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Pubblicazioni recenti - cardiac resynchronization
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Does subclinical atrial fibrillation independently predict adverse outcomes in patients with heart failure and cardiac resynchronization therapy defibrillator.
Clin Cardiol2021 Jan;():. doi: 10.1002/clc.23547.
Chen Jie, Yu Peng, Ma Jianyong, Zheng Chunhua, Liu Xiao,
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Real-world outcomes in cardiac resynchronization therapy patients: design and baseline demographics of the SMART- Registry.
ESC Heart Fail2021 Jan;():. doi: 10.1002/ehf2.13192.
Gardner Roy S, D'Onofrio Antonio, Mark George, Gras Daniel, Hu Yan, Veraghtert Sara, Garcia-Bolao Ignacio,
Abstract
AIMS:
The SMART (Strategic MAnagement to optimize response to cardiac Resynchronization Therapy) Registry was designed to assess real-world outcomes for patients receiving a cardiac resynchronization therapy defibrillator (CRT-D) and to better understand which programming and optimization techniques are used and how effective they are.
METHODS AND RESULTS:
The SMART Registry is a global, multicentre, prospective, observational, post-market CRT-D registry with a planned enrolment of 2000 subjects from a maximum of 200 sites in Europe, North America, and Asia-Pacific region. Each subject will be followed up for a minimum of 12 months. The primary endpoint of CRT response rate at 12 months is defined by a clinical composite score of all-cause mortality, heart failure events, New York Heart Association Class, and quality of life as assessed by a patient global assessment instrument. A subgroup composed of the first 103 consecutive European subjects implanted with an NG4 device will have left ventricular multisite pacing feature enabled at any time during the initial 12 months of follow-up. The primary endpoint for this sub-analysis will be the NG4 PG-related complication-free rate at 36 months.
CONCLUSIONS:
The SMART Registry achieved its recruitment target in August 2019, with 2014 patients enrolled. The baseline demographics demonstrated that patients were generally older, with greater co-morbidity, and on more contemporary medical therapy than in the key CRT trials. The results of the SMART Registry will determine which programming and optimization techniques are effective in this real-world population.
© 2021 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.
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Symptomatic atrioventricular block during biventricular pacing: Facing a double trouble.
Pacing Clin Electrophysiol2020 09;43(9):1024-1027. doi: 10.1111/pace.14031.
Bera Debabrata, Majumder Suchit, Khetan Anup, Sarkar Rakesh, Mukherjee Sanjeev S,
Abstract
Far-field R wave (FFRW) oversensing in atrial channel is known to cause inappropriate automatic mode switch. We describe a case of 63-year-old lady with dual-chamber permanent pacemaker implanted 2 years back for symptomatic infra-hisian complete heart block and normal biventricular function. After 6 months, she underwent upgradation to cardiac resynchronization therapy (CRT-P, Boston Scientific) for right ventricular pacing induced cardiomyopathy. Her LV function normalized after CRT. Later on, FFRW oversensing caused false triggering of an atrial tachycardia, which subsequently opened up an "atrial flutter response" window leading to symptomatic inadvertent atrioventricular block at frequent intervals. Common ways to troubleshoot FFRW oversensing are either by increasing post-ventricular atrial blanking or reducing atrial channel sensitivity. In her case, concomitant P wave under-sensing made the situation more challenging to manage.
© 2020 Wiley Periodicals LLC.
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A case report of advanced heart failure refractory to pharmacological therapy who was successfully recovered by combinatory usage of cardiac resynchronizing therapy, Impella and MitraClip.
Eur Heart J Case Rep2020 Dec;4(6):1-5. doi: 10.1093/ehjcr/ytaa418.
Sobajima Mitsuo, Fukuda Nobuyuki, Ueno Hiroshi, Kinugawa Koichiro,
Abstract
Background :
The safety and efficacy of MitraClip for advanced heart failure (HF) patients who are inotrope-dependent or mechanically supported are unknown.
