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Pubblicazioni recenti - cardiac resynchronization
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A randomized controlled trial of cardiac resynchronization therapy in patients with prolonged atrioventricular interval: the REAL-CRT pilot study.
Europace2019 Nov;():. doi: euz321.
Botto Giovanni Luca, Iuliano Assunta, Occhetta Eraldo, Belotti Giuseppina, Russo Giovanni, Campari Monica, Valsecchi Sergio, Stabile Giuseppe,
Abstract
AIMS:
A prolonged PR interval is known to be associated with increased mortality and a higher risk of developing atrial fibrillation (AF). We tested the hypothesis that cardiac resynchronization therapy (CRT) is superior to conventional dual-chamber pacing with algorithms for right ventricular pacing avoidance (DDD-VPA) in preserving systolic and diastolic function and in preventing new-onset AF in patients with normal systolic function, indication for pacing and prolonged atrioventricular conduction (PR interval ?220?ms).
METHODS AND RESULTS:
We randomly assigned 82 patients with ejection fraction >35%, indication for pacing and PR interval ?220?ms to CRT or to DDD-VPA. On 12-month follow-up examination, the study and control arms did not differ in terms of left ventricular end-systolic volume (44?±?17?mL vs. 47?±?16?mL, P?=?0.511) or ejection fraction (55?±?6% vs. 57?±?8%, P?=?0.291). The E to A mitral wave amplitude ratio was higher in the CRT arm (1.3?±?1.3 vs. 0.8?±?0.4, P?=?0.046) and the E wave deceleration time was longer (262?±?83?ms vs. 205?±?51?ms, P?=?0.027). Left atrial volume was smaller in the CRT arm (64?±?17?mL vs. 84?±?25?mL, P?=?0.035). Moreover, the functional class was lower in CRT patients (1.4?±?0.6 vs. 1.8?±?0.5, P?=?0.010). During follow-up, CRT was associated with a lower risk of new-onset AF [hazard ratio?=?0.37 (0.13-0.98), P?=?0.046].
CONCLUSION:
Cardiac resynchronization therapy proved superior to DDD-VPA in terms of better diastolic function, less left atrial enlargement and lower risk of new-onset AF, at 12?months. These data need to be confirmed in a larger trial with longer follow-up.
CLINICAL TRIAL REGISTRATION:
URL: http://clinicaltrials.gov/ Identifier: NCT02150538.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.
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Sex-Specific Differences in Survival and Heart Failure Hospitalization After Cardiac Resynchronization Therapy With or Without Defibrillation.
J Am Heart Assoc2019 Nov;8(22):e013485. doi: 10.1161/JAHA.119.013485.
Leyva Francisco, Qiu Tian, Zegard Abbasin, McNulty David, Evison Felicity, Ray Daniel, Gasparini Maurizio,
Abstract
Background Women are underrepresented in cardiac resynchronization therapy (CRT) trials. Some studies suggest that women fare better than men after CRT. We sought to explore clinical outcomes in women and men undergoing CRT-defibrillation or CRT-pacing in real-world clinical practice. Methods and Results A national database (Hospital Episode Statistics for England) was used to quantify clinical outcomes in 43 730 patients (women: 10 890 [24.9%]; men: 32 840 [75.1%]) undergoing CRT over 7.6 years, (median follow-up 2.2 years, interquartile range, 1-4 years). In analysis of the total population, the primary end point of total mortality (adjusted hazard ratio [aHR], 0.73; 95% CI, 0.69-0.76) and the secondary end point of total mortality or heart failure hospitalization (aHR, 0.79, 95% CI 0.75-0.82) were lower in women, independent of known confounders. Total mortality (aHR, 0.73; 95% CI, 0.70-0.76) and total mortality or heart failure hospitalization (aHR, 0.79; 95% CI, 0.75-0.82) were lower for CRT-defibrillation than for CRT-pacing. In analyses of patients with (aHR, 0.89; 95% CI, 0.80-0.98) or without (aHR, 0.70; 95% CI, 0.66-0.73) a myocardial infarction, women had a lower total mortality. In sex-specific analyses, total mortality was lower after CRT-defibrillation in women (aHR, 0.83; =0.013) and men (aHR, 0.69; <0.001). Conclusions Compared with men, women lived longer and were less likely to be hospitalized for heart failure after CRT. In both sexes, CRT-defibrillation was superior to CRT-pacing with respect to survival and heart failure hospitalization. The longest survival after CRT was observed in women without a history of myocardial infarction.
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Long-term follow-up of epicardial pacing and left ventricular dysfunction in children with congenital heart block.
Ann Thorac Surg2019 Nov;():. doi: S0003-4975(19)31688-1.
