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Treger JS, Allaw AB, Razminia P, Roy D, Gampa A, Rao S, Beaser AD, Yeshwant S, Aziz Z, Ozcan C, Upadhyay GA. A Revised Definition of Left Bundle Branch Block Using Time to Notch in Lead I. JAMA Cardiol 2024; 9:449-456. [PMID: 38536171 PMCID: PMC10974693 DOI: 10.1001/jamacardio.2024.0265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/28/2024] [Indexed: 05/09/2024]
Abstract
Importance Current left bundle branch block (LBBB) criteria are based on animal experiments or mathematical models of cardiac tissue conduction and may misclassify patients. Improved criteria would impact referral decisions and device type for cardiac resynchronization therapy. Objective To develop a simple new criterion for LBBB based on electrophysiological studies of human patients, and then to validate this criterion in an independent population. Design, Setting, and Participants In this diagnostic study, the derivation cohort was from a single-center, prospective study of patients undergoing electrophysiological study from March 2016 through November 2019. The validation cohort was assembled by retrospectively reviewing medical records for patients from the same center who underwent transcatheter aortic valve replacement (TAVR) from October 2015 through May 2022. Exposures Patients were classified as having LBBB or intraventricular conduction delay (IVCD) as assessed by intracardiac recording. Main Outcomes and Measures Sensitivity and specificity of the electrocardiography (ECG) criteria assessed in patients with LBBB or IVCD. Results A total of 75 patients (median [IQR] age, 63 [53-70.5] years; 21 [28.0%] female) with baseline LBBB on 12-lead ECG underwent intracardiac recording of the left ventricular septum: 48 demonstrated complete conduction block (CCB) and 27 demonstrated intact Purkinje activation (IPA). Analysis of surface ECGs revealed that late notches in the QRS complexes of lateral leads were associated with CCB (40 of 48 patients [83.3%] with CCB vs 13 of 27 patients [48.1%] with IPA had a notch or slur in lead I; P = .003). Receiver operating characteristic curves for all septal and lateral leads were constructed, and lead I displayed the best performance with a time to notch longer than 75 milliseconds. Used in conjunction with the criteria for LBBB from the American College of Cardiology/American Heart Association/Heart Rhythm Society, this criterion had a sensitivity of 71% (95% CI, 56%-83%) and specificity of 74% (95% CI, 54%-89%) in the derivation population, contrasting with a sensitivity of 96% (95% CI, 86%-99%) and specificity of 33% (95% CI, 17%-54%) for the Strauss criteria. In an independent validation cohort of 46 patients (median [IQR] age, 78.5 [70-84] years; 21 [45.7%] female) undergoing TAVR with interval development of new LBBB, the time-to-notch criterion demonstrated a sensitivity of 87% (95% CI, 74%-95%). In the subset of 10 patients with preprocedural IVCD, the criterion correctly distinguished IVCD from LBBB in all cases. Application of the Strauss criteria performed similarly in the validation cohort. Conclusions and Relevance The findings suggest that time to notch longer than 75 milliseconds in lead I is a simple ECG criterion that, when used in conjunction with standard LBBB criteria, may improve specificity for identifying patients with LBBB from conduction block. This may help inform patient selection for cardiac resynchronization or conduction system pacing.
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Affiliation(s)
- Jeremy S. Treger
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Ahmad B. Allaw
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Pouyan Razminia
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Dipayon Roy
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Amulya Gampa
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Swati Rao
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Andrew D. Beaser
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Srinath Yeshwant
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Zaid Aziz
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Cevher Ozcan
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Gaurav A. Upadhyay
- Center for Arrhythmia Care, Section of Cardiology, University of Chicago Pritzker School of Medicine, Chicago, Illinois
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Bijnens J, Trenson S, Voros G, Martens P, Ingelaere S, Betschart P, Voigt JU, Dupont M, Breitenstein A, Steffel J, Willems R, Ruschitzka F, Mullens W, Winnik S, Vandenberk B. Landmark Evolutions in Time and Indication for Cardiac Resynchronization Therapy: Results from a Multicenter Retrospective Registry. J Clin Med 2024; 13:1903. [PMID: 38610667 PMCID: PMC11012510 DOI: 10.3390/jcm13071903] [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: 02/19/2024] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 04/14/2024] Open
Abstract
Background: Cardiac resynchronization therapy (CRT) has evolved into an established therapy for patients with chronic heart failure and a wide QRS complex. Data on long-term outcomes over time are scarce and the criteria for implantation remain a subject of investigation. Methods: An international, multicenter, retrospective registry includes 2275 patients who received CRT between 30 November 2000 and 31 December 2019, with a mean follow-up of 3.6 ± 2.7 years. Four time periods were defined, based on landmark trials and guidelines. The combined endpoint was a composite of all-cause mortality, heart transplantation, or left ventricular assist device implantation. Results: The composite endpoint occurred in 656 patients (29.2%). The mean annual implantation rate tripled from 31.5 ± 17.4/year in the first period to 107.4 ± 62.4/year in the last period. In the adjusted Cox regression analysis, the hazard ratio for the composite endpoint was not statistically different between time periods. When compared to sinus rhythm with left bundle branch block (LBBB), a non-LBBB conduction pattern (sinus rhythm: HR 1.51, 95% CI 1.12-2.03; atrial fibrillation: HR 2.08, 95% CI 1.30-3.33) and a QRS duration below 130 ms (HR 1.64, 95% CI 1.29-2.09) were associated with a higher hazard ratio. Conclusions: Despite innovations, an adjusted regression analysis revealed stable overall survival over time, which can at least partially be explained by a shift in patient characteristics.
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Affiliation(s)
- Jeroen Bijnens
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
| | - Sander Trenson
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiology, Sint-Jan Hospital Bruges, 8000 Bruges, Belgium
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Gabor Voros
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium (M.D.)
| | | | - Pascal Betschart
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Jens-Uwe Voigt
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium (M.D.)
| | | | - Jan Steffel
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
- Hirslanden Heart Clinic, 8008 Zurich, Switzerland
| | - Rik Willems
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, 3600 Genk, Belgium (M.D.)
- Department of Life Sciences, Hasselt University, 3500 Hasselt, Belgium
| | - Stephan Winnik
- Department of Cardiology, University Hospital Zurich, 8091 Zurich, Switzerland
- Zurich Regional Health Center Wetzikon, 8620 Zurich, Switzerland
| | - Bert Vandenberk
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium (G.V.)
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
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3
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Ramdat Misier NL, Moore JP, Nguyen HH, Lloyd MS, Dubin AM, Mah DY, Czosek RJ, Khairy P, Chang PM, Nielsen JC, Aydin A, Pilcher TA, O'Leary ET, Shivkumar K, de Groot NMS. Long-Term Outcomes of Cardiac Resynchronization Therapy in Patients With Repaired Tetralogy of Fallot: A Multicenter Study. Circ Arrhythm Electrophysiol 2024; 17:e012363. [PMID: 38344811 DOI: 10.1161/circep.123.012363] [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: 08/01/2023] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND A growing number of patients with tetralogy of Fallot develop left ventricular systolic dysfunction and heart failure, in addition to right ventricular dysfunction. Although cardiac resynchronization therapy (CRT) is an established treatment option, the effect of CRT in this population is still not well defined. This study aimed to investigate the early and late efficacy, survival, and safety of CRT in patients with tetralogy of Fallot. METHODS Data were analyzed from an observational, retrospective, multicenter cohort, initiated jointly by the Pediatric and Congenital Electrophysiology Society and the International Society of Adult Congenital Heart Disease. Twelve centers contributed baseline and longitudinal data, including vital status, left ventricular ejection fraction (LVEF), QRS duration, and NYHA functional class. Outcomes were analyzed at early (3 months), intermediate (1 year), and late follow-up (≥2 years) after CRT implantation. RESULTS A total of 44 patients (40.3±19.2 years) with tetralogy of Fallot and CRT were enrolled. Twenty-nine (65.9%) patients had right ventricular pacing before CRT upgrade. The left ventricular ejection fraction improved from 32% [24%-44%] at baseline to 42% [32%-50%] at early follow-up (P<0.001) and remained improved from baseline thereafter (P≤0.002). The QRS duration decreased from 180 [160-205] ms at baseline to 152 [133-182] ms at early follow-up (P<0.001) and remained decreased at intermediate and late follow-up (P≤0.001). Patients with upgraded CRT had consistent improvement in left ventricular ejection fraction and QRS duration at each time point (P≤0.004). Patients had a significantly improved New York Heart Association functional class after CRT implantation at each time point compared with baseline (P≤0.002). The transplant-free survival rates at 3, 5, and 8 years after CRT implantation were 85%, 79%, and 73%. CONCLUSIONS In patients with tetralogy of Fallot treated with CRT consistent improvement in QRS duration, left ventricular ejection fraction, New York Heart Association functional class, and reasonable long-term survival were observed. The findings from this multicenter study support the consideration of CRT in this unique population.
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Affiliation(s)
- Nawin L Ramdat Misier
- Department of Cardiology, Erasmus Medical Center, Rotterdam , The Netherlands (N.L.R.M., N.M.S.d.G.)
| | - Jeremy P Moore
- Ahmanson/University of California Los Angeles Adult Congenital Heart Disease Center, Los Angeles, CA (J.P.M., K.S.)
| | - Hoang H Nguyen
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (H.H.N.)
| | - Michael S Lloyd
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (M.S.L.)
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto CA (A.M.D.)
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston MA (D.Y.M., E.T.O.)
| | - Richard J Czosek
- Division of Pediatric Cardiology, Department of Pediatrics, The Heart Institute at Cincinnati Children's Hospital Medical Center, Cincinnati OH (R.J.C.)
| | - Paul Khairy
- Electrophysiology Service and Adult Congenital Heart Center, Montreal Heart Institute, Université de Montréal, Montreal Quebec, Canada (P.K.)
| | - Philip M Chang
- Congenital Heart Center, University of Florida Health, Gainesville, FL (P.M.C.)
| | - Jens C Nielsen
- Department of Clinical Medicine, Aarhus University, Aarhus Denmark (J.C.N.)
- Department of Cardiology, Aarhus University Hospital, Aarhus Denmark (J.C.N.)
| | - Alper Aydin
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario Canada (A.A.)
| | - Thomas A Pilcher
- Division of Pediatric Cardiology, Department of Internal Medicine, University of Utah, Salt Lake City UT (T.A.P.)
| | - Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston MA (D.Y.M., E.T.O.)
| | - Kalyanam Shivkumar
- Ahmanson/University of California Los Angeles Adult Congenital Heart Disease Center, Los Angeles, CA (J.P.M., K.S.)
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Rotterdam , The Netherlands (N.L.R.M., N.M.S.d.G.)
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Yokoshiki H, Shimizu A, Mitsuhashi T, Ishibashi K, Kabutoya T, Yoshiga Y, Kondo Y, Abe H, Shimizu W. Improved outcomes of cardiac resynchronization therapy with a defibrillator in systolic heart failure: Analysis of the Japan cardiac device treatment registry database. J Arrhythm 2024; 40:30-37. [PMID: 38333398 PMCID: PMC10848589 DOI: 10.1002/joa3.12952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/11/2023] [Accepted: 10/23/2023] [Indexed: 02/10/2024] Open
Abstract
Background Temporal change in outcomes of heart failure patients receiving cardiac resynchronization therapy with a defibrillator (CRT-D) is unknown. Methods We assess outcomes and underlying heart diseases of patients receiving CRT-D with analyzing database of the Japan cardiac device treatment registry (JCDTR) at the implantation year 2011-2015 and New JCDTR at the implantation year 2018-2021. Results Proportion of nonischemic heart diseases was about 70% in both the groups (JCDTR: 69%; New JCDTR: 72%). Cardiac sarcoidosis increased with the rate of 5% in the JCDTR to 9% in the New JCDTR group. During an average follow-up of 21 months, death from any cause occurred in 167 of 906 patients in the JCDTR group (18%) and 79 of 611 patients in the New JCDTR group (13%) (adjusted hazard ratio [aHR] in the New JCDTR group, 0.72; 95% confidence interval [CI]: 0.55-0.94; p = .017). The superiority was mainly driven by reduction in the risk of noncardiac death. With regard to appropriate and inappropriate implantable cardioverter-defibrillator (ICD) therapy, there was a significant reduction in the New JCDTR group versus the JCDTR group (aHR in the New JCDTR group, 0.76; 95% CI: 0.59-0.98; p = .032 for appropriate ICD therapy; aHR in the New JCDTR group, 0.24; 95% CI: 0.12-0.50; p < .0001 for inappropriate ICD therapy). Conclusions All-cause mortality was reduced in CRT-D patients implanted during 2018-2021 compared to those during 2011-2015, with a significant reduction in noncardiac death.
