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Stellbrink C. [History of cardiac resynchronization therapy : 30 years of electrotherapeutic management for heart failure]. Herzschrittmacherther Elektrophysiol 2024; 35:68-76. [PMID: 38424340 PMCID: PMC10923969 DOI: 10.1007/s00399-024-01004-2] [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: 02/06/2024] [Indexed: 03/02/2024]
Abstract
The first permanent biventricular pacing system was implanted more than 30 years ago. In this article, the historical development of cardiac resynchronization therapy (CRT), starting with the pathophysiological concept, followed by the initial "proof of concept" studies and finally the large prospective-randomized studies that led to the implementation of CRT in heart failure guidelines, is outlined. Since the establishment of CRT, both an expansion of indications, e.g., for patients with mild heart failure and atrial fibrillation, but also the return to patients with broad QRS complex and left bundle branch block who benefit most of CRT has evolved. New techniques such as conduction system pacing will have major influence on pacemaker therapy in heart failure, both as an alternative or adjunct to CRT.
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Affiliation(s)
- Christoph Stellbrink
- Universitätsklinikum OWL Campus Klinikum Bielefeld., Universitätsklinik für Kardiologie und Internistische Intensivmedizin, Teutoburger Straße 50, 33604, Bielefeld, Deutschland.
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2
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BioECG: Improving ECG Biometrics with Deep Learning and Enhanced Datasets. APPLIED SCIENCES-BASEL 2021. [DOI: 10.3390/app11135880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Nowadays, Deep Learning tools have been widely applied in biometrics. Electrocardiogram (ECG) biometrics is not the exception. However, the algorithm performances rely heavily on a representative dataset for training. ECGs suffer constant temporal variations, and it is even more relevant to collect databases that can represent these conditions. Nonetheless, the restriction in database publications obstructs further research on this topic. This work was developed with the help of a database that represents potential scenarios in biometric recognition as data was acquired in different days, physical activities and positions. The classification was implemented with a Deep Learning network, BioECG, avoiding complex and time-consuming signal transformations. An exhaustive tuning was completed including variations in enrollment length, improving ECG verification for more complex and realistic biometric conditions. Finally, this work studied one-day and two-days enrollments and their effects. Two-days enrollments resulted in huge general improvements even when verification was accomplished with more unstable signals. EER was improved in 63% when including a change of position, up to almost 99% when visits were in a different day and up to 91% if the user experienced a heartbeat increase after exercise.
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Tseng AS, Kunze KL, Lee JZ, Amin M, Neville MR, Almader-Douglas D, Killu AM, Madhavan M, Cha YM, Asirvatham SJ, Friedman PA, Gersh BJ, Mulpuru SK. Efficacy of Pharmacologic and Cardiac Implantable Electronic Device Therapies in Patients With Heart Failure and Reduced Ejection Fraction: A Systematic Review and Network Meta-Analysis. Circ Arrhythm Electrophysiol 2019; 12:e006951. [PMID: 31159582 DOI: 10.1161/circep.118.006951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The treatment of heart failure with reduced ejection fraction has been the subject of numerous randomized controlled trials involving medications and cardiac implantable electronic device therapies. As newer effective pharmacological therapies suggest significant reductions in all-cause mortality, the role of additional device therapy in heart failure with reduced ejection fraction deserves further scrutiny. Methods A systematic review and network meta-analysis on the effect of medication and device therapies in heart failure with reduced ejection fraction on all-cause mortality was performed. Randomized controlled trials published between January 1980 and July 2017 were identified using Medline, EMBASE, and Cochrane Controlled Register of Trials databases. Pcnetmeta package in R was used to calculate treatment arm-based estimated rates, rate ratios, and probability ranks with 95% credible intervals. Results Combination therapy of ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blockers) with β-blockers (BBs) alone or in addition to implantable cardiac defibrillators or cardiac resynchronization therapy with defibrillators demonstrated a significant reduction of all-cause mortality when compared with placebo. By probability rank, implantable cardiac defibrillator+ACE inhibitor or ARB+BB+mineralocorticoid receptor antagonist, implantable cardiac defibrillator+ACE inhibitor or ARB+BB, and angiotensin receptor-neprilysin inhibitor+BB+mineralocorticoid receptor antagonist combination therapies have the highest probability of being ranked the best treatment. There was no significant difference in the rate of mortality when comparing angiotensin receptor-neprilysin inhibitor+BB+mineralocorticoid receptor antagonist to implantable cardiac defibrillator+optimal pharmacological combination therapy. Conclusions BB and renin-angiotensin system blockers alone or in combination with defibrillator device therapy have robust evidence for a reduction in mortality compared with placebo. The comparative efficacy of pharmacological therapy with angiotensin receptor-neprilysin inhibitors and device therapy deserves further investigation.