Song Mi Kyoung, Kim Na Yeon, Bae Eun Jung, Kim Gi Beom, Kwak Jae Gun, Kim Woong Han, Lee Jeong Ryul,
Abstract
BACKGROUND:
Patients with congenital complete atrioventricular block often require lifelong pacemaker therapy which has a risk of left ventricular (LV) dysfunction. The aim of our study was to determine the long-term effects of epicardial pacing on LV function and dyssynchrony in children with congenital heart block.
METHODS:
We conducted a retrospective study at a single tertiary center in which 34 pediatric patients with isolated congenital complete heart block who underwent epicardial pacemaker implantation from 1987 to 2016 were enrolled.
RESULTS:
Their median age during pacemaker insertion was 2.5 years (range, 0-16.7 years) and the median follow-up duration was 12.3 years. The initial pacing sites were the right ventricle (RV) free wall for 10 patients, RV apex for 16, and LV apex for eight. LV dysfunction developed in seven patients, of whom four underwent lead relocation to the RV apex (n = 2) and cardiac resynchronization therapy upgrade (n = 2). RV free wall pacing had a significantly higher risk of LV dysfunction than either LV or RV apical pacing (Odds ratio 52.5; p = 0.003; 95% C.I. 3.9-700). All four patients who underwent lead repositioning showed improvement of LV function (median ejection fraction, 24% to 62.7%).
CONCLUSIONS:
Our study suggests that RV free wall pacing may be a significant risk factor for LV dysfunction. Pacemaker-induced LV dysfunction was improved via lead relocation to the RV apex or cardiac resynchronization therapy upgrade. Future studies with a bigger sample size and longer-term follow-up are required to confirm our results.
Copyright © 2019. Published by Elsevier Inc.
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Association of Cardiac Resynchronization Therapy With Change in Left Ventricular Ejection Fraction in Patients With Chemotherapy-Induced Cardiomyopathy.
JAMA2019 11;322(18):1799-1805. doi: 10.1001/jama.2019.16658.
Singh Jagmeet P, Solomon Scott D, Fradley Michael G, Barac Ana, Kremer Kristina A, Beck Christopher A, Brown Mary W, McNitt Scott, Schleede Susan, Zareba Wojciech, Goldenberg Ilan, Kutyifa Valentina, ,
Abstract
Importance:
The incidence of chemotherapy-induced cardiomyopathy is increasing and is associated with poor clinical outcomes.
Objective:
To assess the association of cardiac resynchronization therapy (CRT) with improvement in cardiac function, as well as clinical improvement in patients with chemotherapy-induced cardiomyopathy.
Design, Setting, and Participants:
The Multicenter Automatic Defibrillator Implantation Trial-Chemotherapy-Induced Cardiomyopathy was an uncontrolled, prospective, cohort study conducted between November 21, 2014, and June 21, 2018, at 12 tertiary centers with cardio-oncology programs in the United States. Thirty patients were implanted with CRT owing to reduced left ventricular ejection fraction (LVEF?35%), New York Heart Association class II-IV heart failure symptoms, and wide QRS complex, with established chemotherapy-induced cardiomyopathy and were followed up for 6 months after CRT implantation. The date of final follow-up was February 6, 2019.
Exposures:
CRT implantation according to standard of care.
Main Outcomes and Measures:
The primary end point was change in LVEF from baseline to 6 months after initiating CRT. Secondary outcomes included all-cause mortality and change in left ventricular end-systolic volume and end-diastolic volume.
Results:
Among 30 patients who were enrolled (mean [SD] age, 64 [11] years; 26 women [87%]; 73% had a history of breast cancer; 20% had a history of lymphoma or leukemia), primary end point data were available for 26 patients and secondary end point data were available for 23 patients. Patients had nonischemic cardiomyopathy with left bundle branch block, median LVEF of 29%, and a mean QRS duration of 152 ms. Patients with CRT experienced a statistically significant improvement in mean LVEF at 6 months from 28% to 39% (difference, 10.6% [95% CI, 8.0%-13.3%]; P?
Conclusions and Relevance:
In this preliminary study of patients with chemotherapy-induced cardiomyopathy, CRT was associated with improvement in LVEF after 6 months. The findings are limited by the small sample size, short follow-up, and absence of a control group.
Trial Registration:
ClinicalTrials.gov Identifier: NCT02164721.
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Biventricular pacing during cardiac magnetic resonance imaging.
Europace2019 Nov;():. doi: euz289.
Vago Hajnalka, Czimbalmos Csilla, Papp Roland, Szabo Liliana, Toth Attila, Dohy Zsofia, Csecs Ibolya, Suhai Ferenc, Kosztin Annamaria, Molnar Levente, Geller Laszlo, Merkely Bela,
Abstract
AIMS:
We aimed to assess the effect of cardiac resynchronization on left ventricular (LV) function, volumes, geometry, and mechanics in order to demonstrate reverse remodelling using cardiac magnetic resonance (CMR) with resynchronization on.