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Affiliation(s)
- Hisashi Yokoshiki
- Department of Cardiovascular MedicineSapporo City General HospitalSapporoJapan
| | | | - Takeshi Mitsuhashi
- Department of Cardiovascular MedicineHoshi General HospitalKoriyamaJapan
| | - Kohei Ishibashi
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Tomoyuki Kabutoya
- Division of Cardiovascular Medicine, Department of MedicineJichi Medical University School of MedicineShimotsukeJapan
| | - Yasuhiro Yoshiga
- Division of Cardiology, Department of Medicine and Clinical ScienceYamaguchi University Graduate School of MedicineUbeJapan
| | - Yusuke Kondo
- Department of Cardiovascular MedicineChiba University Graduate School of MedicineChibaJapan
| | - Haruhiko Abe
- Department of Heart Rhythm ManagementUniversity of Occupational and Environmental HealthKitakyushuJapan
| | - Wataru Shimizu
- Department of Cardiovascular MedicineNippon Medical SchoolBunkyo‐kuJapan
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5
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Yu GI, Kim TH, Cho YH, Bae JS, Ahn JH, Jang JY, Park YW, Kwak CH. Left bundle branch area pacing in mildly reduced heart failure: A systematic literature review and meta-analysis. Clin Cardiol 2023. [PMID: 37144691 DOI: 10.1002/clc.24028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/09/2023] [Accepted: 04/21/2023] [Indexed: 05/06/2023] Open
Abstract
Cardiac resynchronization therapy (CRT) strategy for heart failure with mildly reduced ejection fraction (HFmrEF) is controversial. Left bundle branch area pacing (LBBAP) is an emerging pacing modality and an alternative option to CRT. This analysis aimed to perform a systematic review of the literature and meta-analysis on the impact of the LBBAP strategy in HFmrEF, with left ventricular ejection fraction (LVEF) between 35% and 50%. PubMed, Embase, and Cochrane Library were searched for full-text articles on LBBAP from inception to July 17, 2022. The outcomes of interest were QRS duration and LVEF at baseline and follow-up in mid-range heart failure. Data were extracted and summarized. A random-effect model incorporating the potential heterogeneity was used to synthesize the results. Out of 1065 articles, 8 met the inclusion criteria for 211 mid-range heart failure patients with an implant LBBAP across the 16 centers. The average implant success rate with lumenless pacing lead use was 91.3%, and 19 complications were reported among all 211 enrolled patients. During the average follow-up of 9.1 months, the average LVEF was 39.8% at baseline and 50.5% at follow-up (MD: 10.90%, 95% CI: 6.56-15.23, p < .01). Average QRS duration was 152.6 ms at baseline and 119.3 ms at follow-up (MD: -34.51 ms, 95% CI: -60.00 to -9.02, p < .01). LBBAP could significantly reduce QRS duration and improve systolic function in a patient with LVEF between 35% and 50%. Application of LBBAP as a CRT strategy for HFmrEF may be a viable option.
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Affiliation(s)
- Ga-In Yu
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yun-Ho Cho
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Jae-Seok Bae
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Jong-Hwa Ahn
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Jeong Yoon Jang
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Yong Whi Park
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
| | - Choong Hwan Kwak
- Division of Cardiology, Department of Internal Medicine, GyeongSang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Republic of Korea
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Zand S, Sadeghian H, Kazemisaid A, Lotfi-Tokaldany M, Jalali A, Sardari A. Response to Cardiac Resynchronization Therapy in Cardiomyopathy Patients with Right Bundle Branch Block. J Tehran Heart Cent 2023; 18:109-114. [PMID: 37637276 PMCID: PMC10459338 DOI: 10.18502/jthc.v18i2.13320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/14/2023] [Indexed: 08/29/2023] Open
Abstract
Background The use of cardiac resynchronization therapy (CRT) in heart failure patients with right bundle branch block (RBBB) is under debate. We present early and late echocardiographic characteristics of a series of heart failure patients with RBBB who underwent CRT. Methods In this retrospective descriptive study, 18 patients with RBBB in the surface electrocardiogram underwent CRT between 2005 and 2015. All the patients had the New York Heart Association functional class III/IV, a left ventricular ejection fraction (LVEF) ≤35%, and a QRS duration ≥120 milliseconds. The median follow-up duration was 19 months. The echocardiographic response was based on a ≥5% increase in LVEF. Results Within 48 hours after CRT implantation, LVEF increased from 24.58%±7.08% before to 28.46±8.91% after CRT (P=0.005) and to 30.00±9.44% at follow-up (P=0.008). Among the 18 patients, 12 (66.7%) were responders within 48 hours after CRT. The following baseline echocardiographic parameters were higher in the responders than in those without an increased LVEF, although the difference did not reach statistical significance: septal-to-lateral wall delay (48.33±33.53 vs 43.33±38.82 ms), anteroseptal-to-posterior wall delay (41.7±1.75 vs 38.33±18.35 ms), and interventricular mechanical delay (48.50±21.13 vs 31.17±19.93 ms). The mean QRS duration was higher in the responders than in the non-responders (183.58±40.69 vs 169.00±27.36 ms). Death was reported in 3 out of the 18 patients (16.7%) at follow-up. The 3 deceased patients had a higher baseline interventricular mechanical delay than those who survived. Conclusion Our results indicated that patients with RBBB might benefit from CRT. Further, patients with higher intra and interventricular dyssynchrony and a wider QRS may show better responses.
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Affiliation(s)
- Sara Zand
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hakimeh Sadeghian
- Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Kazemisaid
- Department of Electrophysiology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Masoumeh Lotfi-Tokaldany
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Arash Jalali
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Akram Sardari
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Teixeira RA, Fagundes AA, Baggio Junior JM, Oliveira JCD, Medeiros PDTJ, Valdigem BP, Teno LAC, Silva RT, Melo CSD, Elias Neto J, Moraes Júnior AV, Pedrosa AAA, Porto FM, Brito Júnior HLD, Souza TGSE, Mateos JCP, Moraes LGBD, Forno ARJD, D'Avila ALB, Cavaco DADM, Kuniyoshi RR, Pimentel M, Camanho LEM, Saad EB, Zimerman LI, Oliveira EB, Scanavacca MI, Martinelli Filho M, Lima CEBD, Peixoto GDL, Darrieux FCDC, Duarte JDOP, Galvão Filho SDS, Costa ERB, Mateo EIP, Melo SLD, Rodrigues TDR, Rocha EA, Hachul DT, Lorga Filho AM, Nishioka SAD, Gadelha EB, Costa R, Andrade VSD, Torres GG, Oliveira Neto NRD, Lucchese FA, Murad H, Wanderley Neto J, Brofman PRS, Almeida RMS, Leal JCF. Brazilian Guidelines for Cardiac Implantable Electronic Devices - 2023. Arq Bras Cardiol 2023; 120:e20220892. [PMID: 36700596 PMCID: PMC10389103 DOI: 10.36660/abc.20220892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | - Rodrigo Tavares Silva
- Universidade de Franca (UNIFRAN), Franca, SP - Brasil
- Centro Universitário Municipal de Franca (Uni-FACEF), Franca, SP - Brasil
| | | | - Jorge Elias Neto
- Universidade Federal do Espírito Santo (UFES), Vitória, ES - Brasil
| | - Antonio Vitor Moraes Júnior
- Santa Casa de Ribeirão Preto, Ribeirão Preto, SP - Brasil
- Unimed de Ribeirão Preto, Ribeirão Preto, SP - Brasil
| | - Anisio Alexandre Andrade Pedrosa
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Luis Gustavo Belo de Moraes
- Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | - Mauricio Pimentel
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS - Brasil
| | | | - Eduardo Benchimol Saad
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Hospital Samaritano, Rio de Janeiro, RJ - Brasil
| | | | | | - Mauricio Ibrahim Scanavacca
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Martino Martinelli Filho
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Batista de Lima
- Hospital Universitário da Universidade Federal do Piauí (UFPI), Teresina, PI - Brasil
- Empresa Brasileira de Serviços Hospitalares (EBSERH), Brasília, DF - Brasil
| | | | - Francisco Carlos da Costa Darrieux
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Sissy Lara De Melo
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Eduardo Arrais Rocha
- Hospital Universitário Walter Cantídio, Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
| | - Denise Tessariol Hachul
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Silvana Angelina D'Orio Nishioka
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Roberto Costa
- Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | - Gustavo Gomes Torres
- Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte (UFRN), Natal, RN - Brasil
| | | | | | - Henrique Murad
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ - Brasil
| | | | | | - Rui M S Almeida
- Centro Universitário Fundação Assis Gurgacz, Cascavel, PR - Brasil
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Vij A, Malhotra S. Identifying CRT responders: Moving from electrical to mechanical dyssynchrony. J Nucl Cardiol 2022; 29:2649-2651. [PMID: 35141842 DOI: 10.1007/s12350-022-02914-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
Affiliation(s)
- Aviral Vij
- Division of Cardiology, Cook County Health, Chicago, IL, 60612, USA
- Division of Cardiology, Rush Medical College, Chicago, USA
| | - Saurabh Malhotra
- Division of Cardiology, Cook County Health, Chicago, IL, 60612, USA.
- Division of Cardiology, Rush Medical College, Chicago, USA.
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9
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Darden D, Peterson PN, Xin X, Munir MB, Minges KE, Goldenberg I, Poole JE, Feld GK, Birgersdotter-Green U, Curtis JP, Hsu JC. Temporal trends and long-term outcomes among recipients of cardiac resynchronization therapy with defibrillator in the United States, 2011-2015: Insights from the National Cardiovascular Data Registry. Heart Rhythm O2 2022; 3:405-414. [PMID: 36097450 PMCID: PMC9463686 DOI: 10.1016/j.hroo.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Contemporary data on national trends and outcomes in cardiac resynchronization therapy with defibrillator (CRT-D) recipients following the 2012 updated guidelines has not been studied. Objectives This study assessed the trends in long-term outcomes among CRT-D Medicare-aged recipients implanted in 2011-2015. Methods Patients aged ≥65 years undergoing de novo CRT-D implantation in the National Cardiovascular Data Implantable Cardiac Defibrillator Registry from 2011-2015 with follow-up through 2017 using Medicare data were included and stratified by year of implant. Patient characteristics, in-hospital outcomes, and outcomes up to 2 years following implant were evaluated. Results Among 53,174 patients (aged 75.6-6.4 years, 29.7% women) implanted with CRT-D from 2011 to 2015, there was an increase in implantations based on guideline-concordant recommendations (81.0% to 84.7%, P < .001). Compared to 2011, in-hospital procedural complications decreased in 2015 (3.9% vs 2.9%; adjusted odds ratio, 0.76, 95% confidence interval, 0.66-0.88, P < .001), driven in part by decreased lead dislodgement (1.4% vs 1.0%). After multivariable adjustment, there was a lower risk of all-cause hospitalization, cardiovascular hospitalization, and mortality at 2-year follow-up in 2015 as compared to 2011, while there were no differences in heart failure hospitalizations at follow-up. Conclusion Among Medicare beneficiaries receiving CRT-D from 2011 to 2015, there was an increase in implantations based on guideline-concordant recommendations. Furthermore, there has been a reduction in in-hospital complications and long-term outcomes, including cardiovascular hospitalization, all-cause hospitalization, and mortality; however, there has been no difference in the risk of heart failure hospitalization after adjustment.
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Affiliation(s)
- Douglas Darden
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Pamela N. Peterson
- Division of Cardiology, Denver Health Medical Center, Denver, Colorado
- University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Xin Xin
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Muhammad Bilal Munir
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Karl E. Minges
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ilan Goldenberg
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York
| | - Jeanne E. Poole
- University of Washington School of Medicine, Seattle, Washington
| | - Gregory K. Feld
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Ulrika Birgersdotter-Green
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan C. Hsu
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, California
- Address reprint requests and correspondence: Dr Jonathan C. Hsu, Associate Professor of Medicine, University of California San Diego, 9452 Medical Center Dr, MC7411, La Jolla, CA 92037.
