vegas, Universidad CES, Medellín, Colombia
| | - Inga Drossart
- ESC Patient Forum, Sophia Antipolis, France
- European Society of Cardiology, Sophia Antipolis, France
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Carsten W Israel
- Department of Medicine-Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Krakow, Poland
| | - Jacqueline Joza
- Department of Medicine, McGill University Health Centre, Montreal, Canada
| | - Jarkko Karvonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Christophe Leclercq
- Service de Cardiologie et Maladies Vasculaires, Université de Rennes, CHU Rennes, INSERM, LTSI—UMR 1099, F-35000 Rennes, France
| | | | - Margarida Pujol-Lopez
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Archana Rao
- Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | | - Yoav Michowitz
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, 12 Shmuel Beit Street, 9103102, Jerusalem, Israel
- Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Manetti CA, van Osta N, Beela AS, Herbots L, Prinzen FW, Delhaas T, Lumens J. Impact of myocardial phenotype on optimal atrioventricular delay settings during biventricular and left bundle branch pacing at rest and during exercise: insights from a virtual patient study. Europace 2025; 27:euaf082. [PMID: 40195045 PMCID: PMC12035189 DOI: 10.1093/europace/euaf082] [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: 03/24/2025] [Accepted: 04/01/2025] [Indexed: 04/09/2025] Open
Abstract
AIMS Previous studies have not examined the role of non-electrical myocardial disease substrates in determining the optimal atrio-ventricular delay (AVD) settings. We conducted virtual patient simulations to evaluate whether myocardial disease substrates influence the acute response to AVD optimization at rest and during exercise. METHODS AND RESULTS The CircAdapt cardiovascular model was used to simulate various left ventricular (LV) remodelling found in cardiac resynchronization therapy candidates. We simulated electrical dyssynchrony, LV dilatation with preserved and reduced contractility, and increased LV passive stiffness. We simulated cardiac resynchronization following biventricular (BiVP) and non-selective LBB pacing (nsLBBP). The paced-AVD ranged from 220 to 40 ms. Cardiac output and heart rate were increased to simulate different levels of exercise. The optimal AVD was the one leading to the highest stroke volume (SV) and the lowest mean left atrial pressure (mLAP). At rest, in simulations with healthy myocardium the gain in SV by AVD optimization was larger compared to those with reduced contractility and stiff myocardium. However, mLAP was comparably decreased by AVD optimization in both healthy and diseased myocardium. During exercise, the optimal AVD shifted to shorter values, and mLAP was more sensitive to AVD, particularly in the presence of hypo-contractile and stiff myocardium. CONCLUSION Simulations show that hypocontractility and stiffness reduce the effect of AVD optimization on SV but enhance its benefit in lowering mLAP. Notably, virtual patients with stiff ventricles experience greater benefits from AVD optimization during exercise compared to resting conditions. Furthermore, nsLBBP provides more favourable improvements in mLAP than BiVP.
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Affiliation(s)
- Claudia A Manetti
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Universiteitssingel 40, 6229 ERMaastricht, The Netherlands
| | - Nick van Osta
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Universiteitssingel 40, 6229 ERMaastricht, The Netherlands
| | - Ahmed S Beela
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Universiteitssingel 40, 6229 ERMaastricht, The Netherlands
- Department of Cardiovascular Diseases, Faculty of Medicine, Suez Canal University, Ismailia 41522, Egypt
| | - Lieven Herbots
- Department of Cardiology, Hartcentrum Hasselt, Jessa Hospital, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Universiteitssingel 40, 6229 ERMaastricht, The Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Universiteitssingel 40, 6229 ERMaastricht, The Netherlands
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van Loon T, Rijks J, van Koll J, Wolffs J, Cornelussen R, van Osta N, Luermans J, Prinzen F, Linz D, van Empel V, Delhaas T, Vernooy K, Lumens J. Accelerated atrial pacing reduces left-heart filling pressure: a combined clinical-computational study. Eur Heart J 2024; 45:4953-4964. [PMID: 39589540 PMCID: PMC11631061 DOI: 10.1093/eurheartj/ehae718] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 08/08/2024] [Accepted: 10/06/2024] [Indexed: 11/27/2024] Open
Abstract