METHODS AND RESULTS:
New York Heart Association (NYHA) Class II-III patients on optimal medical therapy with LV ejection fraction (LVEF) ?35%, and complete LBBB with broad QRS (>150 ms) were prospectively recruited. Cardiac magnetic resonance examination was performed at baseline and at 6-month follow-up, applying both biventricular and AOO pacing. The following data were measured: conventional CMR parameters, remodelling indices, global longitudinal, circumferential, radial strain, global dyssynchrony [mechanical dispersion (MD) defined as the standard deviation of time to peak longitudinal/circumferential strain in 16 LV segments], and regional dyssynchrony (maximum differences in time between peak septal and lateral transversal displacement). Thirteen patients (64?±?7?years, 38% male) were enrolled. Comparing the baseline and follow-up CMR parameters measured during biventricular pacing, significant increase in LVEF, and decrease in LV end-diastolic volume index (LVEDVi) and LV end-systolic volume index (LVESVi) were found. Left ventricular remodelling indices, global longitudinal, circumferential, and radial strain values showed significant improvement. Circumferential MD decreased (20.5?±?5.5 vs. 13.4?±?3.4, P?
CONCLUSION:
Cardiac magnetic resonance imaging during biventricular pacing is feasible and enables a more precise quantification of LV function, morphology, and mechanics. As a result, it may contribute to a better understanding of the effects of resynchronization therapy and might improve responder rate in the future.
© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.
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The role of implantable cardioverter-defibrillators and sudden cardiac death prevention: indications, device selection, and outcome.
Eur Heart J2019 Nov;():. doi: ehz788.
Goldenberg Ilan, Huang David T, Nielsen Jens Cosedis,
Abstract
Multiple randomized multicentre clinical trials have established the role of the implantable cardioverter-defibrillator (ICD) as the mainstay in the treatment of ventricular tachyarrhythmias and sudden cardiac death (SCD) prevention. These trials have focused mainly on heart failure patients with advanced left ventricular dysfunction and were mostly conducted two decades ago, whereas a more recent trial has provided conflicting results. Therefore, much remains to be determined on how best to balance the identification of patients at high risk of SCD together with who would benefit most from ICD implantation in a contemporary setting. Implantable cardioverter-defibrillators have also evolved from the simple, defibrillation-only devices implanted surgically to more advanced technologies of multi-chamber devices, with physiologic bradycardic pacing, including cardiac resynchronization therapy, atrial and ventricular therapeutic pacing algorithms, and subcutaneous ICDs. These multiple options necessitate individualized approach to device selection and programming. This review will focus on the current knowledge on selection of patients for ICD treatment, device selection and programming, and future directions of implantable device therapy for SCD prevention.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.
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Radiation exposure during cardiac device implantation: Lessons learned from a multicenter registry.
Pacing Clin Electrophysiol2019 Nov;():. doi: 10.1111/pace.13842.
Bru Paul, Dompnier Antoine, Amara Walid, Haddad Georges, Galuscan Gianina, Sagnol Pascal, Steinbach Mathieu, Montagnier Christian, Taieb Jérôme, Beguec Julien, Milhem Antoine, ,
Abstract
BACKGROUND:
Little data is available about radiation exposure during cardiac electrical device implantation, and no dose reference levels have been published. This multicenter, prospective, observational study assesses patient and staff radiation exposure during cardiac device implantations, and aims at defining dose reference levels.
METHODS:
Patient demographic, procedural and radiation data were obtained for 657 procedures from nine institutions. Physician and staff exposure were measured using real-time dosimeters worn beneath and above lead apron. Statistical analysis included fluoroscopy time, dose-area product, and dose-area product adjusted for fluoroscopy time and body mass index.
RESULTS:
Pacemakers and cardioverter-defibrillators were implanted in 481 and 176 patients, respectively. Of these, 152 were treated with cardiac resynchronization therapy. Median fluoroscopy times were 837 (IQR: 480-1323), 117 (IQR: 69-209) and 101 (IQR: 58-162) seconds, and median dose-area products were 1410 (IQR: 807-2601), 150 (IQR: 72-338) and 129 (IQR: 72-332) cGy.cm² for biventricular, dual chamber and ventricular device implantation, respectively. Dose reference levels correspond to the third quartile values. During cardiac resynchronization therapy, higher exposure was observed with four X-ray systems than with the two newer and customizable ones (adjusted dose area product of 0.90 [IQR: 0.26-1.01] and 0.29 [IQR: 0.23-0.39], respectively; p<0.001).
CONCLUSION:
Based on real-life measurements, this multicenter registry provides dose reference levels and may help centers assess radiation exposure. Although biventricular device implantation was responsible for the highest radiation exposure, fluoroscopy time was meaningfully shortened compared to previously reported values. For a same fluoroscopy time, the use of new generators and custom settings has significantly reduced dose-area product. This article is protected by copyright. All rights reserved.