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10
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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Translation of the document prepared by the Czech Society of Cardiology. COR ET VASA 2022. [DOI: 10.33678/cor.2022.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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11
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Jiang Z, Wu T, Wu Y, Chen Z, Yang W, Chen C, Zhou X, Shan Q. Clinical Outcomes of Permanent Left Bundle Branch Area Pacing in Patients With Left Bundle Branch Block and Left Ventricular Ejection Fraction >35 vs. ≤35%. Front Cardiovasc Med 2022; 9:838708. [PMID: 35369330 PMCID: PMC8968131 DOI: 10.3389/fcvm.2022.838708] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/21/2022] [Indexed: 11/15/2022] Open
Abstract
Aims The present study aimed to compare the effects of left bundle branch area pacing (LBBAP) on cardiac function and clinical outcomes in patients with left bundle branch block (LBBB) and left ventricular ejection fraction (LVEF) >35 vs. ≤35%. Methods and Results Thirty-six consecutive patients with LBBB and LVEF <50% were enrolled. All patients were followed up for a mean of 6 months. The successful LBBAP was defined as a paced QRS complex presented as right bundle branch block (RBBB) morphology and QRSd < 130 ms. Echocardiography parameters, pacing parameters and clinical outcomes were collected. The successful LBBAP was achieved in 77.8% of all cases (28/36). In LVEF > 35% group (70 ± 8 years, 9 male), the success rate was 81.0% (17/21). QRSd significantly decreased from 174 ± 23 ms to 108 ± 13 ms (P < 0.001). The pacing threshold and R-wave amplitude were 0.6 ± 0.2 V @ 0.5 ms and 12 ± 7 mV, respectively. In LVEF ≤ 35% group (69 ± 5 years, 9 male), the success rate was 73.3% (11/15) with QRSd decreasing from 188 ± 25 ms to 107 ± 11 ms (P < 0.001). The hyperresponders to LBBAP (functional recovery and LVEF ≥ 50%) in LVEF > 35% group was 52.9%, which were almost twice of that in LVEF ≤ 35% group (33.3%). Whether patients had LBBAP or left ventricular septal pacing (LVSP), patients in the LVEF > 35% group showed significantly lower incidence of heart failure hospitalizations or death from any cause (hazard ratio in LVEF > 35% group, 0.22; 95%CI, 0.06 to 0.75, P = 0.011). Conclusions LBBAP can significantly shorten the QRSd and improve cardiac function in LBBB patients with either LVEF > 35 or ≤ 35%. LBBAP should be considered as an effective therapy for preventing the deterioration of cardiac function in early-stage heart failure patients with LBBB and LVEF > 35%.
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12
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJ, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. Grupo de trabajo sobre estimulación cardiaca y terapia de resincronización cardiaca de la Sociedad Europea de Cardiología (ESC). Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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13
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Krzowski B, Rokicki J, Główczyńska R, Fajkis-Zajączkowska N, Barczewska K, Mąsior M, Grabowski M, Balsam P. The Use of Machine Learning Algorithms in the Evaluation of the Effectiveness of Resynchronization Therapy. J Cardiovasc Dev Dis 2022; 9:jcdd9010017. [PMID: 35050227 PMCID: PMC8778735 DOI: 10.3390/jcdd9010017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/03/2022] [Accepted: 01/04/2022] [Indexed: 01/15/2023] Open
Abstract
Background: Cardiovascular disease remains the leading cause of death in the European Union and worldwide. Constant improvement in cardiac care is leading to an increased number of patients with heart failure, which is a challenging condition in terms of clinical management. Cardiac resynchronization therapy is becoming more popular because of its grounded position in guidelines and clinical practice. However, some patients do not respond to treatment as expected. One way of assessing cardiac resynchronization therapy is with ECG analysis. Artificial intelligence is increasing in terms of everyday usability due to the possibility of everyday workflow improvement and, as a result, shortens the time required for diagnosis. A special area of artificial intelligence is machine learning. AI algorithms learn on their own based on implemented data. The aim of this study was to evaluate using artificial intelligence algorithms for detecting inadequate resynchronization therapy. Methods: A total of 1241 ECG tracings were collected from 547 cardiac department patients. All ECG signals were analyzed by three independent cardiologists. Every signal event (QRS-complex) and rhythm was manually classified by the medical team and fully reviewed by additional cardiologists. The results were divided into two parts: 80% of the results were used to train the algorithm, and 20% were used for the test (Cardiomatics, Cracow, Poland). Results: The required level of detection sensitivity of effective cardiac resynchronization therapy stimulation was achieved: 99.2% with a precision of 92.4%. Conclusions: Artificial intelligence algorithms can be a useful tool in assessing the effectiveness of resynchronization therapy.
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Affiliation(s)
- Bartosz Krzowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, 00-582 Warsaw, Poland
- Correspondence: ; Tel.: +48-22-599-2958
| | - Jakub Rokicki
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
- Department of Medical Informatics and Telemedicine, Medical University of Warsaw, 00-582 Warsaw, Poland
| | - Renata Główczyńska
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
| | | | | | - Mariusz Mąsior
- Cardiomatics, 31-339 Cracow, Poland; (N.F.-Z.); (K.B.); (M.M.)
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
| | - Paweł Balsam
- 1st Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (J.R.); (R.G.); (M.G.); (P.B.)
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14
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM, Leyva F, Linde C, Abdelhamid M, Aboyans V, Arbelo E, Asteggiano R, Barón-Esquivias G, Bauersachs J, Biffi M, Birgersdotter-Green U, Bongiorni MG, Borger MA, Čelutkienė J, Cikes M, Daubert JC, Drossart I, Ellenbogen K, Elliott PM, Fabritz L, Falk V, Fauchier L, Fernández-Avilés F, Foldager D, Gadler F, De Vinuesa PGG, Gorenek B, Guerra JM, Hermann Haugaa K, Hendriks J, Kahan T, Katus HA, Konradi A, Koskinas KC, Law H, Lewis BS, Linker NJ, Løchen ML, Lumens J, Mascherbauer J, Mullens W, Nagy KV, Prescott E, Raatikainen P, Rakisheva A, Reichlin T, Ricci RP, Shlyakhto E, Sitges M, Sousa-Uva M, Sutton R, Suwalski P, Svendsen JH, Touyz RM, Van Gelder IC, Vernooy K, Waltenberger J, Whinnett Z, Witte KK. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Europace 2022; 24:71-164. [PMID: 34455427 DOI: 10.1093/europace/euab232] [Citation(s) in RCA: 111] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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15
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Gu H, Sidhu BS, Fang L, Webb J, Jackson T, Claridge S, Einarsen E, Razavi R, Papageorgiou N, Chow A, Bhattacharyya S, Chowienczyk P, Rinaldi CA. First-Phase Ejection Fraction Predicts Response to Cardiac Resynchronization Therapy and Adverse Outcomes. JACC Cardiovasc Imaging 2021; 14:2275-2285. [PMID: 34886993 DOI: 10.1016/j.jcmg.2021.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/04/2021] [Accepted: 05/14/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to examine the value of first-phase ejection fraction (EF1), to predict response to cardiac resynchronization therapy (CRT) and clinical outcomes after CRT. BACKGROUND CRT is an important treatment for patients with chronic heart failure. However, even in carefully selected cases, up to 40% of patients fail to respond. EF1, the ejection fraction up to the time of maximal ventricular contraction, is a novel sensitive echocardiographic measure of early systolic function and might relate to response to CRT. METHODS An initial retrospective study was performed in 197 patients who underwent CRT between 2009 and 2018 and were followed to determine clinical outcomes at King's Health Partners in London. A validation study (n = 100) was performed in patients undergoing CRT at Barts Heart Centre in London. RESULTS Volumetric response rate (reduction in end-systolic volume ≥15%) was 92.3% and 12.1% for those with EF1 in the highest and lowest tertiles (P < 0.001). A cutoff value of 11.9% for EF1 had >85% sensitivity and specificity for prediction of response to CRT; on multivariate binary logistic regression analysis incorporating previously defined predictors, EF1 was the strongest predictor of response (odds ratio [OR]: 1.56 per 1% change in EF1; 95% CI: 1.37-1.78; P < 0.001). EF1 was also the strongest predictor of improvement in clinical composite score (OR: 1.11; 95% CI: 1.04-1.19; P = 0.001). Improvement in EF1 at 6 months after CRT implantation (6.5% ± 5.8% vs 1.8% ± 4.3% in responders vs nonresponders; P < 0.001) was the best predictor of heart failure rehospitalization and death after median follow-up period of 20.3 months (HR: 0.81; 95% CI: 0.73-0.90; P < 0.001). In the validation cohort, EF1 was a similarly 1strong predictor of response (OR: 1.45; 95% CI: 1.23-1.70; P < 0.001) as in the original cohort. CONCLUSIONS EF1 is a promising marker to identify patients likely to respond to CRT.
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Affiliation(s)
- Haotian Gu
- British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Baldeep S Sidhu
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Lingyun Fang
- British Heart Foundation Centre, King's College London, London, United Kingdom
| | - Jessica Webb
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Tom Jackson
- Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | - Simon Claridge
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Eigir Einarsen
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Reza Razavi
- Imaging Sciences and Biomedical Engineering, King's College London, London, United Kingdom
| | | | - Anthony Chow
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | - Phil Chowienczyk
- British Heart Foundation Centre, King's College London, London, United Kingdom.
| | - Christopher A Rinaldi
- Cardiology Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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16
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Xiao PL, Cai C, Zhang P, Han J, Mulpuru SK, Deshmukh AJ, Yin YH, Cha YM. Better CRT Response in Patients Who Underwent Atrioventricular Node Ablation or Upgrade From Pacemaker: A Nomogram to Predict CRT Response. Front Cardiovasc Med 2021; 8:760195. [PMID: 34790708 PMCID: PMC8591090 DOI: 10.3389/fcvm.2021.760195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/01/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Response rates for cardiac resynchronization therapy (CRT) in patients without intrinsic left bundle-branch block (LBBB) morphology are poor. Objective: We sought to develop a nomogram model to predict response to CRT in patients without intrinsic LBBB. Methods: We searched electronic health records for patients without intrinsic LBBB who underwent CRT at Mayo Clinic. Logistic regression and Cox proportional hazards regression analysis were performed for the odds of response to CRT and risk of death, respectively. Results were used to develop the nomogram model. Results: 761 patients without intrinsic LBBB were identified. Six months after CRT, 47.8% of patients demonstrated improvement of left ventricular ejection fraction by more than 5%. The 1-, 3-, and 5-year survival rates were 95.9, 82.4, and 66.70%, respectively. Patients with CRT upgrade from pacemaker [odds ratio (OR), 1.67 (95% CI, 1.05–2.66)] or atrioventricular node (AVN) ablation [OR, 1.69 (95% CI, 1.09–2.64)] had a greater odds of CRT response than those patients who had new implant, or who did not undergo AVN ablation. Patients with right bundle-branch block had a low response rate (39.2%). Patients undergoing AVN ablation had a lower mortality rate than those without ablation [hazard ratio, 0.65 (95% CI, 0.46–0.91)]. Eight clinical variables were automatically selected to build a nomogram model and predict CRT response. The model had an area under the receiver operating characteristic curve of 0.71 (95% CI, 0.63–0.78). Conclusions: Among patients without intrinsic LBBB undergoing CRT, upgrade from pacemaker and AVN ablation were favorable factors in achieving CRT response and better long-term outcomes.