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Affiliation(s)
- Andrew S Tseng
- Department of Internal Medicine (A.S.T.), Mayo Clinic Arizona, Phoenix
| | - Katie L Kunze
- Division of Biomedical Statistics and Informatics (K.L.K., M.R.N.), Mayo Clinic Arizona, Phoenix
| | - Justin Z Lee
- Division of Cardiovascular Diseases (J.Z.L., S.K.M.), Mayo Clinic Arizona, Phoenix
| | - Mustapha Amin
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Matthew R Neville
- Division of Biomedical Statistics and Informatics (K.L.K., M.R.N.), Mayo Clinic Arizona, Phoenix
| | | | - Ammar M Killu
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Malini Madhavan
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Yong-Mei Cha
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Siva K Mulpuru
- Division of Cardiovascular Diseases (J.Z.L., S.K.M.), Mayo Clinic Arizona, Phoenix
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Keene D, Arnold A, Shun-Shin MJ, Howard JP, Sohaib SA, Moore P, Tanner M, Quereshi N, Muthumala A, Chandresekeran B, Foley P, Leyva F, Adhya S, Falaschetti E, Tsang H, Vijayaraman P, Cleland JGF, Stegemann B, Francis DP, Whinnett ZI. Rationale and design of the randomized multicentre His Optimized Pacing Evaluated for Heart Failure (HOPE-HF) trial. ESC Heart Fail 2018; 5:965-976. [PMID: 29984912 PMCID: PMC6165934 DOI: 10.1002/ehf2.12315] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/08/2018] [Accepted: 05/30/2018] [Indexed: 01/17/2023] Open
Abstract
Aims In patients with heart failure and a pathologically prolonged PR interval, left ventricular (LV) filling can be improved by shortening atrioventricular delay using His‐bundle pacing. His‐bundle pacing delivers physiological ventricular activation and has been shown to improve acute haemodynamic function in this group of patients. In the HOPE‐HF (His Optimized Pacing Evaluated for Heart Failure) trial, we are investigating whether these acute haemodynamic improvements translate into improvements in exercise capacity and heart failure symptoms. Methods and results This multicentre, double‐blind, randomized, crossover study aims to randomize 160 patients with PR prolongation (≥200 ms), LV impairment (EF ≤ 40%), and either narrow QRS (≤140 ms) or right bundle branch block. All patients receive a cardiac device with leads positioned in the right atrium and the His bundle. Eligible patients also receive a defibrillator lead. Those not eligible for implantable cardioverter defibrillator have a backup pacing lead positioned in an LV branch of the coronary sinus. Patients are allocated in random order to 6 months of (i) haemodynamically optimized dual chamber His‐bundle pacing and (ii) backup pacing only, using the non‐His ventricular lead. The primary endpoint is change in exercise capacity assessed by peak oxygen uptake. Secondary endpoints include change in ejection fraction, quality of life scores, B‐type natriuretic peptide, daily patient activity levels, and safety and feasibility assessments of His‐bundle pacing. Conclusions Hope‐HF aims to determine whether correcting PR prolongation in patients with heart failure and narrow QRS or right bundle branch block using haemodynamically optimized dual chamber His‐bundle pacing improves exercise capacity and symptoms. We aim to complete recruitment by the end of 2018 and report in 2020.
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Affiliation(s)
- Daniel Keene
- Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Ahran Arnold
- Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Matthew J Shun-Shin
- Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - James P Howard
- Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | | | - Philip Moore
- West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK.,Barts Health NHS Trust, London, UK
| | - Mark Tanner
- West Sussex Hospitals NHS Trust, West Sussex, UK
| | | | - Amal Muthumala
- Barts Health NHS Trust, London, UK.,North Middlesex University Hospital, London, UK
| | | | - Paul Foley
- Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | | | | | | | - Hilda Tsang
- Imperial College Trials Unit, Imperial College London, London, UK
| | - Pugal Vijayaraman
- Geisinger Commonwealth School of Medicine, Geisinger Heart Institute, Scranton, PA, USA
| | | | - Berthold Stegemann
- Bakken Research Center B.V. Research and Technology, Maastricht, The Netherlands
| | - Darrel P Francis
- Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Zachary I Whinnett
- Imperial College London, London, UK.,Imperial College Healthcare NHS Trust, London, UK
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Marechaux S, Menet A, Guyomar Y, Ennezat PV, Guerbaai RA, Graux P, Tribouilloy C. Role of echocardiography before cardiac resynchronization therapy: new advances and current developments. Echocardiography 2016; 33:1745-1752. [DOI: 10.1111/echo.13334] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Sylvestre Marechaux
- Lille North of France University/Catholic University Hospital/Catholic School of Medicine; Cardiology Department; Lille Catholic University; Lille France
- INSERM U 1088; University of Picardie; Amiens France
| | - Aymeric Menet
- Lille North of France University/Catholic University Hospital/Catholic School of Medicine; Cardiology Department; Lille Catholic University; Lille France
- INSERM U 1088; University of Picardie; Amiens France
| | - Yves Guyomar
- Lille North of France University/Catholic University Hospital/Catholic School of Medicine; Cardiology Department; Lille Catholic University; Lille France
| | | | - Raphaëlle Ashley Guerbaai
- Cardiology Department; Grenoble University Hospital; Grenoble France
- Cardiovascular and Thoracic Department; Amiens University Hospital; Amiens France
| | - Pierre Graux
- Lille North of France University/Catholic University Hospital/Catholic School of Medicine; Cardiology Department; Lille Catholic University; Lille France
| | - Christophe Tribouilloy
- INSERM U 1088; University of Picardie; Amiens France
- Cardiovascular and Thoracic Department; Amiens University Hospital; Amiens France
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Ketha S, Kusumoto FM. Cardiac Resynchronization Therapy in 2015: Lessons Learned. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2015. [DOI: 10.15212/cvia.2015.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Wang G, Zhao Z, Zhao S, Ding S, Shen S, Wang L. Effect of cardiac resynchronization therapy on patients with heart failure and narrow QRS complexes: a meta-analysis of five randomized controlled trials. J Interv Card Electrophysiol 2015; 44:71-9. [DOI: 10.1007/s10840-015-0018-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 05/10/2015] [Indexed: 10/23/2022]
