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Abstract
PURPOSE OF REVIEW Cardiac resynchronization therapy (CRT) is an effective treatment option for therapy-refractory mild to severe heart failure (HF) patients with reduced ejection fraction and left ventricular (LV) conduction delay. Multiple clinical trials have shown that CRT improves cardiac function and overall quality of life, as well as reduces HF hospitalizations, health care costs, and mortality. RECENT FINDINGS Despite its effectiveness, the "non-response" rate to CRT is around 30%, remaining a major challenge that faces electrophysiologists and researchers. It has been recently suggested that the etiology of CRT non-response is multifactorial, and it requires a multifaceted approach to address it. In this focused review, we will summarize the definitions of CRT non-response, identify key factors for CRT non-response, and offer a simplified framework to address CRT non-response with the main goal of improving CRT outcomes.
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Affiliation(s)
- Syed Yaseen Naqvi
- Heart Research Follow-Up Program, Cardiology Division, University of Rochester Medical Center, 265 Crittenden Blvd., Box 653, Rochester, NY, 14642, USA
| | - Anas Jawaid
- Heart Research Follow-Up Program, Cardiology Division, University of Rochester Medical Center, 265 Crittenden Blvd., Box 653, Rochester, NY, 14642, USA
| | - Ilan Goldenberg
- Heart Research Follow-Up Program, Cardiology Division, University of Rochester Medical Center, 265 Crittenden Blvd., Box 653, Rochester, NY, 14642, USA
| | - Valentina Kutyifa
- Heart Research Follow-Up Program, Cardiology Division, University of Rochester Medical Center, 265 Crittenden Blvd., Box 653, Rochester, NY, 14642, USA.
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Abstract
Several clinical trials have established the role of cardiac resynchronization therapy in patients with heart failure, impaired left ventricular function and dyssynchrony. Challenges to traditional therapy include coronary sinus anatomy and failure to respond. Left ventricular endocardial pacing could overcome anatomic constraints, provide more flexibility, and allow for more physiologic activation. Cases and case series have demonstrated the promise of the approach. Preclinical studies support the superior hemodynamic effects of left ventricular endocardial pacing. Leadless left ventricular endocardial pacing is a recent innovation that is undergoing prospective testing. Successful delivery may be associated with clinical response and positive cardiac structural remodeling.
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Affiliation(s)
- Alan Hanley
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - E Kevin Heist
- Cardiac Arrhythmia Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Tolosana JM, Brugada J. Optimizing Cardiac Resynchronization Therapy Devices in Follow-up to Improve Response Rates and Outcomes. Card Electrophysiol Clin 2019; 11:89-98. [PMID: 30717856 DOI: 10.1016/j.ccep.2018.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although cardiac resynchronization therapy (CRT) will improve symptoms and survival in selected heart failure patients, there still remains a high percentage of CRT recipients who do not obtain benefit from the therapy. During CRT follow-up, an effort should be made to identify and to treat reversible causes of nonresponse to CRT. This effort includes optimization of medical therapy, checking for appropriate and effective biventricular pacing, and treatment of arrhythmias and other reversible causes of CRT malfunction.
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Affiliation(s)
- Jose María Tolosana
- Cardiovascular Institute, Hospital Clínic, Arrhythmia Unit Hospital Clinic, University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Josep Brugada
- Pediatric Arrhythmia Unit, Cardiovascular Institute, Hospital Clínic, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain.
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Roque C, Trevisi N, Silberbauer J, Oloriz T, Mizuno H, Baratto F, Bisceglia C, Sora N, Marzi A, Radinovic A, Guarracini F, Vergara P, Sala S, Paglino G, Gulletta S, Mazzone P, Cireddu M, Maccabelli G, Della Bella P. Electrical storm induced by cardiac resynchronization therapy is determined by pacing on epicardial scar and can be successfully managed by catheter ablation. Circ Arrhythm Electrophysiol 2014; 7:1064-9. [PMID: 25221332 DOI: 10.1161/circep.114.001796] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The mechanism of cardiac resynchronization therapy (CRT)-induced proarrhythmia remains unknown. We postulated that pacing from a left ventricular (LV) lead positioned on epicardial scar can facilitate re-entrant ventricular tachycardia. The aim of this study was to investigate the relationship between CRT-induced proarrhythmia and LV lead location within scar. METHODS AND RESULTS Twenty-eight epicardial and 63 endocardial maps, obtained from 64 CRT patients undergoing ventricular tachycardia ablation, were analyzed. A positive LV lead/scar relationship, defined as a lead tip positioned on scar/border zone, was determined by overlaying fluoroscopic projections with LV electroanatomical maps. CRT-induced proarrhythmia occurred in 8 patients (12.5%). They all presented early with electrical storm (100% versus 39% of patients with no proarrhythmia; P<0.01), requiring temporary biventricular pacing discontinuation in half of cases. They more frequently presented with heart failure/cardiogenic shock (50% versus 7%; P<0.01), requiring intensive care management. Ventricular tachycardia was re-entrant in all. The LV lead location within epicardial scar was significantly more frequent in the proarrhythmia group (60% versus 9% P=0.03 on epicardial bipolar scar, 80% versus 17% P=0.02 on epicardial unipolar scar, and 80% versus 17% P=0.02 on any-epicardial scar). Ablation was performed within epicardial scar, close to the LV lead, and allowed CRT reactivation in all patients. CONCLUSIONS CRT-induced proarrhythmia presented early with electrical storm and was associated with an LV lead positioning within epicardial scar. Catheter ablation allowed for resumption of biventricular stimulation in all patients.
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Affiliation(s)
- Carla Roque
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Nicola Trevisi
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - John Silberbauer
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Teresa Oloriz
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Hiroya Mizuno
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Francesca Baratto
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Caterina Bisceglia
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Nicoleta Sora
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Alessandra Marzi
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Andrea Radinovic
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Fabrizio Guarracini
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Pasquale Vergara
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Simone Sala
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Gabriele Paglino
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Simone Gulletta
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Patrizio Mazzone
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Manuela Cireddu
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Giuseppe Maccabelli
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Paolo Della Bella
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy.
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