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Affiliation(s)
- Pei-Lin Xiao
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Cheng Cai
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Pei Zhang
- Department of Cardiology, Sir Run Run Shaw Hospital, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Jie Han
- Department of Cardiology and Atrial Fibrillation Center, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Siva K Mulpuru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Abhishek J Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Yue-Hui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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17
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Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM, Barrabés JA, Boriani G, Braunschweig F, Brignole M, Burri H, Coats AJS, Deharo JC, Delgado V, Diller GP, Israel CW, Keren A, Knops RE, Kotecha D, Leclercq C, Merkely B, Starck C, Thylén I, Tolosana JM. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J 2021; 42:3427-3520. [PMID: 34455430 DOI: 10.1093/eurheartj/ehab364] [Citation(s) in RCA: 791] [Impact Index Per Article: 263.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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18
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Drucker MN, Manyam H, Singh G, Glascock DN, Gillett S, Miller C, Sharmin K, Parks KA. MultiPole pacing in non-responders to cardiac resynchronization therapy: Results from the QP ExCELs/MPP sub-study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1683-1690. [PMID: 34405423 DOI: 10.1111/pace.14339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 07/26/2021] [Accepted: 08/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Multisite LV stimulation therapy allows for stimulation of two different left ventricular pacing vectors within a single LV lead and may improve responsiveness to cardiac resynchronization therapy (CRT). This study prospectively evaluated the safety and efficacy of the MultiPole Pacing (MPP) feature in CRT non-responder patients. METHODS AND RESULTS CRT non-responders with a standard CRT-D indication were eligible for enrollment into the MPP Sub-Study. Patient status, NYHA classification, Patient Global Assessment (PGA), and adverse events were collected at follow-up. A clinical composite score (CCS) was determined at the 6 month follow-up visit. The primary objective was defined as the proportion of patients with an improved CCS. Safety was evaluated as freedom from MPP system related adverse events requiring additional invasive intervention to resolve. A total of 53 patients were enrolled across 26 U.S. centers. The cumulative follow-up duration was 24.1 years. CCS was improved in 35.6% of patients (p < .0001 when compared to a performance goal of 3%) after 6 months of MPP therapy. When incorporating patient feedback into a modified CCS, 60.0% of patients showed an improvement. Three patients (5.7%) experienced hospitalization for heart failure, and three patient deaths occurred over the follow-up period. No MPP system-related events were reported for an AE-free rate of 100% (95% CI 93.28% to 100.0%). CONCLUSIONS The results of this small, non-randomized study suggest that the MPP feature is safe, and may be effective at converting a percentage of CRT non-responders to responders. Larger, randomized studies are needed to confirm this result.
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Affiliation(s)
| | | | | | | | | | | | | | - Kimberly A Parks
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
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19
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Fabiszak T, Łach P, Ratajczak J, Koziński M, Krupa W, Kubica J. Influence of QRS duration and axis on response to cardiac resynchronization therapy in chronic heart failure with reduced left ventricular ejection fraction: A single center study including patients with left bundle branch block. Cardiol J 2021; 27:575-582. [PMID: 30444259 DOI: 10.5603/cj.a2018.0138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/22/2018] [Accepted: 10/31/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The aim of the study was to evaluate QRS duration and axis as predictors of response to cardiac resynchronization therapy (CRT) in order to reduce the proportion of non-responders. METHODS Retrospective single-center study including 42 CRT recipients, with left bundle branch block (LBBB), left ventricular ejection fraction (LVEF) < 40%, in New York Heart Association (NYHA) class ≥ II. Response to CRT was declared as NYHA class improvement ≥ 1 (symptomatic) and LVEF improvement by ≥ 10% (echocardiographic) > 6 months post implantation. RESULTS Symptomatic responders had longer pre- (172.3 ± 17.9 vs. 159.0 ± 18.3 ms; p = 0.027) and postimplantation (157.2 ± 24.1 vs. 136.7 ± 23.2 ms; p = 0.009) QRS duration. Preimplantation QRS < 150 ms predicted poor response (odds ratio [OR] for response vs. lack of response 0.04; 95% confidence interval [CI] 0.001-0.74). Predictors of symptomatic response included: postimplantation QRS > 160 ms (OR 7.2; 95% CI 1.24-41.94), longer QRS duration before (OR for a 1 ms increase 1.04, 95% CI 1.00-1.08) and post implantation (OR for a 1 ms increase 1.04; 95% CI 1.01-1.07). Area under the curve (AUC) for pre- and postimplantation QRS duration was 0.672 (95% CI 0.51-0.84) and 0.727 (95% CI 0.57-0.89), respectively, with cut-off points of 178.5 ms and 157 ms. For post implantation QRS axis, AUC was 0.689 (95% CI 0.53-0.85), with cut-off points of -60.5° or -38.5°. Preimplantation QRS axis was the only predictor of echocardiographic response (OR 0.98; 95% CI 0.96-1.00), with AUC of 0.693 (95% CI 0.54-0.85) and a threshold of -36°. CONCLUSIONS Marked pre- and postimplantation QRS prolongation and preimplantation negative QRS axis deviation are moderate predictors of response to CRT.
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Affiliation(s)
- Tomasz Fabiszak
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland.
| | - Piotr Łach
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland
| | - Jakub Ratajczak
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland
| | - Marek Koziński
- Department of Principles of Clinical Medicine, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland
| | - Wojciech Krupa
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland
| | - Jacek Kubica
- Department of Cardiology and Internal Medicine, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Poland
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Abstract
Despite constant breakthroughs in heart failure (HF) therapy, the population of HF patients resume to grow and is linked to increased mortality and morbidity. Ventricular arrhythmias (VA) are one of the leading causes of mortality in HF subjects. Implantable cardioverter-defibrillators (ICDs) are currently the gold standard in treatment, preventing arrhythmic sudden cardiac death (SCD) episodes. However, the death rates related to HF remain elevated, as not all HF subjects benefit equally. Cardiac resynchronization therapy (CRT) has emerged as a novel approach for HF patients. These devices have been thoroughly investigated in major randomized controlled studies but continue to be underutilized in various countries. This review discusses the use of ICD
in HF populations on top of treatments.
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21
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Reitan C, Platonov PG, Borgquist R. The CHA2DS2-VASc Score and Its Association with Long-Term Outcome in a Cardiac Resynchronization Therapy Population. Cardiology 2021; 146:453-463. [PMID: 33965960 DOI: 10.1159/000513955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/17/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is commonly used in patients with heart failure and left ventricular dyssynchrony. Several scoring systems have been tested in order to predict long-term outcome. Although intended for use in patients with atrial fibrillation, we sought to assess the performance of the CHA2DS2-VASc score in a CRT population. METHODS Data on 796 consecutive CRT patients were retrospectively gathered from hospital records and healthcare registries. CHA2DS2-VASc scores were calculated, as well as other stratification scores for comparison. The outcomes were crude mortality, time to first heart failure hospitalization, and a composite of the 2. CHA2DS2-VASc score was evaluated against the end points with survival analyses and compared to other risk stratification scores. RESULTS The CHA2DS2-VASc score was significantly correlated with both outcomes in univariable and multivariable analysis adjusting for other known predictors of CRT outcome (unadjusted HR 1.28, 95% CI 1.21-1.36 and HR 1.19, 95% CI 1.13-1.25 for the mortality and heart failure hospitalization end points, respectively). Its performance compared well to other validated scores for the mortality end point (Harrell's C: 0.61, range for other scoring systems: 0.57-0.65), as well as the heart failure hospitalization end point (Harrell's C: 0.57, range of other scoring systems: 0.58-0.62). It correlated to 5- and 10-year survival with an area under the curve of 0.63 and 0.73, respectively. CONCLUSION When tested for association with outcome in a CRT population, the CHA2DS2-VASc score correlates to increased mortality and risk of heart failure hospitalization. It performs similarly to CRT-specific scores. However, the results of this study indicate that all tested scores should be used with caution in CRT patients.
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Affiliation(s)
- Christian Reitan
- Department of Cardiology, Institution for Clinical Sciences, Lund University, Lund, Sweden.,Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden.,Danderyd University Hospital, Danderyd, Sweden
| | - Pyotr G Platonov
- Department of Cardiology, Institution for Clinical Sciences, Lund University, Lund, Sweden.,Arrhythmia Department, Scania University Hospital, Lund, Sweden
| | - Rasmus Borgquist
- Department of Cardiology, Institution for Clinical Sciences, Lund University, Lund, Sweden.,Arrhythmia Department, Scania University Hospital, Lund, Sweden
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22
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Younis A, Aktas MK, Zareba W, McNitt S, Kutyifa V, Goldenberg I. Risk factors for ventricular tachyarrhythmic events in patients without left bundle branch block who receive cardiac resynchronization therapy. Ann Noninvasive Electrocardiol 2021; 26:e12847. [PMID: 33772947 PMCID: PMC8293612 DOI: 10.1111/anec.12847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/22/2021] [Accepted: 03/01/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) may be pro-arrhythmic in patients with non-left bundle branch block (non-LBBB). We hypothesized that combined assessment of risk factors (RF) for ventricular tachyarrhythmias (VTAs) can be used to stratify non-LBBB patients for CRT implantation. METHODS The study comprised 412 non-LBBB patients from MADIT-CRT randomized to CRT-D (n = 215) versus ICD only (n = 197). Best-subset regression analysis was performed to identify RF associated with increased VTA risk in CRT-D patients without LBBB. The primary end point was first occurrence of sustained VTA during follow-up. Secondary end points included VTA/death and appropriate shock. RESULTS Four RFs were associated with increased VTA risk: blood urea nitrogen >25mg/dl, ejection fraction <20%, prior nonsustained VT, and female gender. Among CRT-D patients, 114 (53%) had no RF, while 101 (47%) had ≥1 RF. The 4-year cumulative probability of VTA was higher among those with ≥1 RF compared with those without RF (40% vs. 14%, p < .001). Multivariate analysis showed that in patients without RF, treatment with CRT-D was associated with a 61% reduction in VTA compared with ICD-only therapy (p = .002), whereas among patients with ≥1 RF, treatment with CRT-D was associated with a corresponding 73% (p = .025) risk increase. Consistent results were observed when the secondary end points of VTA/death and appropriate ICD shocks were assessed. CONCLUSION Combined assessment of factors associated with increased risk for VTA can be used for improved selection of non-LBBB patients for CRT-D.
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Affiliation(s)
- Arwa Younis
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Mehmet K Aktas
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Wojciech Zareba
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Scott McNitt
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Valentina Kutyifa
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Ilan Goldenberg
- Clinical Cardiovascular Research Center, University of Rochester Medical Center, Rochester, NY, USA
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23
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Corbisiero R, Mathew A, Bickert C, Muller D. Multipoint Pacing with Fusion-optimized Cardiac Resynchronization Therapy: Using It All to Narrow QRS Duration. J Innov Card Rhythm Manag 2021; 12:4355-4362. [PMID: 33520350 PMCID: PMC7834044 DOI: 10.19102/icrm.2021.120102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 08/18/2020] [Indexed: 11/25/2022] Open
Abstract
Adaptive atrioventricular (AV)-shortening algorithms have achieved QRS duration (QRSd) narrowing in traditional cardiac resynchronization therapy (CRT) patients. Multipoint pacing (MPP) has also demonstrated benefit in this population. An additional site of activation via intrinsic conduction of the septum may further contribute to CRT; however, the incorporation of all strategies together has yet to be explored. We therefore developed and tested a method combining MPP-CRT and controlled septal contribution to create a multifuse pacing (MFP) technique, establishing four ventricular activation sites for CRT patients using measurements from intracardiac electrograms (EGMs) and incorporating an AV-delay shortening algorithm (SyncAV™; Abbott Laboratories, Chicago, IL, USA) to narrow the QRSd. Patients in sinus rhythm with an AV conduction time of less than 350 ms were included in this analysis and were further stratified by strictly defined left bundle branch block (sLBBB) or nonspecific intraventricular conduction delay (IVCD). EGM-based measurements to determine the QRS septal onset to right ventricular (RV) time (SRAT) and the left ventricular (LV) to RV pacing conduction time were collected and applied to a formula to facilitate MFP. QRSd was compared between before and after programming. A total of 22 patients (19 men and three women) with similar baseline characteristics were compared (all values in mean ± standard deviation). The overall baseline QRSd of 153.31 ± 24.60 ms was decreased to 115.31 ± 16.31 ms after MFP programming (p < 0.0001). The measured SRAT was 59.40 ± 28.49 ms, resulting in a negative AV offset of −20.0 ± 24.97 ms. Patients in the sLBBB group (n = 7) were aged 67.8 ± 13.3 years and had a QRSd of 168.85 ± 27.29 ms that decreased to 113 ± 16.69 ms for a reduction of 55.42 ± 19.3 ms or 32.1% (p = 0.0003). In the IVCD group (n = 15), the baseline QRSd of 146.06 ± 20.29 ms was decreased to 116 ± 16.66 ms for a reduction of 30.07 ± 16.41 ms or 20.62% (p = 0.0001). When comparing the sLBBB and IVCD groups, the sLBBB group was favored by a reduction of 25.35 ms (p = 0.00046). Ultimately, MFP achieved statistically significant reductions in QRSd in all patients tested in this analysis. The benefit was also significantly better in the sLBBB group as compared with in the IVCD group.