BACKGROUND AND AIMS Accelerated atrial pacing offers potential benefits for patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF), compared with standard lower-rate pacing. The study investigates the relationship between atrial pacing rate and left-heart filling pressure. METHODS Seventy-five consecutive patients undergoing catheter ablation for AF underwent assessment of mean left atrial pressure (mLAP) and atrioventricular (AV) conduction delay (PR interval) in sinus rhythm and accelerated atrial pacing with 10 bpm increments up to Wenckebach block. Computer simulations (CircAdapt) of a virtual HFpEF cohort complemented clinical observations and hypothesized the modulating effects of AV coupling and atrial (dys)function. RESULTS In the study cohort, 49(65%) patients had a high HFpEF likelihood (H2FPEF ≥ 5.0), and 28(37%) an elevated mLAP ≥ 15 mmHg at sinus rhythm. Optimal pacing rates of 100 [70-110]bpm (median [IQR]) significantly reduced mLAP from 12.8 [10.0-17.4]mmHg in sinus rhythm (55 [52-61]bpm) to 10.4 [7.8-14.8]mmHg (P < .001). Conversely, higher pacing rates (130 [110-140]bpm) significantly increased mLAP to 14.7 [11.0-17.8]mmHg (P < .05). PR interval and, hence, AV conduction delay prolonged incrementally with increasing pacing rates. Simulations corroborated these clinical findings, showing mLAP reduction at a moderately increased pacing rate and a subsequent increase at higher rates. Moreover, simulations suggested that mLAP reduction is optimized when AV conduction delay shortens with increasing rate. CONCLUSIONS Accelerated pacing acutely reduces left-heart filling pressure in patients undergoing AF catheter ablation and computer simulations with HFpEF features, suggesting it as a potential therapeutic strategy to alleviate congestion symptoms. Virtual HFpEF patient cohorts hypothesize that AV sequential pacing may further optimize this therapy's beneficial effects.
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Affiliation(s)
- Tim van Loon
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Jesse Rijks
- Department of Cardiology, Cardiovascular Research institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Johan van Koll
- Department of Cardiology, Cardiovascular Research institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joey Wolffs
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Richard Cornelussen
- Department of Physiology, Cardiovascular Research institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Nick van Osta
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Justin Luermans
- Department of Cardiology, Cardiovascular Research institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Frits Prinzen
- Department of Physiology, Cardiovascular Research institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Vanessa van Empel
- Department of Cardiology, Cardiovascular Research institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Universiteitssingel 40, 6229 ER Maastricht, The Netherlands
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Rijks JHJ, Heckman L, Westra S, Cornelussen R, Ghosh S, Curila K, Smisek R, Grieco D, Bressi E, Nguyên UC, Lumens J, van Stipdonk AMW, Linz D, Prinzen FW, Luermans JGLM, Vernooy K. Assessment of ventricular electrical heterogeneity in left bundle branch pacing and left ventricular septal pacing by using various electrophysiological methods. J Cardiovasc Electrophysiol 2024; 35:2282-2292. [PMID: 39313856 DOI: 10.1111/jce.16435] [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: 04/02/2024] [Revised: 08/13/2024] [Accepted: 09/08/2024] [Indexed: 09/25/2024]
Abstract
INTRODUCTION Left bundle branch area pacing (LBBAP) comprises pacing at the left ventricular septum (LVSP) or left bundle branch (LBBP). The aim of the present study was to investigate the differences in ventricular electrical heterogeneity between LVSP, LBBP, right ventricular pacing (RVP) and intrinsic conduction with different dyssynchrony measures using the ECG, vectorcardiograpy, ECG belt, and Ultrahigh frequency (UHF-)ECG. METHODS Thirty-seven patients with a pacemaker indication for bradycardia or cardiac resynchronization therapy underwent LBBAP implantation. ECG, vectorcardiogram, ECG belt and UHF-ECG signals were recorded during RVP, LVSP and LBBP, and intrinsic activation. QRS duration (QRSd) was measured from the ECG, QRS area was calculated from the vectorcardiogram, LV activation time (LVAT) and standard deviation of activation time (SDAT) from ECG belt and electrical dyssynchrony (e-DYS16) from UHF-ECG. RESULTS Both LVSP and LBBP significantly reduced ventricular electrical heterogeneity as compared to underlying LBBB and RV pacing in terms of QRS area (p < .001), SDAT (p < .001), LVAT (p < .001) and e-DYS16 (p < .001). QRSd was only reduced as compared to RV pacing(p < .001). QRS area was similar during LBBP and normal intrinsic conduction, e-DYS16 was similar during LVSP and normal intrinsic conduction, whereas SDAT was similar for LVSP, LBBP and normal intrinsic conduction. For all these variables there was no significant difference between LVSP and LBBP. CONCLUSION Both LVSP and LBBP resulted in a more synchronous LV activation than LBBB and RVP. Especially LBBP resulted in levels of LV synchrony comparable to normal intrinsic conduction.