This article is protected by copyright. All rights reserved.
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The European Society of Cardiology Cardiac Resynchronization Therapy Survey II: A comparison of cardiac resynchronization therapy implantation practice in Europe and France.
Arch Cardiovasc Dis2019 Nov;():. doi: S1875-2136(19)30171-8.
Galand Vincent, Linde Cecilia, Lellouche Nicolas, Mansourati Jacques, Deharo Jean-Claude, Sagnol Pascal, Da Costa Antoine, Horvilleur Jerome, Defaye Pascal, Boveda Serge, Steinbach Mathieu, Bru Paul, Rumeau Philippe, Beard Thierry, Younsi Salem, Dickstein Kenneth, Normand Camilla, Leclercq Christophe,
Abstract
BACKGROUND:
The first European Cardiac Resynchronization Therapy (CRT) Survey, conducted in 2008-2009, showed considerable variations in guideline adherence and implantation practice. A second prospective survey (CRT Survey II) was then performed to describe contemporary clinical practice regarding CRT among 42 European countries.
AIM:
To compare the characteristics of French CRT recipients with the overall European population of CRT Survey II.
METHODS:
Demographic and procedural data from French centres recruiting all consecutive patients undergoing either de novo CRT implantation or an upgrade to a CRT system were collected and compared with data from the European population.
RESULTS:
A total of 11,088 patients were enrolled in CRT Survey II, 754 of whom were recruited in France. French patients were older (44.7% aged?75 years vs 31.1% in the European group), had less severe heart failure symptoms, a higher baseline left ventricular ejection fraction and fewer co-morbidities. Additionally, French patients had a shorter intrinsic QRS duration (19.1% had a QRS<130ms vs 12.3% in the European cohort). Successful implantation rates were similar, but procedural and fluoroscopy times were shorter in France. French patients were more likely to receive a CRT pacemaker than European patients overall. Of note, antibiotic prophylaxis was reported to be administered less frequently in France, and a higher rate of early device-related infection was observed. Importantly, French patients were less likely to receive optimal drugs for treating heart failure at hospital discharge.
CONCLUSION:
This study highlights contemporary clinical practice in France, and describes substantial differences in patient selection, implantation procedure and outcomes compared with the other European countries participating in CRT Survey II.
Copyright © 2019. Published by Elsevier Masson SAS.
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Long-term experience of atrioventricular node ablation in patients with refractory atrial arrhythmias.
Heart Vessels2019 Nov;():. doi: 10.1007/s00380-019-01536-5.
Willy Kevin, Reinke Florian, Ellermann Christian, Leitz Patrick, Wasmer Kristina, Köbe Julia, Lange Philipp S, Kochhäuser Simon, Dechering Dirk, Eckardt Lars, Frommeyer Gerrit,
Abstract
Atrial fibrillation and other atrial tachyarrhythmias are increasing with age and concomitant morbidity. First options in symptomatic patients are drug treatment and catheter ablation. Nevertheless, a considerable number of patients suffer from refractory atrial tachyarrhythmias despite treatment. Atrioventricular node ablation (AVNA) may be helpful in many of these patients. Therefore, we investigated AVNA patients with a long-term follow-up. We enrolled 82 patients with a follow-up longer than 1 year receiving AVNA for drug- and ablation-resistant atrial tachyarrhythmias (AA) in a retrospective manner. Mean follow-up duration was 48?±?24 months. 50% of the patients initially received AVNA to optimize biventricular pacing in cardiac resynchronization therapy, the other 50% because of refractory symptomatic tachyarrhythmias. Persistent AV block was achieved in every patient. Symptom relief and patient satisfaction were high during follow-up. Due to system upgrades there were 63% of patients with a biventricular system during follow-up. In these patients, left-ventricular ejection fraction (LV-EF) increased by 7% (42-49%) after ablation. AVNA is effective in increasing biventricular pacing as well as for symptom relief in patients with refractory atrial tachyarrhythmias. AVNA should be considered as a valuable option in patients with refractory atrial tachyarrhythmias lacking other treatment options.
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European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS).
Europace2019 Nov;():. doi: euz246.
Blomström-Lundqvist Carina, Traykov Vassil, Erba Paola Anna, Burri Haran, Nielsen Jens Cosedis, Bongiorni Maria Grazia, Poole Jeanne, Boriani Giuseppe, Costa Roberto, Deharo Jean-Claude, Epstein Laurence M, Saghy Laszlo, Snygg-Martin Ulrika, Starck Christoph, Tascini Carlo, Strathmore Neil, ,
Abstract
Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.
© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.
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The effect of posture, exercise, and atrial pacing on atrioventricular conduction in systolic heart failure.
J Cardiovasc Electrophysiol2019 Nov;():. doi: 10.1111/jce.14264.