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24
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AlTurki A, Lima PY, Vidal A, Toscani B, Diaz S, Garcia D, Montemezzo M, Al-Dossari A, Bernier ML, Hadjis T, Joza J, Essebag V. Fusion pacing in patients with right bundle branch block who undergo cardiac resynchronization therapy. J Electrocardiol 2020; 64:66-71. [PMID: 33348136 DOI: 10.1016/j.jelectrocard.2020.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/26/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE Patients with right bundle branch block (RBBB) are less likely to respond to cardiac resynchronization therapy (CRT). We aimed to assess whether patients with RBBB respond to CRT with biventricular fusion pacing. METHODS Consecutive patients with RBBB at a single tertiary care center, who were implanted with a CRT device capable of biventricular fusion pacing using SyncAV programming, were assessed and compared to a historical cohort of CRT patients with RBBB. QRSd was measured and compared during intrinsic conduction, nominal CRT pacing and manual electrocardiogram-based optimized SyncAV programming. Left ventricular ejection fraction (LVEF) was also compared before and 6 months after CRT. RESULTS We included 8 consecutive patients with RBBB (group 1) who were able to undergo SyncAV programming and 16 patients with RBBB (group 2) from a historical cohort. In group 1, compared to mean intrinsic conduction QRSd (155 ± 13 ms), mean nominally-paced QRSd was 156 ± 15 ms (ΔQRSd 1.3 ± 11.6; p = 0.77) and SyncAV-optimized paced QRSd was 135 ± 14 ms (ΔQRSd -20.0 ± 20.4; p = 0.03 and ΔQRSd -21.3 ± 16.3; p = 0.008; compared to intrinsic conduction and nominal pacing respectively). In group 2, mean QRSd with nominal pacing was 160 ± 24 ms (ΔQRSd 3.8 ± 33.4; p = 0.66 compared to intrinsic conduction). In group 1, baseline LVEF was 22.1 ± 11.5 and after 6 months of follow-up was 27.8 ± 8.6 (p = 0.047). In group 2, the baseline LVEF was 27.2 ± 10.6 and after 6 months of follow-up was 25.0 ± 10.0 (p = 0.45). CONCLUSIONS CRT programed to allow biventricular fusion pacing significantly improved electrical synchrony and LVEF in patients with RBBB. Larger studies are required to confirm these findings.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Pedro Y Lima
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Alejandro Vidal
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Bruno Toscani
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Sergio Diaz
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Daniel Garcia
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | | | - Alaa Al-Dossari
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Martin L Bernier
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Tomy Hadjis
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Jacqueline Joza
- Division of Cardiology, McGill University Health Center, Montreal, Canada
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Montreal, Canada.
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25
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Salden OAE, van Stipdonk AMW, den Ruijter HM, Cramer MJ, Kloosterman M, Rienstra M, Maass AH, Prinzen FW, Vernooy K, Meine M. Heart Size Corrected Electrical Dyssynchrony and Its Impact on Sex-Specific Response to Cardiac Resynchronization Therapy. Circ Arrhythm Electrophysiol 2020; 14:e008452. [PMID: 33296227 DOI: 10.1161/circep.120.008452] [Citation(s) in RCA: 7] [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 Women are less likely to receive cardiac resynchronization therapy, yet, they are more responsive to the therapy and respond at shorter QRS duration. The present study hypothesized that a relatively larger left ventricular (LV) electrical dyssynchrony in smaller hearts contributes to the better cardiac resynchronization therapy response in women. For this, the vectorcardiography-derived QRS area is used, since it allows for a more detailed quantification of electrical dyssynchrony compared with conventional electrocardiographic markers. METHODS Data from a multicenter registry of 725 cardiac resynchronization therapy patients (median follow-up, 4.2 years [interquartile range, 2.7-6.1]) were analyzed. Baseline electrical dyssynchrony was evaluated using the QRS area and the corrected QRS area for heart size using the LV end-diastolic volume (QRSarea/LVEDV). Impact of the QRSarea/LVEDV ratio on the association between sex and LV reverse remodeling (LV end-systolic volume change) and sex and the composite outcome of all-cause mortality, LV assist device implantation, or heart transplantation was assessed. RESULTS At baseline, women (n=228) displayed larger electrical dyssynchrony than men (QRS area, 132±55 versus 123±58 μVs; P=0.043), which was even more pronounced for the QRSarea/LVEDV ratio (0.76±0.46 versus 0.57±0.34 μVs/mL; P<0.001). After multivariable analyses, female sex was associated with LV end-systolic volume change (β=0.12; P=0.003) and a lower occurrence of the composite outcome (hazard ratio, 0.59 [0.42-0.85]; P=0.004). A part of the female advantage regarding reverse remodeling was attributed to the larger QRSarea/LVEDV ratio in women (25-fold change in β from 0.12 to 0.09). The larger QRSarea/LVEDV ratio did not contribute to the better survival observed in women. In both volumetric responders and nonresponders, female sex remained strongly associated with a lower risk of the composite outcome (adjusted hazard ratio, 0.59 [0.36-0.97]; P=0.036; and 0.55 [0.33-0.90]; P=0.018, respectively). CONCLUSIONS Greater electrical dyssynchrony in smaller hearts contributes, in part, to more reverse remodeling observed in women after cardiac resynchronization therapy, but this does not explain their better long-term outcomes.
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Affiliation(s)
- Odette A E Salden
- Department of Cardiology (O.A.E.S., M.J.C., M.M.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | | | - Hester M den Ruijter
- Laboratory of Experimental Cardiology (H.M.d.R.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Maarten Jan Cramer
- Department of Cardiology (O.A.E.S., M.J.C., M.M.), University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Mariëlle Kloosterman
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M.K., M.R., A.H.M.)
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M.K., M.R., A.H.M.)
| | - Alexander H Maass
- Department of Cardiology, University of Groningen, University Medical Center Groningen, the Netherlands (M.K., M.R., A.H.M.)
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, the Netherlands (F.W.P.)
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center, the Netherlands (A.M.W.v.S., K.V.)
| | - Mathias Meine
- Department of Cardiology (O.A.E.S., M.J.C., M.M.), University Medical Center Utrecht, Utrecht University, the Netherlands
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26
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Martignani C, Massaro G, Diemberger I, Ziacchi M, Angeletti A, Galiè N, Biffi M. Cost-effectiveness of cardiac resynchronization therapy. J Med Econ 2020; 23:1375-1378. [PMID: 33026264 DOI: 10.1080/13696998.2020.1833893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Cristian Martignani
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Giulia Massaro
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Igor Diemberger
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Matteo Ziacchi
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Andrea Angeletti
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
| | - Mauro Biffi
- Cardiology Unit, Cardio-Thoracic and Vascular Department, S.Orsola University Hospital, University of Bologna, Bologna, Italy
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27
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Kvasnička J, Havlíček A, Bělohlávek J, Večeřa J, Čermáková E. Why is the clinical response to cardiac resynchronization better in LBBB patients? ESC Heart Fail 2020; 7:3667-3675. [PMID: 32945621 PMCID: PMC7754895 DOI: 10.1002/ehf2.12893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 06/17/2020] [Accepted: 06/24/2020] [Indexed: 11/16/2022] Open
Abstract
Aims The improved clinical response in patients with left bundle branch block (LBBB) over LBBB‐free patients treated with cardiac resynchronization therapy with a defibrillator (CRT‐D) is commonly attributed to an LBBB abnormality. We aimed to find an alternative explanation. Methods and results We analysed an immediate effect of selecting the LBBB group of patients in a cohort of 63 non‐ischaemic cardiomyopathy (non‐ICM) and 83 ischaemic cardiomyopathy (ICM) patients treated with CRT‐D; 75% of non‐ICM and 51% of ICM patients had an LBBB abnormality on the electrocardiogram, with a significant difference (P = 0.0032 by χ2). As a result of this difference, the proportion of non‐ICM patients increased from 43% in the primary cohort to 53% in LBBB selection and decreased to 28% in non‐LBBB group. By nonparametric survival analysis, the hazard ratio in non‐ICM patients in the LBBB selection decreased from 0.48 (P = 0.0488) to 0.36 (P = 0.0251) and increased in the non‐LBBB group to 0.75 (P = 0.6496). Any comparison of LBBB and non‐LBBB groups must compare sets with a significantly altered proportion of patients of different aetiologies. Most publications on LBBB patients are erroneous because they compare LBBB with non‐LBBB groups, not taking into account that the groups have been substantially changed by the selection process. Conclusions The declared outcome of the LBBB groups reflects inevitably the survival outcome of their non‐ICM patients and not the intended outcome of patients with LBBB. CRT‐D in patients with different aetiologies of cardiomyopathy calls for separate evaluation.
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Affiliation(s)
- Jiří Kvasnička
- Department of Invasive Arrhythmology, Cardiac Center AGEL AGEL AS Pardubice Czech Republic
- Cardiology Department Internal Medicine Clinic, Pardubice Hospital Pardubice Czech Republic
- 1st Department of Internal Medicine ‐ Cardioangiology Charles University Medical Faculty and Teaching Hospital Hradec Králové Czech Republic
| | - Aleš Havlíček
- Department of Invasive Arrhythmology, Cardiac Center AGEL AGEL AS Pardubice Czech Republic
- Cardiology Department Internal Medicine Clinic, Pardubice Hospital Pardubice Czech Republic
| | - Jan Bělohlávek
- Department of Invasive Arrhythmology, Cardiac Center AGEL AGEL AS Pardubice Czech Republic
- Cardiology Department Internal Medicine Clinic, Pardubice Hospital Pardubice Czech Republic
| | - Jan Večeřa
- Department of Invasive Arrhythmology, Cardiac Center AGEL AGEL AS Pardubice Czech Republic
- Cardiology Department Internal Medicine Clinic, Pardubice Hospital Pardubice Czech Republic
| | - Eva Čermáková
- Department of Medical Biophysics Charles University, Medical Faculty Hradec Králové Czech Republic
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28
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Verdonschot JAJ, Merken JJ, van Stipdonk AMW, Pliger P, Derks KWJ, Wang P, Henkens MTHM, van Paassen P, Abdul Hamid MA, van Empel VPM, Knackstedt C, Luermans JGLM, Crijns HJGM, Brunner-La Rocca HP, Brunner HG, Poelzl G, Vernooy K, Heymans SRB, Hazebroek MR. Cardiac Inflammation Impedes Response to Cardiac Resynchronization Therapy in Patients With Idiopathic Dilated Cardiomyopathy. Circ Arrhythm Electrophysiol 2020; 13:e008727. [PMID: 32997547 DOI: 10.1161/circep.120.008727] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an established therapy in patients with dilated cardiomyopathy (DCM) and conduction disorders. Still, one-third of the patients with DCM do not respond to CRT. This study aims to depict the underlying cardiac pathophysiological processes of nonresponse to CRT in patients with DCM using endomyocardial biopsies. METHODS Within the Maastricht and Innsbruck registries of patients with DCM, 99 patients underwent endomyocardial biopsies before CRT implantation, with histological quantification of fibrosis and inflammation, where inflammation was defined as >14 infiltrating cells/mm2. Echocardiographic left ventricular end-systolic volume reduction ≥15% after 6 months was defined as response to CRT. RNA was isolated from cardiac biopsies of a representative subset of responders and nonresponders. RESULTS Sixty-seven patients responded (68%), whereas 32 (32%) did not respond to CRT. Cardiac inflammation before implantation was negatively associated with response to CRT (25% of responders, 47% of nonresponders; odds ratio 0.3 [0.12-0.76]; P=0.01). Endomyocardial biopsies fibrosis did not relate to CRT response. Cardiac inflammation improved the robustness of prediction beyond well-known clinical predictors of CRT response (likelihood ratio test P<0.001). Cardiac transcriptomic profiling of endomyocardial biopsies reveals a strong proinflammatory and profibrotic signature in the hearts of nonresponders compared with responders. In particular, COL1A1, COL1A2, COL3A1, COL5A1, POSTN, CTGF, LOX, TGFβ1, PDGFRA, TNC, BGN, and TSP2 were significantly higher expressed in the hearts of nonresponders. CONCLUSIONS Cardiac inflammation along with a transcriptomic profile of high expression of combined proinflammatory and profibrotic genes are associated with a poor response to CRT in patients with DCM.