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Affiliation(s)
- Jesse H J Rijks
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Luuk Heckman
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Sjoerd Westra
- Department of Cardiology, Radboud University Medical Center (RadboudUMC), Nijmegen, The Netherlands
| | | | - Subham Ghosh
- Medtronic, Fridley, Minnesota, United States of America
| | - Karol Curila
- Department of Cardiology, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Pregue, Czechia
| | - Radovan Smisek
- The Czech Academy of Sciences, Institute of Scientific Instruments, Brno, Czechia
| | - Domenico Grieco
- Department of Cardiology, Policlinico Casilino of Rome, Rome, Italy
| | - Edoardo Bressi
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
- Department of Cardiology, Policlinico Casilino of Rome, Rome, Italy
| | - Uyên Châu Nguyên
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Antonius M W van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
| | - Dominik Linz
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), Maastricht, The Netherlands
- Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Justin G L M Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+ (MUMC+), 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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7
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Graterol FR, Pujol-López M, Borràs R, Ayala B, Uribe L, Guasch E, Regany-Closa M, Niebla M, Carro E, Guichard JB, Castel MÁ, Arbelo E, Porta-Sánchez A, Sitges M, Brugada J, Roca-Luque I, Doltra A, Mont L, Tolosana JM. Predictors of failed left bundle branch pacing implant in heart failure with reduced ejection fraction: Importance of left ventricular diameter and QRS morphology. Heart Rhythm 2024; 21:2571-2578. [PMID: 38906515 DOI: 10.1016/j.hrthm.2024.06.019] [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: 04/05/2024] [Revised: 05/31/2024] [Accepted: 06/13/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Left bundle branch pacing (LBBP) is considered an alternative to cardiac resynchronization therapy (CRT). However, LBBP is not suitable for all patients with heart failure. OBJECTIVE The aim of our study was to identify predictors of unsuccessful LBBP implantation in CRT candidates. METHODS A cohort of consecutive patients with indications for CRT were included. Clinical, echocardiographic, and electrocardiographic variables were prospectively recorded. RESULTS A total of 187 patients were included in the analysis. LBBP implantation was successful in 152 of 187 patients (81.2%) and failed in 35 of 187 patients (18.7%). The causes of unsuccessful implantation were unsatisfactory paced QRS morphology (28 of 35 [80%]), inability to screw the helix (4 of 35 [11.4%]), lead instability (2 of 35 [5.7%]), and high pacing thresholds (1 of 35 [2.8%]). The left ventricular end-diastolic diameter (LVEDD), non-LBBB (left bundle branch block) QRS morphology, and QRS width were predictors of failed implantation according to the univariate analysis. According to the multivariate regression analysis, LVEDD (odds ratio 1.31 per 5-mm increase; 95% confidence interval 1.05-1.63 per 5-mm increase; P = .02) and non-LBBB (odds ratio 3.07; 95% confidence interval 1.08-8.72; P = .03) were found to be independent predictors of unsuccessful LBBP implantation. An LVEDD of 60 mm has 60% sensitivity and 71% specificity for predicting LBBP implant failure. CONCLUSION When LBBP was used as CRT, LVEDD and non-LBBB QRS morphology predicted unsuccessful implantation. Non-LBBB triples the likelihood of failed implantation independent of LVEDD. Caution should be taken when considering these parameters to plan the best pacing strategy for patients.