Niu Hongxia, Yu Yinghong, Sturdivant John L, An Qi, Gold Michael R,
Abstract
BACKGROUND:
Optimization of atrioventricular (AV) intervals for cardiac resynchronization therapy (CRT) programming is typically performed in supine patients at rest, which may not reflect AV timing in other conditions.
OBJECTIVE:
To evaluate the effects of posture, exercise, and atrial pacing on intrinsic AV intervals in patients with CRT devices.
METHODS:
Rate-dependent A-V delay by exercise was a multicenter, prospective trial of patients in sinus rhythm following CRT implantation. Intracardiac electrograms were recorded to analyze atrial to right ventricular (ARV), atrial to left ventricular (ALV), and RV to LV (VV) time intervals. Heart rate was increased with incremental atrial pacing in different postures, followed by an exercise treadmill test.
RESULTS:
This study included 36 patients. At rest, AV intervals changed minimally with posture. With atrial pacing, AV interval immediately increased compared with sinus rhythm, with ARV slopes being 8.1?±?7.7, 8.8?±?13.4, and 6.8?±?6.5?milliseconds per beat per minute (ms/bpm) and ALV slopes being 8.2?±?7.7, 9.1?±?12.8, and 7.0?±?6.5?ms/bpm for supine, standing and sitting positions, respectively. As the paced heart rate increased, ARV and ALV intervals increased more gradually with similar trends. Interventricular conduction times changed less than 0.2?ms/bpm with atrial pacing. During exercise, the direction of change of intrinsic ARV intervals, as heart rate increased, was variable between patients with relatively small overall group changes (0.1?±?1.4 and 0.2?±?1.2?ms/bpm for ARV and ALV, respectively).
CONCLUSION:
Posture and exercise have a smaller effect on AV timing compared with atrial pacing. However, individualized optimization and dynamic rate related changes may be needed to maintain optimal fusion with left ventricular (LV) stimulation.
© 2019 Wiley Periodicals, Inc.
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Biomarkers to predict the response to cardiac resynchronization therapy.
Europace2019 Nov;21(11):1609-1620. doi: 10.1093/europace/euz168.
Heggermont Ward, Auricchio Angelo, Vanderheyden Marc,
Abstract
Cardiac resynchronization therapy (CRT) is an established non-pharmacological treatment for selected heart failure patients with wide QRS duration. However, there is a persistent number of non-responders throughout. The prediction of the CRT response is paramount to adequately select the correct patients for CRT. One of the expanding fields of research is the development of biomarkers that predict the response to CRT. A review of the available literature on biomarkers in CRT patients has been performed to formulate a critical appraisal of the available data. The main conclusion of our review is that biomarker research in this patient population is very fragmented and broad. This results in the use of non-uniform endpoints to define the CRT response, which precludes an in-depth comparison of the available data. To improve research development in this field, a uniform definition of the CRT response and relevant endpoints is necessary to better predict the CRT response.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.
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Sleep-disordered breathing and effectiveness of cardiac resynchronization therapy in heart failure patients: gender differences?
Sleep Med2019 Jul;64():106-111. doi: S1389-9457(19)30235-7.
Mascia Giuseppe, Paoletti Perini Alessandro, Cartei Stella, Binazzi Barbara, Gigliotti Francesco, Solimene Francesco, Mascioli Giosue, Giaccardi Marzia,
Abstract
OBJECTIVES:
This study evaluated heart failure (HF) patients who underwent cardiac resynchronization therapy (CRT) and who had device-documented sleep-disordered breathing (SDB). We found gender differences in acute changes in SDB due to CRT impact.
BACKGROUND:
SDB typically occurs in HF patients. However, the role of SDB and its response to CRT in HF patients, as well as the relation with gender are currently not fully researched.
METHODS:
Among 63 consecutive patients who received CRT with an SDB algorithm, 23 patients documented SDB at one-month cardiac device interrogation and represented our population. We defined a Sleep apnoea Severity SCore(SSSC), and consequently, patients were categorized to have mild, moderate, and severe sleep apnoea syndrome divided into two groups: Group-1: 18 males (78%); Group-2: 5 females (22%). We evaluated the variation of apnoea burden and CRT response based on gender differences.
RESULTS:
A significantly higher proportion of patients in the male group were non-responders to CRT at 12-months follow-up (p = 0.076) while in the female population 5/5 patients (100%) were responders to CRT at the same follow-up time (p = 0.021). Among Group-2 subjects, we documented a significant linear decrease in SSSC(p > 0,01) while in Group-1 the CRT effect on SSSC was variable. At 12-months follow-up, the difference in SSSC between the two groups was statistically significant (p < 0.001).
CONCLUSIONS:
Our study reports a correlation between CRT response and sleep apnoea burden considering gender differences. In particular, HF-women responders to CRT demonstrate a significant linear decrease in sleep apnoea burden determined through a device algorithm, when compared to a similar male population. Further research is needed to confirm these findings.
