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Kaza N, Htun V, Miyazawa A, Simader F, Porter B, Howard JP, Arnold AD, Naraen A, Luria D, Glikson M, Israel C, Francis DP, Whinnett ZI, Shun-Shin MJ, Keene D. Upgrading right ventricular pacemakers to biventricular pacing or conduction system pacing: a systematic review and meta-analysis. Europace 2023; 25:1077-1086. [PMID: 36352513 PMCID: PMC10062368 DOI: 10.1093/europace/euac188] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/08/2022] [Indexed: 11/11/2022] Open
Abstract
Guidelines recommend patients undergoing a first pacemaker implant who have even mild left ventricular (LV) impairment should receive biventricular or conduction system pacing (CSP). There is no corresponding recommendation for patients who already have a pacemaker. We conducted a meta-analysis of randomized controlled trials (RCTs) and observational studies assessing device upgrades. The primary outcome was the echocardiographic change in LV ejection fraction (LVEF). Six RCTs (randomizing 161 patients) and 47 observational studies (2644 patients) assessing the efficacy of upgrade to biventricular pacing were eligible for analysis. Eight observational studies recruiting 217 patients of CSP upgrade were also eligible. Fourteen additional studies contributed data on complications (25 412 patients). Randomized controlled trials of biventricular pacing upgrade showed LVEF improvement of +8.4% from 35.5% and observational studies: +8.4% from 25.7%. Observational studies of left bundle branch area pacing upgrade showed +11.1% improvement from 39.0% and observational studies of His bundle pacing upgrade showed +12.7% improvement from 36.0%. New York Heart Association class decreased by -0.4, -0.8, -1.0, and -1.2, respectively. Randomized controlled trials of biventricular upgrade found improvement in Minnesota Heart Failure Score (-6.9 points) and peak oxygen uptake (+1.1 mL/kg/min). This was also seen in observational studies of biventricular upgrades (-19.67 points and +2.63 mL/kg/min, respectively). In studies of the biventricular upgrade, complication rates averaged 2% for pneumothorax, 1.4% for tamponade, and 3.7% for infection over 24 months of mean follow-up. Lead-related complications occurred in 3.3% of biventricular upgrades and 1.8% of CSP upgrades. Randomized controlled trials show significant physiological and symptomatic benefits of upgrading pacemakers to biventricular pacing. Observational studies show similar effects between biventricular pacing upgrade and CSP upgrade.
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Affiliation(s)
- Nandita Kaza
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Varanand Htun
- School of Public Health, Imperial College London, London, UK
| | - Alejandra Miyazawa
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Florentina Simader
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Bradley Porter
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - James P Howard
- Warrington and Halton Hospitals NHS Foundation Trust, Liverpool, UK
| | - Ahran D Arnold
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Akriti Naraen
- Warrington and Halton Hospitals NHS Foundation Trust, Liverpool, UK
| | - David Luria
- Hebrew University Jerusalem, Jerusalem, Israel
| | | | | | - Darrel P Francis
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Zachary I Whinnett
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Daniel Keene
- National Heart and Lung Institute, Imperial College London, B Block, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
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Kaza N, Htun V, Miyazawa A, Simader F, Porter B, Howard JP, Arnold A, Francis DP, Whinnett ZI, Shun-Shin MJ, Keene D. A systematic review and meta-analysis of upgrade to biventricular or conduction system pacing approaches. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
Chronic RV pacing has been recognised as being harmful to cardiac function. Patients undergoing a de novo pacemaker implant with even mild LV impairment are recommended to instead receive a physiological pacing strategy (biventricular or conduction system pacing [CSP]). No corresponding guideline recommendation exists for patients who already have a pacemaker.
Methods
We undertook a random-effects meta-analysis of all RCTs and observational studies covering device upgrade to biventricular pacing or conduction system pacing.
Results
6 RCTs assessing effect of upgrade to BiV pacing randomising 161 patients were eligible for analysis. Eligible observational studies included 46 of BiV upgrade and 7 of CSP upgrade totalling 2795 patients.
Mean LVEF improved by +8.3% from 34.4% in BiV upgrade RCTs (p=0.001) and +8.3% from 25.7% in BiV upgrade observational studies (p<0.001).