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Affiliation(s)
- Job A J Verdonschot
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands.,Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands
| | - Jort J Merken
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Antonius M W van Stipdonk
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Philipp Pliger
- Clinical Division of Cardiology and Angiology, Innsbruck Medical University, Austria (P.P., G.P.)
| | - Kasper W J Derks
- Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands
| | - Ping Wang
- Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands
| | - Michiel T H M Henkens
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Pieter van Paassen
- Immunology (P.v.P.), Maastricht University Medical Center, the Netherlands
| | | | - Vanessa P M van Empel
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Christian Knackstedt
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Justin G L M Luermans
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Harry J G M Crijns
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Hans-Peter Brunner-La Rocca
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
| | - Han G Brunner
- Clinical Genetics (J.A.J.V., K.W.J.D., P.W., H.G.B.), Maastricht University Medical Center, the Netherlands.,GROW Institute for Developmental Biology and Cancer (H.G.B.), Maastricht University Medical Center, the Netherlands.,Department of Human Genetics, Donders Institute for Brain, Cognition and Behaviour (H.G.B.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gerhard Poelzl
- Clinical Division of Cardiology and Angiology, Innsbruck Medical University, Austria (P.P., G.P.)
| | - Kevin Vernooy
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands.,Department of Cardiology (K.V.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Stephane R B Heymans
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands.,Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, KU Leuven, Belgium (S.R.B.H.).,The Netherlands Heart Institute, Nl-HI, Utrecht (S.R.B.H.)
| | - Mark R Hazebroek
- Cardiovascular Research Institute (CARIM), Departments of Cardiology (J.A.J.V., J.J.M., A.M.W.v.S., M.T.H.M.H., V.P.M.v.E., C.K., J.G.L.M.L., H.J.G.M.C., H.-P.B.-L.R., K.V., S.R.B.H., M.R.H.), Maastricht University Medical Center, the Netherlands
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Singh JP, Berger RD, Doshi RN, Lloyd M, Moore D, Stone J, Daoud EG. Targeted Left Ventricular Lead Implantation Strategy for Non-Left Bundle Branch Block Patients. JACC Clin Electrophysiol 2020; 6:1171-1181. [DOI: 10.1016/j.jacep.2020.04.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 04/20/2020] [Accepted: 04/30/2020] [Indexed: 10/23/2022]
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Wilkoff BL, Birnie D, Gold MR, Hersi AS, Jacobs S, Gerritse B, Kusano K, Leclercq C, Mullens W, Filippatos G. Differences in clinical characteristics and reported quality of life of men and women undergoing cardiac resynchronization therapy. ESC Heart Fail 2020; 7:2972-2982. [PMID: 32790108 PMCID: PMC7524066 DOI: 10.1002/ehf2.12914] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 06/13/2020] [Accepted: 07/13/2020] [Indexed: 01/15/2023] Open
Abstract
Aims Response to cardiac resynchronization therapy (CRT) is known to be associated with a number of clinical characteristics, including QRS duration and morphology, gender, height, and the aetiology of heart failure (HF). We assessed the relation of gender and baseline characteristics with QRS duration and Kansas City Cardiomyopathy Questionnaire. Methods and results AdaptResponse is a global randomized trial. The trial enrolled CRT‐indicated patients with New York Heart Association classes II–IV HF, left bundle branch block (QRS ≥ 140 ms in men, ≥130 ms in women), and baseline PR interval ≤200 ms. In total, 3620 patients were randomized, including 1569 women (43.3%) approaching the actual proportion of women in the HF population. Women were older and more often New York Heart Association class III or IV than men (55.6% vs. 48.7%), had less frequent ischaemic cardiomyopathy (21.2% vs. 39.5%), and had a 5.1 ms shorter QRS duration than men. Women were more often depressed (18.5% vs. 9.7%), had a significantly lower Kansas City Cardiomyopathy Questionnaire score, and had differences in medication prescriptions. Conclusions AdaptResponse is the largest randomized CRT trial and enrolled more women than any other landmark CRT trial. Women differed from men with regard to baseline characteristics and quality of life. Whether these differences translate into clinical outcome differences will be examined further in the AdaptResponse trial.
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Affiliation(s)
| | - David Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael R Gold
- Department of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Ahmad S Hersi
- Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sandra Jacobs
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Bart Gerritse
- Medtronic Bakken Research Center, Maastricht, The Netherlands
| | - Kengo Kusano
- National Cerebral and Cardiovascular Center, Osaka, Japan
| | | | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium and Hasselt University, Hasselt, Belgium
| | - Gerasimos Filippatos
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,School of Medicine, University of Cyprus, Nicosia, Cyprus
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Tung R, Upadhyay GA. Defining Left Bundle Branch Block Patterns in Cardiac Resynchronisation Therapy: A Return to His Bundle Recordings. Arrhythm Electrophysiol Rev 2020; 9:28-33. [PMID: 32637117 PMCID: PMC7330724 DOI: 10.15420/aer.2019.12] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Left bundle branch block (LBBB) is associated with improved outcome after cardiac resynchronisation therapy (CRT). One historical presumption of LBBB has been that the underlying pathophysiology involved diffuse disease throughout the distal conduction system. The ability to normalize wide QRS patterns with His bundle pacing (HBP) has called this notion into question. The determination of LBBB pattern is conventionally made by assessment of surface 12-lead ECGs and can include patients with and without conduction block, as assessed by invasive electrophysiology study (EPS). During a novel extension of the classical EPS to involve left-sided recordings, we found that conduction block associated with the LBBB pattern is most often proximal, usually within the left-sided His fibres, and these patients are the most likely to demonstrate QRS correction with HBP for resynchronisation. Patients with intact Purkinje activation and intraventricular conduction delay are less likely to benefit from HBP. Future EPS are required to determine the impact of newer approaches to conduction system pacing, including intraseptal or left ventricular septal pacing. Left-sided EPS has the potential to refine patient selection in CRT trials and may be used to physiologically phenotype distinct conduction patterns beyond LBBB pattern.
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Affiliation(s)
- Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, Chicago, IL, US
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, University of Chicago, Chicago, IL, US
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Yang S, Liu Z, Li W, Hu Y, Liu S, Jing R, Hua W. Validation of Three European Risk Scores to Predict Long-Term Outcomes for Patients Receiving Cardiac Resynchronization Therapy in an Asian Population. J Cardiovasc Transl Res 2020; 14:754-760. [PMID: 32372168 DOI: 10.1007/s12265-020-09999-y] [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: 11/29/2019] [Accepted: 04/01/2020] [Indexed: 11/26/2022]
Abstract
To validate externally and recalibrate three European risk scores for all-cause mortality and transplantation in patients receiving cardiac resynchronization therapy (CRT) in an Asian population. Data were collected at our institution between January 2010 and December 2017. The primary endpoints were all-cause mortality and heart transplantation. Of the 506 patients who were followed for 2 years, 104 reached the primary endpoint. The Kaplan-Meier event-free survival analysis, stratified according to the three scores, yielded significant results (log-rank test, all P < 0.05), with a good fit between the predicted and observed event rates (Hosmer-Lemeshow goodness-of-fit test, all P > 0.05). The ScREEN score yielded the best discriminatory power for the primary endpoints compared with the VALID-CRT and EAARN scores. ScREEN was the best predictor of all-cause mortality and heart transplantation. Risk scores based on different populations should be selected cautiously. Graphical Abstract.
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Affiliation(s)
- Shengwen Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100039, China
| | - Zhimin Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100039, China
| | - Wenran Li
- MOE Key Laboratory of Bioinformatics, Bioinformatics Division and Center for Synthetic and Systems Biology, BNRist, Department of Automation, Tsinghua University, Beijing, 100084, China
| | - Yiran Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100039, China
| | - Shangyu Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100039, China
| | - Ran Jing
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100039, China
| | - Wei Hua
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100039, China.
- , Beijing, China.
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Yang S, Liu Z, Hu Y, Jing R, Gu M, Niu H, Ding L, Xing A, Zhang S, Hua W. A novel risk model for mortality and hospitalization following cardiac resynchronization therapy in patients with non-ischemic cardiomyopathy: the alpha-score. BMC Cardiovasc Disord 2020; 20:205. [PMID: 32345229 PMCID: PMC7189497 DOI: 10.1186/s12872-020-01460-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 04/01/2020] [Indexed: 02/07/2023] Open
Abstract
Background Non-ischemic cardiomyopathy (NICM) has been associated with a better left ventricle reverse remodeling response and improved clinical outcomes after cardiac resynchronization therapy (CRT). The aims of our study were to identify the predictors of mortality and heart failure hospitalization in patients treated with CRT and design a risk score for prognosis. Methods A cohort of 422 consecutive NICM patients with CRT was retrospectively enrolled between January 2010 and December 2017. The primary endpoint was all-cause mortality and heart transplantation. Results In a multivariate analysis, the predictors of all-cause death were left atrial diameter [Hazard ratio (HR): 1.056, 95% confidence interval (CI): 1.020–1.093, P = 0.002]; non-left bundle branch block [HR: 1.793, 95% CI: 1.131–2.844, P = 0.013]; high sensitivity C-reactive protein [HR: 1.081, 95% CI: 1.029–1.134 P = 0.002]; and N-terminal pro-B-type natriuretic peptide [HR: 1.018, 95% CI: 1.007–1.030, P = 0.002]; and New York Heart Association class IV [HR: 1.018, 95% CI: 1.007–1.030, P = 0.002]. The Alpha-score (Atrial diameter, non-LBBB, Pro-BNP, Hs-CRP, NYHA class IV) was derived from each independent risk factor. The novel score had good calibration (Hosmer-Lemeshow test, P > 0.05) and discrimination for both primary endpoints [c-statistics: 0.749 (95% CI: 0.694–0.804), P < 0.001] or heart failure hospitalization [c-statistics: 0.692 (95% CI: 0.639–0.745), P < 0.001]. Conclusion The Alpha-score may enable improved discrimination and accurate prediction of long-term outcomes among NICM patients with CRT.
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Affiliation(s)
- Shengwen Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Zhimin Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China.
| | - Yiran Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Ran Jing
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Min Gu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Hongxia Niu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Ligang Ding
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | | | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China
| | - Wei Hua
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167 Beilishi Road, Xicheng District, Beijing, 100037, China.
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Cardiac Resynchronization Defibrillator Therapy for Nonspecific Intraventricular Conduction Delay Versus Right Bundle Branch Block. J Am Coll Cardiol 2020; 73:3082-3099. [PMID: 31221257 DOI: 10.1016/j.jacc.2019.04.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 02/17/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND The benefits of cardiac resynchronization therapy (CRT) in patients with non-left bundle branch block (LBBB) conduction abnormality have not been fully explored. OBJECTIVES This study sought to evaluate clinical outcomes among Medicare-aged patients with nonspecific intraventricular conduction delay (NICD) versus right bundle branch block (RBBB) in patients eligible for implantation with a CRT with defibrillator (CRT-D). METHODS Using the National Cardiovascular Data Registry implantable cardioverter-defibrillator (ICD) registry data between 2010 and 2013, the authors compared outcomes in CRT-eligible patients implanted with CRT-D versus ICD-only therapy among patients with NICD and RBBB. Also, among all CRT-D-implanted patients, the authors compared outcomes in those with NICD versus RBBB. Survival curves and multivariable adjusted hazard ratios (HRs) were used to assess outcomes including hospitalization and death. RESULTS In 11,505 non-LBBB CRT-eligible patients, after multivariable adjustment, among patients with RBBB, CRT-D was not associated with better outcomes, compared with ICD alone, regardless of QRS duration. Among patients with NICD and a QRS ≥150 ms, CRT-D was associated with decreased mortality at 3 years compared with ICD alone (HR: 0.602; 95% confidence interval [CI]: 0.416 to 0.871; p = 0.0071). Among 5,954 CRT-D-implanted patients, after multivariable adjustment NICD compared with RBBB was associated with lower mortality at 3 years in those with a QRS duration of ≥150 ms (HR: 0.757; 95% CI: 0.625 to 0.917; p = 0.0044). CONCLUSIONS Among non-LBBB CRT-D-eligible patients, CRT-D implantation was associated with better outcomes compared with ICD alone specifically in NICD patients with a QRS duration of ≥150 ms. Careful patient selection should be considered for CRT-D implantation in patients with non-LBBB conduction.