Copyright © 2019 Elsevier B.V. All rights reserved.
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Dynamic atrioventricular delay programming improves ventricular electrical synchronization as evaluated by 3D vectorcardiography.
J Electrocardiol2019 Oct;58():1-6. doi: S0022-0736(19)30574-6.
Engels Elien B, Thibault Bernard, Mangual Jan, Badie Nima, McSpadden Luke C, Calò Leonardo, Ritter Philippe, Pappone Carlo, Bode Kerstin, Varma Niraj, Prinzen Frits W,
Abstract
BACKGROUND:
Optimal timing of the atrioventricular delay in cardiac resynchronization therapy (CRT) can improve synchrony in patients suffering from heart failure. The purpose of this study was to evaluate the impact of SyncAV? on electrical synchrony as measured by vectorcardiography (VCG) derived QRS metrics during bi-ventricular (BiV) pacing.
METHODS:
Patients implanted with a cardiac resynchronization therapy (CRT) device and quadripolar left ventricular (LV) lead underwent 12?lead ECG recordings. VCG metrics, including QRS duration (QRSd) and area, were derived from the ECG by a blinded observer during: intrinsic conduction, BiV with nominal atrioventricular delays (BiV Nominal), and BiV with SyncAV programmed to the optimal offset achieving maximal synchronization (BiV?+?SyncAV Opt).
RESULTS:
One hundred patients (71% male, 40% ischemic, 65% LBBB, 32?±?9% ejection fraction) completed VCG assessment. QRSd during intrinsic conduction (166?±?25?ms) was narrowed successively by BiV Nominal (137?±?23?ms, p?
CONCLUSION:
With VCG-based, patient-specific optimization of the programmable offset, SyncAV reduced electrical dyssynchrony beyond conventional CRT.
Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.
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Severe chronic kidney disease is associated with poor survival after initial CRT-defibrillator tachyarrhythmia therapy.
Pacing Clin Electrophysiol2019 Nov;():. doi: 10.1111/pace.13823.
Adelstein Evan C, Saba Samir, Jain Sandeep, Wang Norman C,
Abstract
BACKGROUND:
Implantable cardioverter-defibrillator (ICD) recipients who receive appropriate device therapies have limited survival, and survival benefit in chronic kidney disease (CKD) has been questioned. We examined the association between CKD and survival after cardiac resynchronization therapy (CRT)-defibrillator tachyarrhythmia therapies.
METHODS:
We compared overall survival after appropriate shocks or anti-tachycardia pacing in 439 CRT-defibrillator recipients with LVEF ?35%, non-right bundle-branch block QRS pattern, and QRS duration > 130 ms according to glomerular filtration rate (GFR) at implant, including 31 patients with GFR ?30, 164 patients with GFR 31-60, and 244 patients with GFR > 60. At least 1 shock occurred in 302 patients (24 with GFR ?30, 102 with GFR 31-60, and 176 with GFR > 60). Serial echocardiograms were also compared.
RESULTS:
Patients were followed 64 months (IQR 29-94) after implant, including 32 months (IQR 12-61) after first therapy. Time to first therapy or shock was similar across GFR groups. However, survival after first therapy declined directly with declining GFR (p < 0.001), with median post-shock survival 90 days for GFR ?30 (95% CI 0-233), 612 days (95% CI 365-859) for GFR 31-60, and 1672 days (95% CI 1396-1948) for GFR > 60. Declining GFR category, ischemic heart disease, diabetes, and increasing age were independently associated with increased post-shock mortality. Echocardiographic response was similar across GFR groups and was not associated with post-therapy survival.
CONCLUSIONS:
Survival after appropriate tachyarrhythmia therapies, particularly shocks, is attenuated in patients with GFR ?30. This raises concern over potential lack of survival benefit conferred by CRT-defibrillators versus CRT-pacemakers in this population. This article is protected by copyright. All rights reserved.
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Efficacy and safety of new-generation atrial antitachycardia pacing for atrial tachyarrhythmias in patients implanted with cardiac resynchronization therapy devices.
J Cardiol2019 Oct;():. doi: S0914-5087(19)30320-X.
Ueda Nobuhiko, Kamakura Tsukasa, Noda Takashi, Nakajima Kenzaburo, Kataoka Naoya, Wada Mitsuru, Yamagata Kenichiro, Ishibashi Kohei, Inoue Yuko, Miyamoto Koji, Nagase Satoshi, Aiba Takeshi, Izumi Chisato, Noguchi Teruo, Yasuda Satoshi, Kusano Kengo,
Abstract
BACKGROUND:
Atrial tachyarrhythmias (ATAs) have a significant negative impact on the prognosis of patients implanted with cardiac resynchronization therapy (CRT) devices. New-generation atrial antitachycardia pacing (Reactive ATP, Medtronic Inc., Minneapolis, MN, USA) is effective in managing ATAs in patients implanted with pacemakers. The purpose of this study was to evaluate the efficacy and safety of Reactive ATP in patients implanted with CRT devices.