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Colquitt JL, Mendes D, Clegg AJ, Harris P, Cooper K, Picot J, Bryant J. Implantable cardioverter defibrillators for the treatment of arrhythmias and cardiac resynchronisation therapy for the treatment of heart failure: systematic review and economic evaluation. Health Technol Assess 2015; 18:1-560. [PMID: 25169727 DOI: 10.3310/hta18560] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND This assessment updates and expands on two previous technology assessments that evaluated implantable cardioverter defibrillators (ICDs) for arrhythmias and cardiac resynchronisation therapy (CRT) for heart failure (HF). OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of ICDs in addition to optimal pharmacological therapy (OPT) for people at increased risk of sudden cardiac death (SCD) as a result of ventricular arrhythmias despite receiving OPT; to assess CRT with or without a defibrillator (CRT-D or CRT-P) in addition to OPT for people with HF as a result of left ventricular systolic dysfunction (LVSD) and cardiac dyssynchrony despite receiving OPT; and to assess CRT-D in addition to OPT for people with both conditions. DATA SOURCES Electronic resources including MEDLINE, EMBASE and The Cochrane Library were searched from inception to November 2012. Additional studies were sought from reference lists, clinical experts and manufacturers' submissions to the National Institute for Health and Care Excellence. REVIEW METHODS Inclusion criteria were applied by two reviewers independently. Data extraction and quality assessment were undertaken by one reviewer and checked by a second. Data were synthesised through narrative review and meta-analyses. For the three populations above, randomised controlled trials (RCTs) comparing (1) ICD with standard therapy, (2) CRT-P or CRT-D with each other or with OPT and (3) CRT-D with OPT, CRT-P or ICD were eligible. Outcomes included mortality, adverse events and quality of life. A previously developed Markov model was adapted to estimate the cost-effectiveness of OPT, ICDs, CRT-P and CRT-D in the three populations by simulating disease progression calculated at 4-weekly cycles over a lifetime horizon. RESULTS A total of 4556 references were identified, of which 26 RCTs were included in the review: 13 compared ICD with medical therapy, four compared CRT-P/CRT-D with OPT and nine compared CRT-D with ICD. ICDs reduced all-cause mortality in people at increased risk of SCD, defined in trials as those with previous ventricular arrhythmias/cardiac arrest, myocardial infarction (MI) > 3 weeks previously, non-ischaemic cardiomyopathy (depending on data included) or ischaemic/non-ischaemic HF and left ventricular ejection fraction ≤ 35%. There was no benefit in people scheduled for coronary artery bypass graft. A reduction in SCD but not all-cause mortality was found in people with recent MI. Incremental cost-effectiveness ratios (ICERs) ranged from £14,231 per quality-adjusted life-year (QALY) to £29,756 per QALY for the scenarios modelled. CRT-P and CRT-D reduced mortality and HF hospitalisations, and improved other outcomes, in people with HF as a result of LVSD and cardiac dyssynchrony when compared with OPT. The rate of SCD was lower with CRT-D than with CRT-P but other outcomes were similar. CRT-P and CRT-D compared with OPT produced ICERs of £27,584 per QALY and £27,899 per QALY respectively. The ICER for CRT-D compared with CRT-P was £28,420 per QALY. In people with both conditions, CRT-D reduced the risk of all-cause mortality and HF hospitalisation, and improved other outcomes, compared with ICDs. Complications were more common with CRT-D. Initial management with OPT alone was most cost-effective (ICER £2824 per QALY compared with ICD) when health-related quality of life was kept constant over time. Costs and QALYs for CRT-D and CRT-P were similar. The ICER for CRT-D compared with ICD was £27,195 per QALY and that for CRT-D compared with OPT was £35,193 per QALY. LIMITATIONS Limitations of the model include the structural assumptions made about disease progression and treatment provision, the extrapolation of trial survival estimates over time and the assumptions made around parameter values when evidence was not available for specific patient groups. CONCLUSIONS In people at risk of SCD as a result of ventricular arrhythmias and in those with HF as a result of LVSD and cardiac dyssynchrony, the interventions modelled produced ICERs of < £30,000 per QALY gained. In people with both conditions, the ICER for CRT-D compared with ICD, but not CRT-D compared with OPT, was < £30,000 per QALY, and the costs and QALYs for CRT-D and CRT-P were similar. A RCT comparing CRT-D and CRT-P in people with HF as a result of LVSD and cardiac dyssynchrony is required, for both those with and those without an ICD indication. A RCT is also needed into the benefits of ICD in non-ischaemic cardiomyopathy in the absence of dyssynchrony. STUDY REGISTRATION This study is registered as PROSPERO number CRD42012002062. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Jill L Colquitt
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Diana Mendes
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Andrew J Clegg
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Petra Harris
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Keith Cooper
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Joanna Picot
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
| | - Jackie Bryant
- Southampton Health Technology Assessments Centre (SHTAC), University of Southampton, Southampton, UK
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Jackson T, Claridge S, Behar J, Sammut E, Webb J, Carr-White G, Razavi R, Rinaldi CA. Narrow QRS systolic heart failure: is there a target for cardiac resynchronization? Expert Rev Cardiovasc Ther 2015; 13:783-97. [PMID: 26048215 DOI: 10.1586/14779072.2015.1049945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiac resynchronization therapy has revolutionized the management of systolic heart failure in patients with prolonged QRS during the past 20 years. Initially, the use of this treatment in patients with shorter QRS durations showed promising results, which have since been opposed by larger randomized controlled trials. Despite this, some questions remain, such as, whether correction of mechanical dyssynchrony is the therapeutic target by which biventricular pacing may confer benefit in this group, or are there other mechanisms that need consideration? In addition, novel techniques of cardiac resynchronization therapy delivery such as endocardial and multisite pacing may reduce potential detrimental effects of biventricular pacing, thereby improving the benefit/harm balance of this therapy in some patients.