In observational studies of upgrade to CSP, LVEF increased by +10.1% from 38.4% (p=0.001) despite less severe LV impairment at baseline (p=0.004 vs mean EF in BiV RCTs and p<0.0001 vs mean EF in BiV observational studies).
LVESV decreased significantly by −25.4 ml, −23.7 ml, and −19.8 ml in BiV RCTs, BiV observational studies and CSP observational studies. Significant changes were also seen in NYHA class (decreased by −0.4, −0.8 and −1.0 respectively).
Minnesota Heart Failure Score (−6.9 points) and peak oxygen uptake (+1.1 ml/kg/min) increased significantly in RCTs of BiV upgrade. This was also seen in observational studies of BiV upgrade (−21.0 points and +2.63 ml/kg/min respectively).
Conclusions
RCTs and observational studies of upgrade to BiV pacing show significant physiological and symptomatic benefit. Observational studies of CSP upgrade show similar benefit with significant improvements in LVEF, LVESV and NYHA class in patients with an even milder degree of baseline LV impairment.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- N Kaza
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - V Htun
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - A Miyazawa
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - F Simader
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - B Porter
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - J P Howard
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - A Arnold
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - D P Francis
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - Z I Whinnett
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - M J Shun-Shin
- National Heart and Lung Institute Imperial College , London , United Kingdom
| | - D Keene
- National Heart and Lung Institute Imperial College , London , United Kingdom
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Saratzis A, Jaspers NEM, Gwilym B, Thomas O, Tsui A, Lefroy R, Parks M, Htun V, Mera Z, Thatcher A, Bosanquet D, Forsythe R, Benson R, Dattani N, Dovell G, Lane T, Shalhoub J, Sidloff D, Visseren FLJ, Dorresteijn JAN, Richards T. Observational study of the medical management of patients with peripheral artery disease. Br J Surg 2019; 106:1168-1177. [PMID: 31259387 DOI: 10.1002/bjs.11214] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 02/21/2019] [Accepted: 03/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Previous research has suggested that patients with peripheral artery disease (PAD) are not offered adequate risk factor modification, despite their high cardiovascular risk. The aim of this study was to assess the cardiovascular profiles of patients with PAD and quantify the survival benefits of target-based risk factor modification. METHODS The Vascular and Endovascular Research Network (VERN) prospectively collected cardiovascular profiles of patients with PAD from ten UK vascular centres (April to June 2018) to assess practice against UK and European goal-directed best medical therapy guidelines. Risk and benefits of risk factor control were estimated using the SMART-REACH model, a validated cardiovascular prediction tool for patients with PAD. RESULTS Some 440 patients (mean(s.d.) age 70(11) years, 24·8 per cent women) were included in the study. Mean(s.d.) cholesterol (4·3(1·2) mmol/l) and LDL-cholesterol (2·7(1·1) mmol/l) levels were above recommended targets; 319 patients (72·5 per cent) were hypertensive and 343 (78·0 per cent) were active smokers. Only 11·1 per cent of patients were prescribed high-dose statin therapy and 39·1 per cent an antithrombotic agent. The median calculated risk of a major cardiovascular event over 10 years was 53 (i.q.r. 44-62) per cent. Controlling all modifiable cardiovascular risk factors based on UK and European guidance targets (LDL-cholesterol less than 2 mmol/l, systolic BP under 140 mmHg, smoking cessation, antiplatelet therapy) would lead to an absolute risk reduction of the median 10-year cardiovascular risk by 29 (20-38) per cent with 6·3 (4·0-9·3) cardiovascular disease-free years gained. CONCLUSION The medical management of patients with PAD in this secondary care cohort was suboptimal. Controlling modifiable risk factors to guideline-based targets would confer significant patient benefit.