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Yang T, Gregg RE, Babaeizadeh S. Detection of strict left bundle branch block by neural network and a method to test detection consistency. Physiol Meas 2020; 41:025005. [PMID: 31962304 DOI: 10.1088/1361-6579/ab6e55] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To develop an automatic algorithm to detect strict left bundle branch block (LBBB) on electrocardiograms (ECG) and propose a procedure to test the consistency of neural network detections. APPROACH The database for the classification of strict LBBB was provided by Telemetric and Holter ECG Warehouse. It contained 10 s ECGs taken from the MADIT-CRT clinical trial. The database was divided into a training dataset (N = 300, strict LBBB = 174, non-strict LBBB = 126) and a test dataset (N = 302, strict LBBB = 156, non-strict LBBB = 146). LBBB-related features were extracted by Philips DXL™ algorithm, selected by a random forest classifier, and fed into a 5-layer neural network (NN) for the classification of strict LBBB on the training dataset. The performance of NN on the test dataset was compared to two random forest classifiers, an algorithm applying strict LBBB criteria, a wavelet-based approach, and a support-vector-machine approach. The consistency of NN's detection was tested on 549 2 min recordings of the PTB diagnostic ECG database. LBBB annotations are not required to measure consistency. MAIN RESULTS The performance of NN on the test dataset were sensitivity = 91. 7%, specificity = 85.6% and accuracy = 88.7% (PPV = 87.2%, NPV = 90.6%). The consistency score of strict-LBBB and non-strict-LBBB detection was 0.9341 and 0.9973 respectively. CONCLUSION NN achieved the highest specificity, accuracy, and PPV. Using random forest for feature selection and NN for classification increased interpretability and reduced computational cost. The consistency test showed that NN achieved high consistency scores in the detection of strict LBBB. SIGNIFICANCE This work proposed an approach for selecting features and training NN for the detection of strict LBBB as well as a consistency test for black-box algorithms.
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Affiliation(s)
- Ting Yang
- Advanced Algorithm Research Center, Philips Healthcare, Andover, MA, United States of America
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Salden OA, Vernooy K, van Stipdonk AM, Cramer MJ, Prinzen FW, Meine M. Strategies to Improve Selection of Patients Without Typical Left Bundle Branch Block for Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2020; 6:129-142. [DOI: 10.1016/j.jacep.2019.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 11/14/2019] [Accepted: 11/18/2019] [Indexed: 10/25/2022]
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Ueda N, Noda T, Ishibashi K, Nakajima K, Kataoka N, Kamakura T, Wada M, Yamagata K, Inoue Y, Miyamoto K, Nagase S, Aiba T, Kanzaki H, Izumi C, Noguchi T, Yasuda S, Kusano K. Efficacy of a Device-Based Continuous Optimization Algorithm for Patients With Cardiac Resynchronization Therapy. Circ J 2019; 84:18-25. [PMID: 31656236 DOI: 10.1253/circj.cj-19-0691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is less effective in patients with mildly wide QRS or non-left bundle branch block (non-LBBB). A new algorithm of every minute's optimization (adaptive CRT: aCRT algorithm) is effective in patients with CRT devices. This study investigated the clinical effect of the aCRT algorithm, especially in mildly wide QRS (120≤QRS<150 ms) or non-LBBB patients receiving CRT.Methods and Results:This study included 104 CRT patients (48 patients using the aCRT algorithm [adaptive group] and 56 patients not using the aCRT algorithm [non-adaptive group]). The primary endpoint was a composite clinical outcome of cardiac death and/or heart failure (HF) hospitalization. During a median follow-up of 700 days (interquartile range 362-1,173 days), aCRT reduced the risk of the clinical outcome, even in patients with mildly wide QRS or non-LBBB (log-rank P=0.0030 and P=0.0077, respectively) by Kaplan-Meier analysis. Use of the aCRT algorithm was an independent predictor of clinical outcomes in the multivariate analysis (hazard ratio (HR) 0.28, 95% confidence interval (CI): 0.096-0.78, P=0.015), the same as in patients with mildly wide QRS (HR 0.12, 95% CI: 0.006-0.69, P=0.015). CONCLUSIONS The new aCRT algorithm was useful and significantly reduced the risk of the clinical outcome, even in patients with mildly wide QRS.
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Affiliation(s)
- Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kenzaburo Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Naoya Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Kenichiro Yamagata
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yuko Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center.,Department of Advanced Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
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Kurita T. Can a New Algorithm of Cardiac Resynchronization Therapy (Adaptive CRT) Expand Its Utility? Circ J 2019; 84:11-12. [PMID: 31801921 DOI: 10.1253/circj.cj-19-0945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Okafor O, Zegard A, van Dam P, Stegemann B, Qiu T, Marshall H, Leyva F. Changes in QRS Area and QRS Duration After Cardiac Resynchronization Therapy Predict Cardiac Mortality, Heart Failure Hospitalizations, and Ventricular Arrhythmias. J Am Heart Assoc 2019; 8:e013539. [PMID: 31657269 PMCID: PMC6898809 DOI: 10.1161/jaha.119.013539] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [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 Predicting clinical outcomes after cardiac resynchronization therapy (CRT) and its optimization remain a challenge. We sought to determine whether pre‐ and postimplantation QRS area (QRSarea) predict clinical outcomes after CRT. Methods and Results In this retrospective study, QRSarea, derived from pre‐ and postimplantation vectorcardiography, were assessed in relation to the primary end point of cardiac mortality after CRT with or without defibrillation. Other end points included total mortality, total mortality or heart failure (HF) hospitalization, total mortality or major adverse cardiac events, and the arrhythmic end point of sudden cardiac death or ventricular arrhythmias with or without a shock. In patients (n=380, age 72.0±12.4 years, 68.7% male) undergoing CRT over 7.7 years (median follow‐up: 3.8 years [interquartile range 2.3–5.3]), preimplantation QRSarea ≥102 μVs predicted cardiac mortality (HR: 0.36; P<0.001), independent of QRS duration (QRSd) and morphology (P<0.001). A QRSarea reduction ≥45 μVs after CRT predicted cardiac mortality (HR: 0.19), total mortality (HR: 0.50), total mortality or heart failure hospitalization (HR: 0.44), total mortality or major adverse cardiac events (HR: 0.43) (all P<0.001) and the arrhythmic end point (HR: 0.26; P<0.001). A concomitant reduction in QRSarea and QRSd was associated with the lowest risk of cardiac mortality and the arrhythmic end point (both HR: 0.12, P<0.001). Conclusions Pre‐implantation QRSarea, derived from vectorcardiography, was superior to QRSd and QRS morphology in predicting cardiac mortality after CRT. A postimplant reduction in both QRSarea and QRSd was associated with the best outcomes, including the arrhythmic end point.
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Affiliation(s)
- Osita Okafor
- Aston Medical Research Institute Aston Medical School Aston University Birmingham United Kingdom
| | - Abbasin Zegard
- Aston Medical Research Institute Aston Medical School Aston University Birmingham United Kingdom
| | | | - Berthold Stegemann
- Aston Medical Research Institute Aston Medical School Aston University Birmingham United Kingdom
| | - Tian Qiu
- Aston Medical Research Institute Aston Medical School Aston University Birmingham United Kingdom.,Queen Elizabeth Hospital Birmingham United Kingdom
| | | | - Francisco Leyva
- Aston Medical Research Institute Aston Medical School Aston University Birmingham United Kingdom
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Breitenstein A, Steffel J. Devices in Heart Failure Patients-Who Benefits From ICD and CRT? Front Cardiovasc Med 2019; 6:111. [PMID: 31457018 PMCID: PMC6700378 DOI: 10.3389/fcvm.2019.00111] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 07/22/2019] [Indexed: 12/28/2022] Open
Abstract
Despite advances in heart failure treatment, this condition remains a relevant medical issue and is associated with a high morbidity and mortality. The cause of death in patients suffering from heart failure is not only a result of hemodynamic failure, but can also be due to ventricular arrhythmias. Implantable cardioverter defibrillators (ICDs) are these days the only tool to significantly reduce arrhythmic sudden death; but not all patients benefit to the same extend. In addition, cardiac resynchronization therapy (CRT) is another tool which is used in patients suffering from heart fialure. Even though both devices have been investigated in large randomized trials, both ICD and CRT remain underutilized in many countries. This brief review focuses on various aspects in this regard including a short overview on upcoming device novelties in the near future.
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Affiliation(s)
- Alexander Breitenstein
- Electrophysiology, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Jan Steffel
- Electrophysiology, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
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Fudim M, Borges-Neto S. A troubled marriage: When electrical and mechanical dyssynchrony don't go along. J Nucl Cardiol 2019; 26:1240-1242. [PMID: 29450822 DOI: 10.1007/s12350-018-1227-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 02/01/2018] [Indexed: 01/14/2023]
Affiliation(s)
- Marat Fudim
- Duke Department of Medicine and Division of Cardiology, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Salvador Borges-Neto
- Duke Department of Radiology and Division of Nuclear Medicine, 2301 Erwin Road, Durham, NC, 27710, USA.
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Sandhu A, Bao H, Minges KE, Varosy PD, Borne RT, Zipse MM, Marzec L, Peterson P, Masoudi F, Bradley SM. Use of Cardiac Resynchronization Therapy Defibrillator in US Hospitals. JAMA Cardiol 2019; 4:804-809. [PMID: 31215970 DOI: 10.1001/jamacardio.2019.1755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Cardiac resynchronization therapy (CRT) provides significant reduction in morbidity and mortality in select patients with left ventricular systolic dysfunction and specific parameters of electrocardiographic evidence of dyssynchrony. Relative to the 2012 American College of Cardiology/American Heart Association/Heart Rhythm Society guideline update for patient selection, little is known about the contemporary use of CRT in the United States. Objective To describe the use of CRT defibrillator (CRT-D) in the period around guideline revision. Design, Setting, and Participants All patients undergoing new CRT-D implantations in the National Cardiovascular Data Registry for implantable cardioverter-defibrillators from January 1, 2012, to December 31, 2015, at 1710 participating hospitals were identified for this population-based study. Rates of CRT-D implantation that were concordant and discordant with the 2012 American College of Cardiology/American Heart Association/Heart Rhythm Society update of the 2008 guidelines for device-based therapy were determined. Analysis began in January 2012. Main Outcomes and Measures Increase in guideline-concordant CRT-D implantation. Results Among 135 253 patients undergoing initial CRT-D implantation, 88 923 were included in the study cohort, of which 73 859 implants (83.1%) were guideline concordant. The proportion of guideline-concordant devices increased from 81.2% (16 710 of 20 481) in 2012 to 84.2% (20 515 of 24 356) in 2015 (P for trend < .001). Significant clustering was noted with 33% (565 of 1710) of hospitals accounting for greater than 70% (10 545 of 15 065) of guideline-discordant CRT-D implants. Conduction abnormalities, in particular, underlying right bundle branch block (3597 [23.9%] vs 7425 [10.1%]; P < .001) and nonspecific intraventricular conduction delay (3341 [22.2%] vs 4769 [6.5%]; P < .001) were more common in those who received guideline-discordant devices. Conclusions and Relevance Rates of guideline-concordant CRT-D implantation increased during the study. The major fraction of guideline-discordant implants were clustered at a minority of hospitals. Conduction abnormalities, particularly non-left bundle branch block and nonspecific intraventricular conduction delay, correlated with guideline-discordant implants indicating continued opportunity for dissemination and understanding of guideline updates.