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Affiliation(s)
- Freddy R Graterol
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Margarida Pujol-López
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Roger Borràs
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red, Salud Mental (CIBERSAM), Instituto de Salut Carlos III, Madrid, Madrid, Spain
| | - Bernardo Ayala
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Laura Uribe
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Eduard Guasch
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Mariona Regany-Closa
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Mireia Niebla
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Esther Carro
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Jean-Baptiste Guichard
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - M Ángeles Castel
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Elena Arbelo
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Andreu Porta-Sánchez
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain
| | - Marta Sitges
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Josep Brugada
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Ivo Roca-Luque
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - Adelina Doltra
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain
| | - Lluís Mont
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain
| | - José M Tolosana
- Institut Clínic Cardiovascular (ICCV), Hospital Clínic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Madrid, Madrid, Spain.
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8
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Capuano E, Regazzoni F, Maines M, Fornara S, Locatelli V, Catanzariti D, Stella S, Nobile F, Greco MD, Vergara C. Personalized computational electro-mechanics simulations to optimize cardiac resynchronization therapy. Biomech Model Mechanobiol 2024; 23:1977-2004. [PMID: 39192164 PMCID: PMC11554892 DOI: 10.1007/s10237-024-01878-8] [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: 02/09/2024] [Accepted: 07/12/2024] [Indexed: 08/29/2024]
Abstract
In this study, we present a computational framework designed to evaluate virtual scenarios of cardiac resynchronization therapy (CRT) and compare their effectiveness based on relevant clinical biomarkers. Our approach involves electro-mechanical numerical simulations personalized, for patients with left bundle branch block, by means of a calibration obtained using data from Electro-Anatomical Mapping System (EAMS) measures acquired by cardiologists during the CRT procedure, as well as ventricular pressures and volumes, both obtained pre-implantation. We validate the calibration by using EAMS data coming from right pacing conditions. Three patients with fibrosis and three without are considered to explore various conditions. Our virtual scenarios consist of personalized numerical experiments, incorporating different positions of the left electrode along reconstructed epicardial veins; different locations of the right electrode; different ventriculo-ventricular delays. The aim is to offer a comprehensive tool capable of optimizing CRT efficiency for individual patients. We provide preliminary answers on optimal electrode placement and delay, by computing some relevant biomarkers such as d P / d t max , ejection fraction, stroke work. From our numerical experiments, we found that the latest activated segment during sinus rhythm is an effective choice for the non-fibrotic cases for the location of the left electrode. Also, our results showed that the activation of the right electrode before the left one seems to improve the CRT performance for the non-fibrotic cases. Last, we found that the CRT performance seems to improve by positioning the right electrode halfway between the base and the apex. This work is on the line of computational works for the study of CRT and introduces new features in the field, such as the presence of the epicardial veins and the movement of the right electrode. All these studies from the different research groups can in future synergistically flow together in the development of a tool which clinicians could use during the procedure to have quantitative information about the patient's propagation in different scenarios.
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Affiliation(s)
- Emilia Capuano
- MOX, Dipartimento di Mathematica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Francesco Regazzoni
- MOX, Dipartimento di Mathematica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Massimiliano Maines
- Cardiology department, S.M. del Carmine Hospital, APSS, Corso Verona, 4, Rovereto, 38068, Trento, Italy
| | - Silvia Fornara
- LABS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Vanessa Locatelli
- LABS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Domenico Catanzariti
- Cardiology department, S.M. del Carmine Hospital, APSS, Corso Verona, 4, Rovereto, 38068, Trento, Italy
| | - Simone Stella
- MOX, Dipartimento di Mathematica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy
| | - Fabio Nobile
- Institute of Mathematics, École Polytechnique Fédérale de Lausanne, Station 8, Av. Piccard, CH-1015, Lausanne, Switzerland
| | - Maurizio Del Greco
- Cardiology department, S.M. del Carmine Hospital, APSS, Corso Verona, 4, Rovereto, 38068, Trento, Italy
| | - Christian Vergara
- LABS, Dipartimento di Chimica, Materiali e Ingegneria Chimica, Politecnico di Milano, Piazza Leonardo da Vinci, 32, 201333, Milan, Italy.