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Affiliation(s)
- A Saratzis
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester, UK
| | - N E M Jaspers
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - B Gwilym
- Vascular and Endovascular Research Network, Birmingham, UK
| | - O Thomas
- Vascular and Endovascular Research Network, Birmingham, UK
| | - A Tsui
- Vascular and Endovascular Research Network, Birmingham, UK
| | - R Lefroy
- Vascular and Endovascular Research Network, Birmingham, UK
| | - M Parks
- Vascular and Endovascular Research Network, Birmingham, UK
| | - V Htun
- Vascular and Endovascular Research Network, Birmingham, UK
| | - Z Mera
- Vascular and Endovascular Research Network, Birmingham, UK
| | - A Thatcher
- Vascular and Endovascular Research Network, Birmingham, UK
| | - D Bosanquet
- Vascular and Endovascular Research Network, Birmingham, UK
| | - R Forsythe
- Vascular and Endovascular Research Network, Birmingham, UK
| | - R Benson
- Vascular and Endovascular Research Network, Birmingham, UK
| | - N Dattani
- Vascular and Endovascular Research Network, Birmingham, UK
| | - G Dovell
- Vascular and Endovascular Research Network, Birmingham, UK
| | - T Lane
- Vascular and Endovascular Research Network, Birmingham, UK
| | - J Shalhoub
- Vascular and Endovascular Research Network, Birmingham, UK
| | - D Sidloff
- Vascular and Endovascular Research Network, Birmingham, UK
| | - F L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - J A N Dorresteijn
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - T Richards
- Department of Vascular Surgery, University of Western Australia, Perth, Western Australia, Australia
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Lockman KA, Htun V, Sinha R, Treskes P, Nelson LJ, Martin SF, Rogers SM, Le Bihan T, Hayes PC, Plevris JN. Proteomic profiling of cellular steatosis with concomitant oxidative stress in vitro. Lipids Health Dis 2016; 15:114. [PMID: 27368608 PMCID: PMC4930558 DOI: 10.1186/s12944-016-0283-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 06/24/2016] [Indexed: 12/14/2022] Open
Abstract
Background Nutrient excess underpins the development of nonalcoholic fatty liver disease (NAFLD). The ensuing metabolic derangement is characterised by increased cellular respiration, oxidative stress and mitochondrial impairment. We have previously recapitulated these events in an in vitro cellular steatosis model. Here, we examined the distinct patterns of protein expression involved using a proteomics approach. Methods Human hepatoblastoma C3A cells were treated with a combination of energy substrates; lactate (L), pyruvate (P), octanoate (O) and ammonia (N). Proteins extracts were trypsinized and analyzed on a capillary HPLC OrbitrapXL mass spectrometer. Proteins were quantified using a label-free intensity based approach. Functional enrichment analysis was performed using ToppCluster via Gene Ontology (GO) database. Results Of the 1327 proteins identified, 104 were differentially expressed between LPON and untreated cells (defined as: ≥2 peptides; fold change ≥1.5; p-value <0.05). Seventy of these were upregulated with LPON. Functional enrichment analysis revealed enhanced protein biosynthesis accompanied by downregulation of histones H2A type 1-A, H1.2, H1.5 and H1.0I in LPON cells. Lipid binding annotations were also enriched as well as proteins involved in cholesterol synthesis, uptake and efflux. Increased expression of aldo-keto reductase family 1, member C1 and C3 suggests enhanced sterol metabolism and increased ROS-mediated lipid peroxidation. Conclusions The surge of energy substrates diverts free fatty acid metabolism towards pathways that can mitigate lipotoxicity. The histones depletion may represent an adaptation to increased protein synthesis. However, this can also expose DNA to oxidative stress thus should be explored further in the context of NAFLD progression.
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Affiliation(s)
- Khalida Ann Lockman
- Hepatology Laboratory, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland, UK
| | - Varanand Htun
- Hepatology Laboratory, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland, UK
| | - Rohit Sinha
- Hepatology Laboratory, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland, UK
| | - Philipp Treskes
- Hepatology Laboratory, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland, UK
| | - Leonard J Nelson
- Hepatology Laboratory, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland, UK
| | - Sarah F Martin
- Kinetic Parameter Facility, SynthSys - Centre for Synthetic and Systems Biology, University of Edinburgh, Edinburgh, EH9 3BF, UK
| | - Sophie M Rogers
- Kinetic Parameter Facility, SynthSys - Centre for Synthetic and Systems Biology, University of Edinburgh, Edinburgh, EH9 3BF, UK
| | - Thierry Le Bihan
- Kinetic Parameter Facility, SynthSys - Centre for Synthetic and Systems Biology, University of Edinburgh, Edinburgh, EH9 3BF, UK
| | - Peter C Hayes
- Hepatology Laboratory, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland, UK
| | - John N Plevris
- Hepatology Laboratory, University of Edinburgh, 49 Little France Crescent, Edinburgh, EH16 4SB, Scotland, UK.
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