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Affiliation(s)
- Amneet Sandhu
- Division of Cardiology, University of Colorado School of Medicine, Aurora.,Eastern Colorado VA Medical Center, Aurora
| | - Haikun Bao
- Yale University School of Medicine, New Haven, Connecticut
| | - Karl E Minges
- Yale University School of Medicine, New Haven, Connecticut
| | - Paul D Varosy
- Division of Cardiology, University of Colorado School of Medicine, Aurora.,Eastern Colorado VA Medical Center, Aurora
| | - Ryan T Borne
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Mathew M Zipse
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | | | - Pamela Peterson
- Division of Cardiology, University of Colorado School of Medicine, Aurora.,Division of Cardiology, Denver Health Medical Center, Denver, Colorado
| | - Frederick Masoudi
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Steven M Bradley
- Minneapolis Heart Institute, Minneapolis, Minnesota.,Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
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de Waard D, Manlucu J, Gillis AM, Sapp J, Bernick J, Doucette S, Tang A, Wells G, Parkash R. Cardiac Resynchronization in Women: A Substudy of the Resynchronization-Defibrillation for Ambulatory Heart Failure Trial. JACC Clin Electrophysiol 2019; 5:1036-1044. [PMID: 31537332 DOI: 10.1016/j.jacep.2019.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This study sought to evaluate the effect of cardiac resynchronization therapy with defibrillator (CRT-D) as compared with implantable cardioverter-defibrillator (ICD) on mortality, heart failure (HF) hospitalization, and ventricular arrhythmia in women versus men. BACKGROUND CRT-D has demonstrated reduced mortality and HF hospitalizations with greater benefit observed in women compared with men. However, whether CRT-D prevented ventricular arrhythmias in women compared with men was unclear. METHODS The RAFT (Resynchronization-Defibrillation for Ambulatory Heart Failure Trial) study randomized 1,798 patients to an ICD or CRT-D. In this post hoc analysis, women and men were compared by randomized group. By using a multivariable model, the outcomes of death and HF hospitalization and incidence of ventricular arrhythmia were compared between men and women. RESULTS There were 1,490 (83%) men (732, ICD; 758, CRT-D) and 308 (17%) women (172, ICD; 136, CRT-D) included in the analysis. Women with CRT-D had a significantly reduced incidence of death and HF hospitalization compared with men with CRT-D (hazard ratio: 0.52; 95% confidence interval: 0.33 to 0.81; p < 0.001) on multivariable analysis. Women with a primary prevention indication and CRT-D had the lowest rate of ventricular arrhythmia compared with men (hazard ratio: 0.59; 95% confidence interval: 0.39 to 0.91; p = 0.016). CONCLUSIONS Women have improved rates of death and HF hospitalization with CRT-D and were less likely to experience ventricular arrhythmia when compared with men, after adjusting for differences in baseline characteristics over a prolonged follow-up. Whether these improved outcomes reflect inherent sex differences in the underlying myocardial substrate resulting in an enhanced response to CRT-D requires further research.
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Affiliation(s)
| | - Jaimie Manlucu
- London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
| | - Anne M Gillis
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - John Sapp
- Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada
| | - Jordan Bernick
- Ottawa Cardiovascular Research Methods Center, Ottawa, Ontario, Canada
| | | | - Anthony Tang
- London Health Sciences Center, University of Western Ontario, London, Ontario, Canada
| | - George Wells
- Ottawa Cardiovascular Research Methods Center, Ottawa, Ontario, Canada
| | - Ratika Parkash
- Queen Elizabeth II Health Sciences Center, Halifax, Nova Scotia, Canada.
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Impaired Recovery of Left Ventricular Function in Patients With Cardiomyopathy and Left Bundle Branch Block. J Am Coll Cardiol 2019; 71:306-317. [PMID: 29348023 DOI: 10.1016/j.jacc.2017.11.020] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with left bundle branch block (LBBB) often respond to cardiac resynchronization therapy (CRT) with left ventricular ejection fraction (LVEF) improvement. Guideline-directed medical therapy (GDMT), not CRT, is first-line therapy for patients with reduced LVEF with LBBB. However, there are little data on how patients with reduced LVEF and LBBB respond to GDMT. OBJECTIVES This study examined patients with cardiomyopathy and sought to assess rates of LVEF improvement for patients with LBBB compared to other QRS morphologies. METHODS Using data from the Duke Echocardiography Laboratory Database, the study identified patients with baseline electrocardiography and LVEF ≤35% who had a follow-up LVEF 3 to 6 months later. The study excluded patients with severe valve disease, a cardiac device, left ventricular assist device, or heart transplant. QRS morphology was classified as LBBB, QRS duration <120 ms (narrow QRS duration), or a wide QRS duration ≥120 ms but not LBBB. Analysis of variance testing compared mean change in LVEF among the 3 groups with adjustment for significant comorbidities and GDMT. RESULTS There were 659 patients that met the criteria: 111 LBBB (17%), 59 wide QRS duration ≥120 ms but not LBBB (9%), and 489 narrow QRS duration (74%). Adjusted mean increase in LVEF over 3 to 6 months in the 3 groups was 2.03%, 5.28%, and 8.00%, respectively (p < 0.0001). Results were similar when adjusted for interim revascularization and myocardial infarction. Comparison of mean LVEF improvement between patients with LBBB on GDMT and those not on GDMT showed virtually no difference (3.50% vs. 3.44%). The combined endpoint of heart failure hospitalization or mortality was highest for patients with LBBB. CONCLUSIONS LBBB is associated with a smaller degree of LVEF improvement compared with other QRS morphologies, even with GDMT. Some patients with LBBB may benefit from CRT earlier than guidelines currently recommend.
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Harb SC, Toro S, Bullen JA, Obuchowski NA, Xu B, Trulock KM, Varma N, Rickard J, Grimm R, Griffin B, Flamm SD, Kwon DH. Scar burden is an independent and incremental predictor of cardiac resynchronisation therapy response. Open Heart 2019; 6:e001067. [PMID: 31354957 PMCID: PMC6615837 DOI: 10.1136/openhrt-2019-001067] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 05/01/2019] [Accepted: 05/30/2019] [Indexed: 01/07/2023] Open
Abstract
Objective Determine the prognostic impact of scar quantification (scar %) by cardiac magnetic resonance (CMR) in predicting heart failure admission, death and left ventricular (LV) function improvement following cardiac resynchronisation therapy (CRT), after controlling for the presence of left bundle branch block (LBBB), QRS duration (QRSd) and LV lead tip location and polarity. Methods Consecutive patients who underwent CMR between 2002 and 2014 followed by CRT were included. The primary endpoint was death or heart failure admission. The secondary endpoint was change in ejection fraction (EF) ≥3 months after CRT. Cox proportional hazards, linear regression models and change in the area under the receiver operating characteristic curve (AUC) were used. Results A total of 84 patients were included (63% male, 51% with ischaemic cardiomyopathy). After adjusting for clinical factors, presence of LBBB and QRSd and LV lead tip location and polarity, greater scar % remained associated with a higher risk for clinical events (HR=1.06; 95% CI 1.02 to 1.10; p<0.001) and a smaller improvement in EF (slope: −0.61%; 95% CI −0.93% to 0.29%; p<0.001). When adding scar % to QRSd and LBBB, there was significant improvement in predicting clinical events at 3 years (AUC increased to 0.831 from 0.638; p=0.027) and EF increase ≥10% (AUC 0.869 from 0.662; p=0.007). Conclusion Scar quantification by CMR has an incremental value in predicting response to CRT, in terms of heart failure admission, death and EF improvement, independent of the presence of LBBB, QRSd, LV lead tip location and polarity.
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Affiliation(s)
- Serge C Harb
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Saleem Toro
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jennifer A Bullen
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Bo Xu
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kevin M Trulock
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Niraj Varma
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John Rickard
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Richard Grimm
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Griffin
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott D Flamm
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Deborah H Kwon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Balla C, Cappato R. When to choose cardiac resynchronization therapy in chronic heart failure: type and duration of the conduction delay. Eur Heart J Suppl 2019; 21:B31-B35. [PMID: 30948941 PMCID: PMC6439948 DOI: 10.1093/eurheartj/suz026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure (HF), impaired left ventricular (LV) function, and wide QRS complex. The initial randomized clinical trials, which led to the widespread use of CRT, selected patients on the basis of QRS duration, not focusing on QRS morphology. However, recent evidences emphasized the role of left bundle branch block morphology in patients that underwent CRT in order to predict better response to therapy. Moreover, conventional right ventricular apical pacing might have long-term detrimental effects on cardiac structure and LV function, possibly leading to the development of HF. Therefore, current guidelines recommend upgrade from conventional pacemaker or implantable cardioverter-defibrillator to CRT or de novo CRT in patients with high (or expected high) percentage of ventricular pacing and reduced EF. We reviewed current knowledge on candidates’ selection for CRT based on conduction delays that lead to electrical and mechanical dyssynchrony of the left ventricle.
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Affiliation(s)
- Cristina Balla
- Cardiovascular Center, University of Ferrara, Ferrara, Italy
| | - Riccardo Cappato
- Department of Biomedical Sciences, Humanitas Clinical Research Institute, Humanitas University, Milan, Italy
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Iiya M, Shimizu M, Fujii H, Suzuki M, Nishizaki M. True complete left bundle branch block reveals dyssynchrony evaluated by semiconductor single-photon emission computed tomography. J Arrhythm 2019; 35:70-78. [PMID: 30805046 PMCID: PMC6373645 DOI: 10.1002/joa3.12148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 11/02/2018] [Accepted: 11/19/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Conventional complete left bundle branch block (CLBBB) criteria sometimes result in a false-positive diagnosis that does not represent dyssynchrony. Recently, true CLBBB criteria have been proposed to detect responders to cardiac resynchronization therapy (CRT), although their correlation with severity of dyssynchrony or natural prognosis is unclear. METHODS Ninety-four consecutive patients (74 ± 9 years, 63 men) with conventional CLBBB during sinus rhythm underwent semiconductor SPECT. They were divided into two groups: patients with true CLBBB and others. True CLBBB was characterized by the mid-QRS notching/slurring and wide QRS duration (male, ≥140 milliseconds; female, ≥130 milliseconds). Multivariate analysis was performed to detect left ventricular dyssynchrony (LVD), defined as bandwidth ≥145° and/or phase standard deviation (SD) ≥43°. Primary endpoints (hospitalization for heart failure or cardiac death) were evaluated. RESULTS True CLBBB had wider bandwidth (145 ± 83° vs 110 ± 64°, P = 0.024) and higher phase SD (48 ± 26° vs 35 ± 19°, P = 0.007). Ejection fraction (EF), end-diastolic volume (EDV), summed rest score (SRS), and the presence of ischemic heart disease (IHD) showed no differences between groups (P = 0.401, 0.591, 0.165, and 0.212, respectively). Multivariate analysis revealed that true CLBBB, EF, and EDV were significant predictors of LVD (odds ratio, 12.6, 0.90, 1.03; P = 0.003, 0.002, 0.022, respectively). At 3-year follow-up (median 667 days), primary endpoints were comparable in both groups (log-rank, P = 0.92). CONCLUSIONS Patients with true CLBBB had more severe dyssynchrony on single-photon emission computed tomography than patients with nontrue CLBBB. On the other hand, the two groups showed no differences in EF, EDV, the presence of IHD, hospitalization for heart failure, and cardiac death.
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Affiliation(s)
- Munehiro Iiya
- Department of CardiologyYokohama Minami Kyosai HospitalYokohamaJapan
| | - Masato Shimizu
- Department of CardiologyYokohama Minami Kyosai HospitalYokohamaJapan
| | - Hiroyuki Fujii
- Department of CardiologyYokohama Minami Kyosai HospitalYokohamaJapan
| | - Makoto Suzuki
- Department of CardiologyYokohama Minami Kyosai HospitalYokohamaJapan
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48
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Contractibility sensor signal evolution predicts cardiovascular events in patients with cardiac resynchronization therapy. Arch Cardiovasc Dis 2019; 112:22-30. [DOI: 10.1016/j.acvd.2018.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 06/08/2018] [Accepted: 07/23/2018] [Indexed: 11/21/2022]
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49
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Jastrzębski M, Baranchuk A, Fijorek K, Kisiel R, Kukla P, Sondej T, Czarnecka D. Cardiac resynchronization therapy-induced acute shortening of QRS duration predicts long-term mortality only in patients with left bundle branch block. Europace 2018; 21:281-289. [DOI: 10.1093/europace/euy254] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 10/11/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Marek Jastrzębski
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Kopernika str. 17, Krakow 31-052, Poland
| | - Adrian Baranchuk
- Heart Rhythm Service, Kingston Heart Sciences Center, Kingston, ON, Canada
| | - Kamil Fijorek
- Department of Statistics, Cracow University of Economics, Krakow, Poland
| | - Roksana Kisiel
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Kopernika str. 17, Krakow 31-052, Poland
| | - Piotr Kukla
- Department of Cardiology, H. Klimontowicz Specialistic Hospital, Gorlice, Poland
| | - Tomasz Sondej
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Kopernika str. 17, Krakow 31-052, Poland
| | - Danuta Czarnecka
- First Department of Cardiology, Interventional Electrocardiology and Hypertension, Jagiellonian University, Medical College, Kopernika str. 17, Krakow 31-052, Poland
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50
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The definition of left bundle branch block influences the response to cardiac resynchronization therapy. Int J Cardiol 2018; 269:165-169. [DOI: 10.1016/j.ijcard.2018.07.060] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/24/2018] [Accepted: 07/11/2018] [Indexed: 01/21/2023]
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