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9
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Mirmaksudov M, Ross S, Kongsgård E, Edvardsen T. Enhancing cardiac pacing strategies: a review of conduction system pacing compared with right and biventricular pacing and their influence on myocardial function. Eur Heart J Cardiovasc Imaging 2024; 25:879-887. [PMID: 38565632 PMCID: PMC11210972 DOI: 10.1093/ehjci/jeae090] [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: 01/28/2024] [Revised: 03/20/2024] [Accepted: 03/30/2024] [Indexed: 04/04/2024] Open
Abstract
Traditional right ventricular pacing (RVP) has been linked to the deterioration of both left ventricular diastolic and systolic function. This worsening often culminates in elevated rates of hospitalization due to heart failure, an increased risk of atrial fibrillation, and increased morbidity. While biventricular pacing (BVP) has demonstrated clinical and echocardiographic improvements in patients afflicted with heart failure and left bundle branch block, it has also encountered significant challenges such as a notable portion of non-responders and procedural failures attributed to anatomical complexities. In recent times, the interest has shifted towards conduction system pacing, initially, His bundle pacing, and more recently, left bundle branch area pacing, which are seen as promising alternatives to established methods. In contrast to other approaches, conduction system pacing offers the advantage of fostering more physiological and harmonized ventricular activation by directly stimulating the His-Purkinje network. This direct pacing results in a more synchronized systolic and diastolic function of the left ventricle compared with RVP and BVP. Of particular note is the capacity of conduction system pacing to yield a shorter QRS, conserve left ventricular ejection fraction, and reduce rates of mitral and tricuspid regurgitation when compared with RVP. The efficacy of conduction system pacing has also been found to have better clinical and echocardiographic improvement than BVP in patients requiring cardiac resynchronization. This review will delve into myocardial function in conduction system pacing compared with that in RVP and BVP.
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Affiliation(s)
- Mirakhmadjon Mirmaksudov
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway
- Department of Electrophysiology, Republican Specialized Scientific Practical Medical Center of Cardiology, Osiyo St. 4, 100052 Tashkent, Uzbekistan
| | - Stian Ross
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway
| | - Erik Kongsgård
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Sognsvannsveien 20, 0372 Oslo, Norway
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10
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Strocchi M, Wijesuriya N, Mehta V, de Vere F, Rinaldi CA, Niederer SA. Computational Modelling Enabling In Silico Trials for Cardiac Physiologic Pacing. J Cardiovasc Transl Res 2024; 17:685-694. [PMID: 37870689 PMCID: PMC11219462 DOI: 10.1007/s12265-023-10453-y] [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: 08/21/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
Conduction system pacing (CSP) has the potential to achieve physiological-paced activation by pacing the ventricular conduction system. Before CSP is adopted in standard clinical practice, large, randomised, and multi-centre trials are required to investigate CSP safety and efficacy compared to standard biventricular pacing (BVP). Furthermore, there are unanswered questions about pacing thresholds required to achieve optimal pacing delivery while preventing device battery draining, and about which patient groups are more likely to benefit from CSP rather than BVP. In silico studies have been increasingly used to investigate mechanisms underlying changes in cardiac function in response to pathologies and treatment. In the context of CSP, they have been used to improve our understanding of conduction system capture to optimise CSP delivery and battery life, and noninvasively compare different pacing methods on different patient groups. In this review, we discuss the in silico studies published to date investigating different aspects of CSP delivery.
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Affiliation(s)
- Marina Strocchi
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK.
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
| | - Nadeev Wijesuriya
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Vishal Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Felicity de Vere
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Steven A Niederer
- National Heart and Lung Institute, Imperial College London, 72 Du Cane Road, W12 0HS, London, UK
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- The Alan Turing Institute, London, UK
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11
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Anand S, Cronin EM. Arrhythmias in Patients with Pulmonary Hypertension and Right Ventricular Failure: Importance of Rhythm Control Strategies. J Clin Med 2024; 13:1866. [PMID: 38610631 PMCID: PMC11012772 DOI: 10.3390/jcm13071866] [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: 02/05/2024] [Revised: 03/14/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024] Open
Abstract
Arrhythmias frequently complicate the course of advanced pulmonary hypertension, often leading to hemodynamic compromise, functional impairment, and mortality. Given the importance of right atrial function in this physiology, the restoration and maintenance of sinus rhythm are of critical importance. In this review, we outline the pathophysiology of arrhythmias and their impact on right heart performance; describe considerations for antiarrhythmic drug selection, anesthetic and periprocedural management; and discuss the results of catheter ablation techniques in this complex and challenging patient population.