Case summary :
The patient was a 71-year-old man diagnosed as dilated cardiomyopathy in 2003. He was admitted due to worsening HF in January 2019 and became dependent upon intravenous infusion of inotropes. During the 8-month hospitalization, his haemodynamics were relatively static with bed rest and continuous inotropes, but he was definitely dependent on them. Our multidisciplinary team decided to perform both cardiac resynchronization therapy (CRT) and MitraClip under Impella support. First, Impella was inserted from left subclavian artery. After a week, CRT was implanted from right subclavian vein, and the QRS duration of electrocardiogram became remarkably narrow. MitraClip was performed 2 weeks after Impella, and functional mitral regurgitation improved from severe to mild, and Impella was removed on the same day. Inotropes could be ceased, and he was discharged 2 months after MitraClip.
Discussion :
During inotrope-dependent status, there was a risk that HF would worsen with haemodynamic collapse when performing CRT implantation, and we firstly supported his haemodynamics by Impella. Cardiac resynchronization therapy implantation before MitraClip seemed to be crucial. In fact, the mitral valve morphology before Impella insertion had very poor coaptation of the anterior and posterior leaflets that was not optimal for MitraClip procedure. But the Impella support and correction of dyssynchrony by CRT markedly improved the coaptation of those leaflets. The combination therapy of CRT and MitraClip unloading with Impella maybe a new therapeutic option for advanced HF.
© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.
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Upgrade of cardiac resynchronization therapy by utilizing additional His-bundle pacing in patients with inotrope-dependent end-stage heart failure: a case series.
Eur Heart J Case Rep2020 Dec;4(6):1-9. doi: 10.1093/ehjcr/ytaa303.
Baba Masako, Yoshida Kentaro, Hanaki Yuichi, Yamamoto Masayoshi, Shinoda Yasutoshi, Takeyasu Noriyuki, Nogami Akihiko,
Abstract
Background:
His-bundle pacing (HBP) alone may become an alternative to conventional cardiac resynchronization therapy (CRT) utilizing right ventricular apical (RVA) and left ventricular (LV) pacing (BiV) in selected patients, but the effects of CRT utilizing HBP and LV pacing (BiV) on cardiac resynchronization and heart failure (HF) are unclear.
Case summary:
We presented two patients with inotrope-dependent end-stage HF in whom the upgrade from conventional BiV to BiV pacing by the addition of a lead for HBP improved their HF status. Patient 1 was a 32-year-old man with lamin A/C cardiomyopathy, atrial fibrillation, and complete atrioventricular (AV) block. Patient 2 was a 70-year-old man with ischaemic cardiomyopathy complicated by AV block and worsening of HF resulting from ablation for ventricular tachycardia storm. The HF status of both patients improved dramatically following the upgrade from BiV to BiV pacing.
Discussion:
End-stage HF patients suffer from diffuse intraventricular conduction defect not only in the LV but also in the right ventricle (RV). The resulting dyssynchrony may not be sufficiently corrected by conventional BiV pacing or HBP alone. Right ventricular apical pacing itself may also impair RV synchrony. An upgrade to BiV pacing could be beneficial in patients who become non-responsive to conventional BiV pacing as the His-Purkinje conduction defect progresses.
© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.
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Delayed occurrence of an accelerated idioventricular rhythm with alternating bundle branch block after myocardial infarction as predictor of sudden cardiac arrest: a case report.
Eur Heart J Case Rep2020 Dec;4(6):1-7. doi: 10.1093/ehjcr/ytaa378.
Bettin Markus, Koopmann Matthias, Mönnig Gerold, Pott Christian,
Abstract
Background:
Accelerated idioventricular rhythm (AIVR) is known as reperfusion arrhythmia in the setting of acute myocardial infarction (AMI). In healthy individuals, it is usually considered to be benign. Alternating bundle branch block (ABBB) often progresses to complete atrioventricular block requiring permanent pacemaker implantation. We report a case of delayed appearance of AIVR following myocardial infarction (MI) in combination with ABBB as precursor of sudden cardiac arrest due to ventricular fibrillation (VF).