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Affiliation(s)
- Tom Jackson
- Department of Cardiovascular Imaging, 4th Floor Lambeth Wing, St Thomas' Hospital, London, SE1 7EH, UK
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Yap LB, Qadir F, Nguyen ST, Ma SK, Koh KW, Muhammad Z, Arshad AH, Ali Z, Daud A, Tay GS, Sahat NA, Said AA, Tamin SS, Hussin A, Kaur S, Omar R. The clinical benefit of cardiac resynchronization therapy for narrow QRS compared to broad QRS complex patients. Int J Cardiol 2015; 183:178-9. [DOI: 10.1016/j.ijcard.2015.01.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 01/11/2015] [Accepted: 01/25/2015] [Indexed: 11/25/2022]
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Jabbour RJ, Shun-Shin MJ, Finegold JA, Afzal Sohaib SM, Cook C, Nijjer SS, Whinnett ZI, Manisty CH, Brugada J, Francis DP. Effect of study design on the reported effect of cardiac resynchronization therapy (CRT) on quantitative physiological measures: stratified meta-analysis in narrow-QRS heart failure and implications for planning future studies. J Am Heart Assoc 2015; 4:e000896. [PMID: 25564370 PMCID: PMC4330047 DOI: 10.1161/jaha.114.000896] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Biventricular pacing (CRT) shows clear benefits in heart failure with wide QRS, but results in narrow QRS have appeared conflicting. We tested the hypothesis that study design might have influenced findings. Method and Results We identified all reports of CRT‐P/D therapy in subjects with narrow QRS reporting effects on continuous physiological variables. Twelve studies (2074 patients) met these criteria. Studies were stratified by presence of bias‐resistance steps: the presence of a randomized control arm over a single arm, and blinded outcome measurement. Change in each endpoint was quantified using a standardized effect size (Cohen's d). We conducted separate meta‐analyses for each variable in turn, stratified by trial quality. In non‐randomized, non‐blinded studies, the majority of variables (10 of 12, 83%) showed significant improvement, ranging from a standardized mean effect size of +1.57 (95%CI +0.43 to +2.7) for ejection fraction to +2.87 (+1.78 to +3.95) for NYHA class. In the randomized, non‐blinded study, only 3 out of 6 variables (50%) showed improvement. For the randomized blinded studies, 0 out of 9 variables (0%) showed benefit, ranging from −0.04 (−0.31 to +0.22) for ejection fraction to −0.1 (−0.73 to +0.53) for 6‐minute walk test. Conclusions Differences in degrees of resistance to bias, rather than choice of endpoint, explain the variation between studies of CRT in narrow‐QRS heart failure addressing physiological variables. When bias‐resistance features are implemented, it becomes clear that these patients do not improve in any tested physiological variable. Guidance from studies without careful planning to resist bias may be far less useful than commonly perceived.
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Affiliation(s)
- Richard J Jabbour
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Matthew J Shun-Shin
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Judith A Finegold
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - S M Afzal Sohaib
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Christopher Cook
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Sukhjinder S Nijjer
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Zachary I Whinnett
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Charlotte H Manisty
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
| | - Josep Brugada
- Hospital Clinic, University of Barcelona, Barcelona, Spain (J.B.)
| | - Darrel P Francis
- International Centre for Circulatory Health, National Heart and Lung Institute, Imperial College, London (R.J.J., M.J.S.S., J.A.F., A.S., C.C., S.S.N., Z.I.W., C.H.M., D.P.F.)
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12
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Kang SH, Oh IY, Kang DY, Cha MJ, Cho Y, Choi EK, Hahn S, Oh S. Cardiac resynchronization therapy and QRS duration: systematic review, meta-analysis, and meta-regression. J Korean Med Sci 2015; 30:24-33. [PMID: 25552880 PMCID: PMC4278024 DOI: 10.3346/jkms.2015.30.1.24] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 09/04/2014] [Indexed: 01/18/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) has been shown to reduce the risk of death and hospitalization in patients with advanced heart failure with left ventricular dysfunction. However, controversy remains regarding who would most benefit from CRT. We performed a meta-analysis, and meta-regression in an attempt to identify factors that determine the outcome after CRT. A total of 23 trials comprising 10,103 patients were selected for this meta-analysis. Our analysis revealed that CRT significantly reduced the risk of all-cause mortality and hospitalization for heart failure compared to control treatment. The odds ratio (OR) of all-cause death had a linear relationship with mean QRS duration (P=0.009). The benefit in survival was confined to patients with a QRS duration ≥145 ms (OR, 0.86; 95% CI, 0.74-0.99), while no benefit was shown among patients with a QRS duration of 130 ms (OR, 1.00; 95% CI, 0.80-1.25) or less. Hospitalization for heart failure was shown to be significantly reduced in patients with a QRS duration ≥127 ms (OR, 0.77; 95% CI, 0.60-0.98). This meta-regression analysis implies that patients with a QRS duration ≥150 ms would most benefit from CRT, and in those with a QRS duration <130 ms CRT implantation may be potentially harmful.