METHODS:
This was a single-center retrospective study involving 72 CRT patients with a history of ATAs [44 patients with a device capable of Reactive ATP (ATP group) and 28 patients with a device without ATP function (Control group)]. The atrial fibrillation (AF) burden, the biventricular pacing rate, and clinical outcomes were compared between the two groups.
RESULTS:
At baseline, there was no significant difference in the AF burden and biventricular pacing rate between the ATP and Control groups. During the 832±489 days of the follow-up period, 23 of the 44 patients (52%) received a total of 2862 ATP deliveries and the median ATP success rate was 23.6% (interquartile range: 12.5-50.0%) in the ATP group. The AF burden was significantly decreased only in the ATP group 6 months after ATP was programmed (from 6.1±18.2% to 2.0±5.4%, p=0.0083) and maintained low throughout the follow-up period. Moreover, there were no Reactive ATP-related complications observed. Patients in the ATP group showed a significantly lower incidence of heart failure (HF) hospitalization (log-rank, p=0.041) and ventricular arrhythmias (log-rank, p=0.039) than those reported in the Control group.
CONCLUSIONS:
Reactive ATP successfully and safely reduced AF burden, and was associated with a lower incidence of HF hospitalization in patients implanted with CRT devices.
Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
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A new electrocardiographic definition of left bundle branch block (LBBB) in patients after transcatheter aortic valve replacement (TAVR).
J Electrocardiol2019 Oct;():. doi: S0022-0736(19)30598-9.
Alqarawi Wael, Sadek Mouhannad M, Golian Mehrdad, Hibbert Benjamin, Redpath Calum J, Nair Girish M, Nery Pablo B, Davis Darryl R, Klein Andres, Birnie David H, Green Martin S,
Abstract
BACKGROUND:
Current LBBB definitions cannot always distinguish LBBB from left ventricular conduction delay. Only patients with LBBB are expected to normalize with His bundle pacing. Patients who develop new LBBB immediately post transcatheter aortic valve replacement (TAVR) provide an excellent model to define electrocardiogram (ECG) features of LBBB. We sought to describe their ECG features and develop a new ECG definition of LBBB.
METHODS:
We screened ECGs from 264 consecutive patients who underwent TAVR at the University of Ottawa Heart Institute. Patients with a baseline QRS of ?100?ms who developed QRS ?120?ms immediately after TAVR were included. Two electrocardiologists reviewed all ECG independently. Baseline demographics and echocardiographic data were retrospectively collected.
RESULTS:
36 patients were included in the analysis. The median age was 85.5?years (IQR, 81.8-89?years) and 52.8% were males. The minimum QRS duration was 126?ms. The median QRS axis was -18° (IQR, -40-4.5°), which is 18.5° leftward compared to the median QRS axis before TAVR. Fourteen patients (38.9%) had left axis deviation. All patients had a notched/slurred R wave in at least one lateral lead and an R wave duration of ?20?ms in V1 when present.
CONCLUSION:
We developed a new ECG definition of LBBB that includes 2 novel findings: notching/slurring of the R wave in at least one lateral lead and an R wave ?20?ms in V1. Further larger studies are warranted to confirm these findings.
Copyright © 2019 Elsevier Inc. All rights reserved.
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Relation of Increasing QRS Duration Over Time and Cardiovascular Events in Outpatients With Heart Failure.
Am J Cardiol2019 Sep;():. doi: S0002-9149(19)31057-4.
Alfraidi Hassan, Seifer Colette M, Hiebert Brett M, Torbiak Lindsay, Zieroth Shelley, McIntyre William F,
Abstract
An increase in the duration of the QRS complex over time has been shown to be associated with poor clinical outcomes in specific subgroups of heart failure (HF) patients. There is a paucity of data on the clinical impact of increasing QRS duration on outcomes in HF with narrow QRS duration. This was a retrospective study of consecutive adult referrals to a tertiary outpatient HF clinic over a 2-year period. All patients with a narrow QRS, (<130 ms) were included. The primary outcome was mortality. Secondary outcomes were HF hospitalization and a composite of HF hospitalization, implantation of cardiac resynchronization therapy or left ventricular assist device and cardiac transplant. A total of 253 patients with 2 or more QRS measurments were included. Death occurred in 41 patients (16%), 258 HF hospitalizations occurred in 116 patients (46%) and the composite occurred in 127 patients (50%). Multivariable analyses found that a rate of QRS duration change of ?1 ms/month was independently associated with increased mortality (odds ratio [OR] 2.26, 95% confidence interval [CI] 1.04 to 4.91), HF hospitalization (relative risk [RR] 2.01, 95% CI 1.37 to 2.94), and the composite (OR 2.40, 95%CI 1.44 to 4.02). A new QRS >130 ms was also independently associated with mortality (OR 3.27, 95%CI 1.29-8.32), HF hospitalization (RR 2.75, 95% CI 1.72 to 4.4) and the composite (OR 2.52, 95%CI 1.27 to 4.99). In conclusion, in patients with HF and a narrow baseline QRS, an increase in QRS duration of ?1 ms per month is associated with increased mortality and HF hospitalization. HF patients may benefit from serial monitoring of QRS duration.