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Affiliation(s)
| | - Edmond M. Cronin
- Section of Cardiology, Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA 19140, USA;
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12
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Chapman D, Morgan F, Tiver KD, Dharmaprani D, Jenkins E, Ullah S, Shahrbabaki SS, Strong C, Ganesan AN. Assessing Torque Transfer in Conduction System Pacing: Development and Evaluation of an Ex Vivo Model. JACC Clin Electrophysiol 2024; 10:306-315. [PMID: 38206259 DOI: 10.1016/j.jacep.2023.10.035] [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: 10/13/2023] [Revised: 10/25/2023] [Accepted: 10/25/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Conduction system pacing (CSP) faces challenges in achieving reliable and safe deployments. Complex interactions between tissue and lead tip can result in endocardial entanglement, a drill effect that prevents penetration. No verified ex vivo model exists to quantitatively assess this relationship. OBJECTIVES The purpose of this study was to quantitatively characterize CSP lead tip to tissue responses for 4 commonly used leads. METHODS CSP leads (from Medtronic, Biotronik, Boston Scientific, and Abbott) were examined for helix rotation efficiency in ex vivo ovine right ventricular septa. A custom jig was utilized for rotation measurements. Fifteen turns were executed, documenting tissue-interface changes every 90° using high-resolution photography. Response curves (input rotation vs helix rotation) were evaluated using piecewise linear regression, with a focus on output vs input response slopes and torque breakpoint events. RESULTS We analyzed 3,840 quarter-turn CSP insertions with 4 different lead types. Helix rotations were consistently less than input: Abbott Tendril = 0.21:1, Medtronic 3830 = 0.21:1, Biotronik Solia = 0.47:1, and Boston Scientific Ingevity = 0.56:1. Torque breakpoint events were observed on average 7.22 times per insertion (95% CI: 6.08-8.35; P = NS) across all leads. In 57.8% of insertions (37 of 64), uncontrolled torque breakpoint events occurred, signaling unexpected excess helix rotations. CONCLUSIONS Using a robust ex vivo model, we revealed a muted helix rotation response compared with input turns on the lead, and frequent torque change events during insertion. This is critical for CSP implanters, emphasizing the potential for unexpected torque breakpoint events, and suggesting the need for novel lead designs or deployment methods to enhance CSP efficiency and safety.
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Affiliation(s)
- Darius Chapman
- College of Medicine and Public Health, Flinders University, Adelaide, Australia; Medical Device Research Institute, Flinders University, Adelaide, Australia
| | - Fraser Morgan
- College of Science and Engineering, Flinders University, Adelaide, Australia
| | - Kathryn D Tiver
- College of Medicine and Public Health, Flinders University, Adelaide, Australia; Department of Cardiac Electrophysiology, Flinders Medical Centre, Adelaide, Australia
| | - Dhani Dharmaprani
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Evan Jenkins
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Shahid Ullah
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | | | - Campbell Strong
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Anand N Ganesan
- College of Medicine and Public Health, Flinders University, Adelaide, Australia; Department of Cardiac Electrophysiology, Flinders Medical Centre, Adelaide, Australia.
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13
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Ložek M, Kovanda J, Kubuš P, Vrbík M, Lhotská L, Lumens J, Delhaas T, Janoušek J. How to assess and treat right ventricular electromechanical dyssynchrony in post-repair tetralogy of Fallot: insights from imaging, invasive studies, and computational modelling. Europace 2024; 26:euae024. [PMID: 38266248 PMCID: PMC10838147 DOI: 10.1093/europace/euae024] [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: 05/25/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND AND AIMS Right bundle branch block (RBBB) and resulting right ventricular (RV) electromechanical discoordination are thought to play a role in the disease process of subpulmonary RV dysfunction that frequently occur post-repair tetralogy of Fallot (ToF). We sought to describe this disease entity, the role of pulmonary re-valvulation, and the potential added value of RV cardiac resynchronization therapy (RV-CRT). METHODS Two patients with repaired ToF, complete RBBB, pulmonary regurgitation, and significantly decreased RV function underwent echocardiography, cardiac magnetic resonance, and an invasive study to evaluate the potential for RV-CRT as part of the management strategy. The data were used to personalize the CircAdapt model of the human heart and circulation. Resulting Digital Twins were analysed to quantify the relative effects of RV pressure and volume overload and to predict the effect of RV-CRT. RESULTS Echocardiography showed components of a classic RV dyssynchrony pattern which could be reversed by RV-CRT during invasive study and resulted in acute improvement in RV systolic function. The Digital Twins confirmed a contribution of electromechanical RV dyssynchrony to RV dysfunction and suggested improvement of RV contraction efficiency after RV-CRT. The one patient who underwent successful permanent RV-CRT as part of the pulmonary re-valvulation procedure carried improvements that were in line with the predictions based on his Digital Twin. CONCLUSION An integrative diagnostic approach to RV dysfunction, including the construction of Digital Twins may help to identify candidates for RV-CRT as part of the lifetime management of ToF and similar congenital heart lesions.