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Affiliation(s)
- Si-Hyuck Kang
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Korea
| | - Il-Young Oh
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Korea
| | - Do-Yoon Kang
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea
| | - Myung-Jin Cha
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea
| | - Youngjin Cho
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea
| | - Seokyung Hahn
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea
| | - Seil Oh
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Hospital, Seoul, Korea
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Leyva F, Nisam S, Auricchio A. 20 Years of Cardiac Resynchronization Therapy. J Am Coll Cardiol 2014; 64:1047-58. [DOI: 10.1016/j.jacc.2014.06.1178] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 06/15/2014] [Accepted: 06/17/2014] [Indexed: 01/14/2023]
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14
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Shah RM, Patel D, Molnar J, Ellenbogen KA, Koneru JN. Cardiac-resynchronization therapy in patients with systolic heart failure and QRS interval <=130 ms: insights from a meta-analysis. Europace 2014; 17:267-73. [DOI: 10.1093/europace/euu214] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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15
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Taylor RJ, Umar F, Moody WE, Meyyappan C, Stegemann B, Townend JN, Hor KN, Miszalski-Jamka T, Mazur W, Steeds RP, Leyva F. Feature-tracking cardiovascular magnetic resonance as a novel technique for the assessment of mechanical dyssynchrony. Int J Cardiol 2014; 175:120-5. [PMID: 24852836 DOI: 10.1016/j.ijcard.2014.04.268] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 04/27/2014] [Accepted: 04/30/2014] [Indexed: 12/14/2022]
Abstract
BACKGROUND Myocardial tagging using cardiovascular magnetic resonance (CMR) is the gold-standard for the assessment of myocardial mechanics. Feature-tracking cardiovascular magnetic resonance (FT-CMR) has been validated against myocardial tagging. We explore the potential of FT-CMR in the assessment of mechanical dyssynchrony, with reference to patients with cardiomyopathy and healthy controls. METHODS Healthy controls (n=55, age: 42.9 ± 13 yrs, LVEF: 70 ± 5%, QRS: 88 ± 9 ms) and patients with cardiomyopathy (n=108, age: 64.7 ± 12 yrs, LVEF: 29 ± 6%, QRS: 147 ± 29 ms) underwent FT-CMR for the assessment of the circumferential (CURE) and radial (RURE) uniformity ratio estimate based on myocardial strain (both CURE and RURE: 0 to 1; 1=perfect synchrony) RESULTS CURE (0.79 ± 0.14 vs. 0.97 ± 0.02) and RURE (0.71 ± 0.14 vs. 0.91 ± 0.04) were lower in patients with cardiomyopathy than in healthy controls (both p<0.0001). CURE (area under the receiver-operator characteristic curve [AUC]: 0.96), RURE (AUC: 0.96) and an average of these (CURE:RUREAVG, AUC: 0.98) had an excellent ability to discriminate between patients with cardiomyopathy and controls (sensitivity 90%; specificity 98% at a cut-off of 0.89). The time taken for semi-automatically tracking myocardial borders was 5.9 ± 1.4 min. CONCLUSION Dyssynchrony measures derived from FT-CMR, such as CURE and RURE, provide almost absolute discrimination between patients with cardiomyopathy and healthy controls. The rapid acquisition of these measures, which does not require specialized CMR sequences, has potential for the assessment of mechanical dyssynchrony in clinical practice.
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Affiliation(s)
- Robin J Taylor
- Department of Cardiology, The Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, United Kingdom; Centre for Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Fraz Umar
- Department of Cardiology, The Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, United Kingdom; Centre for Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - William E Moody
- Department of Cardiology, The Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, United Kingdom; Centre for Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Chitra Meyyappan
- Centre for Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | | | - John N Townend
- Department of Cardiology, The Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, United Kingdom; Centre for Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Kan N Hor
- Department of Cardiology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Tomasz Miszalski-Jamka
- Department of Clinical Radiology and Imaging Diagnostics, 4th Military Hospital, Wrocław, Center for Diagnosis, Prevention and Telemedicine, John Paul II Hospital, Krakow, Poland
| | - Wojciech Mazur
- The Christ Hospital Heart and Vascular Center, Cincinnati, OH, USA
| | - Richard P Steeds
- Department of Cardiology, The Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, United Kingdom; Centre for Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom
| | - Francisco Leyva
- Department of Cardiology, The Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, United Kingdom; Centre for Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kingdom.
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16
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Affiliation(s)
- Frits W. Prinzen
- From the Departments of Physiology (F.W.P.) and Cardiology (K.V.), Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; and the Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Kevin Vernooy
- From the Departments of Physiology (F.W.P.) and Cardiology (K.V.), Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; and the Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (A.A.)
| | - Angelo Auricchio
- From the Departments of Physiology (F.W.P.) and Cardiology (K.V.), Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands; and the Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (A.A.)