Copyright © 2019 Elsevier Inc. All rights reserved.
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Adherence to Mediterranean diet and prognosis in older patients scheduled to undergo cardiac resynchronization therapy.
Nutr Metab Cardiovasc Dis2019 Aug;():. doi: S0939-4753(19)30307-2.
Dominguez-Rodriguez Alberto, Avanzas Pablo, Abreu-Gonzalez Pedro, Baez-Ferrer Nestor, Martín-Sanchez Francisco J, Mirò Óscar,
Abstract
BACKGROUND AND AIMS:
Adherence to the Mediterranean diet (MedDiet) has been associated with prolonged survival in older individuals. However, it is unknown whether adherence to MedDiet is associated with the prognosis in older patients scheduled to undergo cardiac resynchronization therapy (CRT). The aim of this study was to evaluate the association between adherence to the MedDiet and clinical outcomes at 12 months follow-up after CRT implantation in older patients.
METHODS AND RESULTS:
Patients adherents to the MedDiet, defined as ? 9 of 14 points using the PREDIMED (Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Study) questionnaire, was assessed before device implantation in patient's ? 70 years candidates for CRT. The primary outcome was a combined endpoint at 12 months follow-up after CRT implantation, defined as cardiovascular death, cardiac transplantation or decompensated heart failure. The cohort study consisted of 284 patients with a mean age of 73 ± 3 years. One hundred and fifty-nine (55.9%) patients were classified as adherent to the MedDiet. Seventy (24.6%) patients showed the combined endpoint at one year follow-up. Subjects who did not developed the combined endpoint had higher proportion of adherent patients to the MedDiet compared to patients who developed the combined endpoint (85% vs 67.1%, p = 0.002). After adjustment by possible confounders, the adherence to the MedDiet was a protective and significant predictor of the combined endpoint (HR = 0.42, 95% CI 0.22-0.81; p = 0.01).
CONCLUSION:
Adherence to the MedDiet is inversely associated with outcome in older patients following CRT.
Copyright © 2019 The Italian Society of Diabetology, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition, and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.
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Impact of multipoint pacing on projected battery longevity in cardiac resynchronization therapy. An IRON-MPP study sub-analysis.
J Cardiovasc Electrophysiol2019 Oct;():. doi: 10.1111/jce.14254.
Forleo Giovanni B, Gasperetti Alessio, Ricciardi Danilo, Curnis Antonio, Bertaglia Emanuele, Calò Leonardo, Pignalberi Carlo, Calzolari Vittorio, Ribatti Valentina, Lavalle Carlo, Potenza Domenico, Tondi Lara, Natale Veronica, Notarstefano Pasquale, Viecca Maurizio, Morani Giovanni, Biffi Mauro, Giammaria Massimo, Zanon Francesco, Santini Luca,
Abstract
BACKGROUND:
Multipoint pacing (MPP) may improve clinical outcomes in patients with cardiac resynchronization therapy defibrillators (CRT-D), but its impact on battery longevity in a real-world population has not been investigated in large trials.
OBJECTIVE:
Compare projected battery longevity in CRT-D patients with and without MPP during long-term follow-up.
METHODS:
The Italian registry on multipoint left ventricular pacing (IRON-MPP) is a prospective, multicenter registry of patients implanted with MPP-capable CRT-D devices. Projected battery longevity during follow-up was compared for patients with MPP (MPP ON) vs single-site (MPP OFF) left ventricular pacing at CRT-D implantation. A sub-analysis excluded crossover patients with MPP activation or deactivation occurring after implantation. A second sub-analysis excluded patients with a right or left ventricular pacing amplitude >2.5?V.
RESULTS:
Out of 237 CRT-D patients (71?±?9 years, 81% male) followed for 1.9?±?0.8 years, 102 (43%) had MPP ON at implantation. Programmed atrial and ventricular outputs and percentage of pacing were similar between groups. MPP was associated with a 0.44 years reduction in projected battery longevity (P?=?.03) during long-term follow-up. Results were similar for the first and second sub-analyses, with a 0.57 years (P?
CONCLUSION:
In this long-term real-world registry, early MPP activation is associated with less than a 1-year reduction in projected battery life compared to single-site biventricular pacing.
© 2019 Wiley Periodicals, Inc.
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