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Affiliation(s)
- Miroslav Ložek
- Children's Heart Center, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06 Prague, Czech Republic
- Department of Biomedical Informatics, 1st Faculty of Medicine, Charles University in Prague, Kateřinská 1660/32, 121 08 Prague, Czech Republic
| | - Jan Kovanda
- Children's Heart Center, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06 Prague, Czech Republic
| | - Peter Kubuš
- Children's Heart Center, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06 Prague, Czech Republic
| | - Michal Vrbík
- Children's Heart Center, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06 Prague, Czech Republic
| | - Lenka Lhotská
- Czech Institute of Informatics, Robotics, and Cybernetics, Czech Technical University in Prague, Jugoslávských partyzánů 1580/3, 160 00 Prague, Czech Republic
| | - Joost Lumens
- Maastricht University Medical Center, CARIM School for Cardiovascular Diseases, Universiteitssingel 50, 6200 MD Maastricht, The Netherlands
| | - Tammo Delhaas
- Maastricht University Medical Center, CARIM School for Cardiovascular Diseases, Universiteitssingel 50, 6200 MD Maastricht, The Netherlands
| | - Jan Janoušek
- Children's Heart Center, 2nd Faculty of Medicine, Charles University in Prague and Motol University Hospital, V Úvalu 84, 150 06 Prague, Czech Republic
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14
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Glikson M, Jastrzebski M, Gold MR, Ellenbogen K, Burri H. Conventional biventricular pacing is still preferred to conduction system pacing for atrioventricular block in patients with reduced ejection fraction and narrow QRS. Europace 2023; 26:euad337. [PMID: 38153385 PMCID: PMC10754179 DOI: 10.1093/europace/euad337] [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: 10/08/2023] [Accepted: 11/05/2023] [Indexed: 12/29/2023] Open
Abstract
It is well established that right ventricular pacing is detrimental in patients with reduced cardiac function who require ventricular pacing (VP), and alternatives nowadays are comprised of biventricular pacing (BiVP) and conduction system pacing (CSP). The latter modality is of particular interest in patients with a narrow baseline QRS as it completely avoids, or minimizes, ventricular desynchronization associated with VP. In this article, experts debate whether BiVP or CSP should be used to treat these patients.
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Affiliation(s)
- Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Marek Jastrzebski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Michael R Gold
- Virginia Commonwealth University, VCU Medical Center Gateway Building, 1200 E. Marshall Street, Richmond, VA 23219, USA
| | - Kenneth Ellenbogen
- MUSC Division of Cardiology, Medical University of South Carolina, 25 Courtenay Dr, MS-592, Charleston, SC 29425, USA
| | - Haran Burri
- Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Rue Gabrielle Perret Gentil 4, 1211, Geneva, Switzerland
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15
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Koopsen T, Gerrits W, van Osta N, van Loon T, Wouters P, Prinzen FW, Vernooy K, Delhaas T, Teske AJ, Meine M, Cramer MJ, Lumens J. Virtual pacing of a patient's digital twin to predict left ventricular reverse remodelling after cardiac resynchronization therapy. Europace 2023; 26:euae009. [PMID: 38288616 PMCID: PMC10825733 DOI: 10.1093/europace/euae009] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024] Open
Abstract
AIMS Identifying heart failure (HF) patients who will benefit from cardiac resynchronization therapy (CRT) remains challenging. We evaluated whether virtual pacing in a digital twin (DT) of the patient's heart could be used to predict the degree of left ventricular (LV) reverse remodelling post-CRT. METHODS AND RESULTS Forty-five HF patients with wide QRS complex (≥130 ms) and reduced LV ejection fraction (≤35%) receiving CRT were retrospectively enrolled. Echocardiography was performed before (baseline) and 6 months after CRT implantation to obtain LV volumes and 18-segment longitudinal strain. A previously developed algorithm was used to generate 45 DTs by personalizing the CircAdapt model to each patient's baseline measurements. From each DT, baseline septal-to-lateral myocardial work difference (MWLW-S,DT) and maximum rate of LV systolic pressure rise (dP/dtmax,DT) were derived. Biventricular pacing was then simulated using patient-specific atrioventricular delay and lead location. Virtual pacing-induced changes ΔMWLW-S,DT and ΔdP/dtmax,DT were correlated with real-world LV end-systolic volume change at 6-month follow-up (ΔLVESV). The DT's baseline MWLW-S,DT and virtual pacing-induced ΔMWLW-S,DT were both significantly associated with the real patient's reverse remodelling ΔLVESV (r = -0.60, P < 0.001 and r = 0.62, P < 0.001, respectively), while correlation between ΔdP/dtmax,DT and ΔLVESV was considerably weaker (r = -0.34, P = 0.02). CONCLUSION Our results suggest that the reduction of septal-to-lateral work imbalance by virtual pacing in the DT can predict real-world post-CRT LV reverse remodelling. This DT approach could prove to be an additional tool in selecting HF patients for CRT and has the potential to provide valuable insights in optimization of CRT delivery.