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17
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Ruschitzka F, Abraham WT, Singh JP, Bax JJ, Borer JS, Brugada J, Dickstein K, Ford I, Gorcsan J, Gras D, Krum H, Sogaard P, Holzmeister J. Cardiac-resynchronization therapy in heart failure with a narrow QRS complex. N Engl J Med 2013; 369:1395-405. [PMID: 23998714 DOI: 10.1056/nejmoa1306687] [Citation(s) in RCA: 576] [Impact Index Per Article: 52.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Cardiac-resynchronization therapy (CRT) reduces morbidity and mortality in chronic systolic heart failure with a wide QRS complex. Mechanical dyssynchrony also occurs in patients with a narrow QRS complex, which suggests the potential usefulness of CRT in such patients. METHODS We conducted a randomized trial involving 115 centers to evaluate the effect of CRT in patients with New York Heart Association class III or IV heart failure, a left ventricular ejection fraction of 35% or less, a QRS duration of less than 130 msec, and echocardiographic evidence of left ventricular dyssynchrony. All patients underwent device implantation and were randomly assigned to have CRT capability turned on or off. The primary efficacy outcome was the composite of death from any cause or first hospitalization for worsening heart failure. RESULTS On March 13, 2013, the study was stopped for futility on the recommendation of the data and safety monitoring board. At study closure, the 809 patients who had undergone randomization had been followed for a mean of 19.4 months. The primary outcome occurred in 116 of 404 patients in the CRT group, as compared with 102 of 405 in the control group (28.7% vs. 25.2%; hazard ratio, 1.20; 95% confidence interval [CI], 0.92 to 1.57; P=0.15). There were 45 deaths in the CRT group and 26 in the control group (11.1% vs. 6.4%; hazard ratio, 1.81; 95% CI, 1.11 to 2.93; P=0.02). CONCLUSIONS In patients with systolic heart failure and a QRS duration of less than 130 msec, CRT does not reduce the rate of death or hospitalization for heart failure and may increase mortality. (Funded by Biotronik and GE Healthcare; EchoCRT ClinicalTrials.gov number, NCT00683696.).
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Affiliation(s)
- Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
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18
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Abstract
Important advances have been made in the past few years in the fields of clinical cardiac electrophysiology and pacing. Researchers and clinicians have a greater understanding of the pathophysiological mechanisms underlying atrial fibrillation (AF), which has transpired into improved methods of detection, risk stratification, and treatments. The introduction of novel oral anticoagulants has provided clinicians with alternative options in managing patients with AF at moderate to high thromboembolic risk and further data has been emerging on the use of catheter ablation for the treatment of symptomatic AF. Another area of intense research in the field of cardiac arrhythmias and pacing is in the use of cardiac resynchronisation therapy (CRT) for the treatment of patients with heart failure. Following the publication of major landmark randomised controlled trials reporting that CRT confers a survival advantage in patients with severe heart failure and improves symptoms, many subsequent studies have been performed to further refine the selection of patients for CRT and determine the clinical characteristics associated with a favourable response. The field of sudden cardiac death and implantable cardioverter defibrillators also continues to be actively researched, with important new epidemiological and clinical data emerging on improved methods for patient selection, risk stratification, and management. This review covers the major recent advances in these areas related to cardiac arrhythmias and pacing.
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Affiliation(s)
- Reginald Liew
- Duke-NUS Graduate Medical School, Singapore, Singapore.
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19
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Muto C, Solimene F, Gallo P, Nastasi M, La Rosa C, Calvanese R, Iengo R, Canciello M, Sangiuolo R, Diemberger I, Ciardiello C, Tuccillo B. A Randomized Study of Cardiac Resynchronization Therapy Defibrillator Versus Dual-Chamber Implantable Cardioverter-Defibrillator in Ischemic Cardiomyopathy With Narrow QRS. Circ Arrhythm Electrophysiol 2013; 6:538-45. [DOI: 10.1161/circep.113.000135] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Carmine Muto
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Francesco Solimene
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Paolo Gallo
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Maurizio Nastasi
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Concetto La Rosa
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Raimondo Calvanese
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Raffaele Iengo
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Michelangelo Canciello
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Raffaele Sangiuolo
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Igor Diemberger
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Carmine Ciardiello
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
| | - Bernardino Tuccillo
- From the Ospedale S.Maria di Loreto Mare, Napoli, Italy (C.M., R.C., R.I., M.C., B.T.); Casa di cura “Montevergine” Mercogliano (AV), Italy (F.S.); CdC Villa dei Fiori, Acerra (NA), Italy (P.G.); CdC Villa Bianca, Bari, Italy (M.N.); CdC Villa Verde Taranto, Italy (C.L.R.); Ospedale Buon Consiglio Fatebenefratelli, Napoli, Italy (R.S.); Policlinico S. Orsola-Malpighi, Bologna, Italy (I.D.); and Boston Scientific, Milano, Italy (C.C.)