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Affiliation(s)
- Tijmen Koopsen
- Department of Biomedical Engineering, CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 40, 6200 MD, The Netherlands
| | - Willem Gerrits
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Nick van Osta
- Department of Biomedical Engineering, CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 40, 6200 MD, The Netherlands
| | - Tim van Loon
- Department of Biomedical Engineering, CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 40, 6200 MD, The Netherlands
| | - Philippe Wouters
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Frits W Prinzen
- Department of Physiology, CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center (MUMC), Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tammo Delhaas
- Department of Biomedical Engineering, CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 40, 6200 MD, The Netherlands
| | - Arco J Teske
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Mathias Meine
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, Division of Heart and Lungs, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
| | - Joost Lumens
- Department of Biomedical Engineering, CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Universiteitssingel 40, 6200 MD, The Netherlands
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16
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Rodero C, Baptiste TMG, Barrows RK, Lewalle A, Niederer SA, Strocchi M. Advancing clinical translation of cardiac biomechanics models: a comprehensive review, applications and future pathways. FRONTIERS IN PHYSICS 2023; 11:1306210. [PMID: 38500690 PMCID: PMC7615748 DOI: 10.3389/fphy.2023.1306210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Cardiac mechanics models are developed to represent a high level of detail, including refined anatomies, accurate cell mechanics models, and platforms to link microscale physiology to whole-organ function. However, cardiac biomechanics models still have limited clinical translation. In this review, we provide a picture of cardiac mechanics models, focusing on their clinical translation. We review the main experimental and clinical data used in cardiac models, as well as the steps followed in the literature to generate anatomical meshes ready for simulations. We describe the main models in active and passive mechanics and the different lumped parameter models to represent the circulatory system. Lastly, we provide a summary of the state-of-the-art in terms of ventricular, atrial, and four-chamber cardiac biomechanics models. We discuss the steps that may facilitate clinical translation of the biomechanics models we describe. A well-established software to simulate cardiac biomechanics is lacking, with all available platforms involving different levels of documentation, learning curves, accessibility, and cost. Furthermore, there is no regulatory framework that clearly outlines the verification and validation requirements a model has to satisfy in order to be reliably used in applications. Finally, better integration with increasingly rich clinical and/or experimental datasets as well as machine learning techniques to reduce computational costs might increase model reliability at feasible resources. Cardiac biomechanics models provide excellent opportunities to be integrated into clinical workflows, but more refinement and careful validation against clinical data are needed to improve their credibility. In addition, in each context of use, model complexity must be balanced with the associated high computational cost of running these models.
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Affiliation(s)
- Cristobal Rodero
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Tiffany M. G. Baptiste
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Rosie K. Barrows
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
- Department of Biomedical Engineering, School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Alexandre Lewalle
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Steven A. Niederer
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
- Turing Research and Innovation Cluster in Digital Twins (TRIC: DT), The Alan Turing Institute, London, United Kingdom
| | - Marina Strocchi
- Cardiac Electro-Mechanics Research Group (CEMRG), National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
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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: 2.5] [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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