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20
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Thibault B, Harel F, Ducharme A, White M, Ellenbogen KA, Frasure-Smith N, Roy D, Philippon F, Dorian P, Talajic M, Dubuc M, Guerra PG, Macle L, Rivard L, Andrade J, Khairy P. Cardiac Resynchronization Therapy in Patients With Heart Failure and a QRS Complex <120 Milliseconds. Circulation 2013; 127:873-81. [PMID: 23388213 DOI: 10.1161/circulationaha.112.001239] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background—
Although the benefits of cardiac resynchronization therapy are well established in selected patients with heart failure and a prolonged QRS duration, salutary effects in patients with narrow QRS complexes remain to be demonstrated.
Methods and Results—
The Evaluation of Resynchronization Therapy for Heart Failure (LESSER-EARTH) trial is a randomized, double-blind, 12-center study that was designed to compare the effects of active and inactive cardiac resynchronization therapy in patients with severe left ventricular dysfunction and a QRS duration <120 milliseconds. The trial was interrupted prematurely by the Data Safety and Monitoring Board because of futility and safety concerns after 85 patients were randomized. Changes in exercise duration after 12 months were no different in patients with and without active cardiac resynchronization therapy (−0.7 minutes [95% confidence interval (CI), −2.9 to 1.5] versus 0.8 minutes [95% CI, −1.2 to 2.9];
P
=0.31]. Similarly, no significant differences were observed in left ventricular end-systolic volumes (−6.4 mL [95% CI, −18.8 to 5.9] versus 3.1 mL [95% CI, −9.2 to 15.5];
P
=0.28) and ejection fraction (3.3% [95% CI, 0.7–6.0] versus 2.1% [95% CI, −0.5 to 4.8];
P
=0.52). Moreover, cardiac resynchronization therapy was associated with a significant reduction in the 6-minute walk distance (−11.3 m [95% CI, −31.7 to 9.7] versus 25.3 m [95% CI, 6.1–44.5];
P
=0.01), an increase in QRS duration (40.2 milliseconds [95% CI, 34.2–46.2] versus 3.4 milliseconds [95% CI, 0.6–6.2];
P
<0.0001), and a nonsignificant trend toward an increase in heart failure–related hospitalizations (15 hospitalizations in 5 patients versus 4 hospitalizations in 4 patients).
Conclusions—
In patients with a left ventricular ejection fraction ≤35%, symptoms of heart failure, and a QRS duration <120 milliseconds, cardiac resynchronization therapy did not improve clinical outcomes or left ventricular remodeling and was associated with potential harm.
Clinical Trial Registration
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00900549.
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Affiliation(s)
- Bernard Thibault
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - François Harel
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Anique Ducharme
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Michel White
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Kenneth A. Ellenbogen
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Nancy Frasure-Smith
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Denis Roy
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - François Philippon
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Paul Dorian
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Mario Talajic
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Marc Dubuc
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Peter G. Guerra
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Laurent Macle
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Léna Rivard
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Jason Andrade
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
| | - Paul Khairy
- From the Montreal Heart Institute, Université de Montréal, Montreal, QB, Canada (B.T., F.H., A.D., M.W., N.F.-S., D.R., M.T., M.D., P.G.G., L.M., L.R., J.A., P.K.); Medical College of Virginia, Richmond (K.A.E.); Institut Universitaire de Cardiologie et Pneumologie, Université Laval, Quebec City, QC, Canada (F.P.); and St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada (P.D.)
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Abstract
Heart failure (HF) is a global phenomenon, and the overall incidence and prevalence of the condition are steadily increasing. Medical therapies have proven efficacious, but only a small number of pharmacological options are in development. When patients cease to respond adequately to optimal medical therapy, cardiac resynchronization therapy has been shown to improve symptoms, reduce hospitalizations, promote reverse remodelling, and decrease mortality. However, challenges remain in identifying the ideal recipients for this therapy. The field of mechanical circulatory support has seen immense growth since the early 2000s, and left ventricular assist devices (LVADs) have transitioned over the past decade from large, pulsatile devices to smaller, more-compact, continuous-flow devices. Infections and haematological issues are still important areas that need to be addressed. Whereas LVADs were once approved only for 'bridge to transplantation', these devices are now used as destination therapy for critically ill patients with HF, allowing these individuals to return to the community. A host of novel strategies, including cardiac contractility modulation, implantable haemodynamic-monitoring devices, and phrenic and vagus nerve stimulation, are under investigation and might have an impact on the future care of patients with chronic HF.
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Bajraktari G, Batalli A, Poniku A, Ahmeti A, Olloni R, Hyseni V, Vela Z, Morina B, Tafarshiku R, Vela D, Rashiti P, Haliti E, Henein MY. Left ventricular markers of global dyssynchrony predict limited exercise capacity in heart failure, but not in patients with preserved ejection fraction. Cardiovasc Ultrasound 2012; 10:36. [PMID: 22966942 PMCID: PMC3533775 DOI: 10.1186/1476-7120-10-36] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 09/02/2012] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The aim of this study was to prospectively examine echocardiographic parameters that correlate and predict functional capacity assessed by 6 min walk test (6-MWT) in patients with heart failure (HF), irrespective of ejection fraction (EF). METHODS In 147 HF patients (mean age 61 ± 11 years, 50.3% male), a 6-MWT and an echo-Doppler study were performed in the same day. Global LV dyssynchrony was indirectly assessed by total isovolumic time - t-IVT [in s/min; calculated as: 60 - (total ejection time + total filling time)], and Tei index (t-IVT/ejection time). Patients were divided into two groups based on the 6-MWT distance (Group I: ≤ 300 m and Group II: >300 m), and also in two groups according to EF (Group A: LVEF ≥ 45% and Group B: LVEF < 45%). RESULTS In the cohort of patients as a whole, the 6-MWT correlated with t-IVT (r = -0.49, p < 0.001) and Tei index (r = -0.43, p < 0.001) but not with any of the other clinical or echocardiographic parameters. Group I had lower hemoglobin level (p = 0.02), lower EF (p = 0.003), larger left atrium (p = 0.02), thicker interventricular septum (p = 0.02), lower A wave (p = 0.01) and lateral wall late diastolic myocardial velocity a' (p = 0.047), longer isovolumic relaxation time (r = 0.003) and longer t-IVT (p = 0.03), compared with Group II. In the patients cohort as a whole, only t-IVT ratio [1.257 (1.071-1.476), p = 0.005], LV EF [0.947 (0.903-0.993), p = 0.02], and E/A ratio [0.553 (0.315-0.972), p = 0.04] independently predicted poor 6-MWT performance (<300 m) in multivariate analysis. None of the echocardiographic measurements predicted exercise tolerance in HFpEF. CONCLUSION In patients with HF, the limited exercise capacity, assessed by 6-MWT, is related mostly to severity of global LV dyssynchrony, more than EF or raised filling pressures. The lack of exercise predictors in HFpEF reflects its multifactorial pathophysiology.
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Affiliation(s)
- Gani Bajraktari
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Arlind Batalli
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Afrim Poniku
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Artan Ahmeti
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Rozafa Olloni
- Heart Centre and Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Violeta Hyseni
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Zana Vela
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Besim Morina
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Rina Tafarshiku
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Driton Vela
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Premtim Rashiti
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Edmond Haliti
- Service of Cardiology, Clinic of Internal Medicine, University Clinical Centre of Kosova, Rrethi i Spitalit, p.n., Prishtina, Kosova
| | - Michael Y Henein
- Heart Centre and Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Almanac 2011: Heart failure. The national society journals present selected research that has driven recent advances in clinical cardiology. Egypt Heart J 2012. [DOI: 10.1016/j.ehj.2012.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Sipahi I, Chou JC, Hyden M, Rowland DY, Simon DI, Fang JC. Effect of QRS morphology on clinical event reduction with cardiac resynchronization therapy: meta-analysis of randomized controlled trials. Am Heart J 2012; 163:260-7.e3. [PMID: 22305845 DOI: 10.1016/j.ahj.2011.11.014] [Citation(s) in RCA: 192] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Accepted: 11/17/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is effective in reducing clinical events in systolic heart failure patients with a wide QRS. Previous retrospective studies suggest only patients with QRS prolongation due to a left bundle-branch block (LBBB) benefit from CRT. Our objective was to examine this by performing a meta-analysis of all randomized controlled trials of CRT. METHODS Systematic searches of MEDLINE and the Food and Drug Administration official website were conducted for randomized controlled CRT trials. Trials reporting adverse clinical events (eg, all-cause mortality, heart failure hospitalizations) according to QRS morphology were included in the meta-analysis. RESULTS Four randomized trials totaling 5,356 patients met the inclusion criteria. In patients with LBBB at baseline, there was a highly significant reduction in composite adverse clinical events with CRT (RR = 0.64 [95% CI (0.52-0.77)], P = .00001). However no such benefit was observed for patients with non-LBBB conduction abnormalities (RR = 0.97 [95% CI (0.82-1.15)], P = .75). When examined separately, there was no benefit in patients with right-bundle branch block (RR = 0.91 [95% CI (0.69-1.20)], P = .49) or non-specific intraventricular conduction delay (RR = 1.19 [95% CI (0.87-1.63)], P = .28). There was no heterogeneity among the clinical trials with regards to the lack of benefit in non-LBBB patients (I(2) = 0%). When directly compared, the difference in effect of CRT between LBBB versus non-LBBB patients was highly statistically significant (P = .0001 by heterogeneity analysis). CONCLUSIONS While CRT was very effective in reducing clinical events in patients with LBBB, it did not reduce such events in patients with wide QRS due to other conduction abnormalities.
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Donahue T, Niazi I, Leon A, Stucky M, Herrmann K. Acute and Chronic Response to CRT in Narrow QRS Patients. J Cardiovasc Transl Res 2011; 5:232-41. [DOI: 10.1007/s12265-011-9338-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 11/24/2011] [Indexed: 10/14/2022]
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Clark AL. Almanac 2011: heart failure. The national society journals present selected research that has driven recent advances in clinical cardiology. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2011. [DOI: 10.1016/j.repce.2011.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Clark AL. Almanac 2011: heart failure. The national society journals present selected research that has driven recent advances in clinical cardiology. Rev Port Cardiol 2011; 30:941-8. [PMID: 22088682 DOI: 10.1016/j.repc.2011.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 10/04/2011] [Indexed: 11/29/2022] Open
Affiliation(s)
- Andrew L Clark
- Academic Cardiology, Castle Hill Hospital, Castle Road, Cottingham, United Kingdom.
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Buga L, Cleland JGF. Increasing knowledge and changing views in cardiac resynchronization therapy. Heart Fail Rev 2011; 17:721-5. [DOI: 10.1007/s10741-011-9281-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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