Case summary:
A 62-year-old male with pre-existing left bundle branch block (LBBB) was admitted with an acute non-ST segment elevation MI. He underwent successful percutaneous coronary intervention (PCI) of a subtotal proximal left anterior descending artery (LAD) stenosis. Before and after PCI the electrocardiogram (ECG) demonstrated sinus rhythm with LBBB. The patient was discharged 5?days after PCI, left ventricular function at this time was moderately reduced (ejection fraction of 40%). After another 5?days, the patient was admitted for elective cardiac rehabilitation. At this time, the ECG demonstrated an AIVR with right bundle branch block morphology. Due to ABBB, the patient was scheduled for permanent pacemaker implantation. Before pacemaker implantation could take place, the patient developed a sudden cardiac arrest due to VF and was successfully resuscitated. A follow-up coronary angiography revealed no novel lesions. A cardiac resynchronization therapy defibrillator was implanted for secondary prevention of sudden cardiac death.
Discussion:
Delayed occurrence of AIVR in combination with ABBB following AMI could be a predictor of sudden cardiac death. These patients are probably at high risk for malignant ventricular arrhythmias.
© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.
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Cardiac Resynchronization Therapy and Ventricular Tachyarrhythmia Burden.
Heart Rhythm2021 Jan;():. doi: S1547-5271(21)00009-6.
Tankut Sinan, Goldenberg Ilan, Kutyifa Valentine, Zareba Wojciech, Bragazzi Nicola Luigi, McNitt Scott, Huang David T, Aktas Mehmet K, Younis Arwa,
Abstract
BACKGROUND:
Cardiac resynchronization therapy-defibrillator (CRT-D) may reduce the incidence of first ventricular tachyarrhythmia (VTA) in patients with heart failure (HF) and left bundle-branch-block (LBBB).
OBJECTIVE:
To assess the effect of CRT-D on VTA burden in LBBB patients.
METHODS:
We included 1281 patients with LBBB from MADIT-CRT. VTA was defined as any treated or monitored sustained ventricular tachycardia (VT?180 bpm) or ventricular fibrillation (VF). Life-threatening VTA was defined as VT?200 bpm or VF. VTA recurrence was assessed using the Andersen-Gill model.
RESULTS:
During a mean follow-up of 2.5 years, 964 VTA episodes occurred in 264 (21%) patients. The VTA rate per 100 person-years was significantly lower in the CRT-D group when compared with the ICD group (20 vs. 34; respectively; p<0.01). Multivariate analysis demonstrated that CRT-D treatment was associated with a 32% risk reduction for VTA recurrence (HR=0.68; 95%CI 0.57-0.82; p<0.001), 57% risk reduction for recurrent life-threatening VTA, 54% risk reduction for recurrent appropriate ICD-shocks, and a 25% risk reduction for the combined endpoint of VTA and death. The effect of CRT on VTA burden was consistent among all tested subgroups, but was more pronounced among NYHA class I patients. Landmark analysis showed that at 2 years, the cumulative probability of death subsequent to year one was highest (16%) among patients who had ?2 VTA events during their first year.
CONCLUSION:
In patients with LBBB and HF, early intervention with CRT-D reduces mortality, VTA burden, and frequency of multiple appropriate ICD shocks. VTA burden is a powerful predictor of subsequent mortality.
Copyright © 2021. Published by Elsevier Inc.
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Electromagnetic interference between implantable cardiac devices and continuous-flow left ventricular assist devices: a review.
J Interv Card Electrophysiol2021 Jan;():. doi: 10.1007/s10840-020-00930-8.
Gordon Jonathan S, Maynes Elizabeth J, O'Malley Thomas J, Pavri Behzad B, Tchantchaleishvili Vakhtang,
Abstract
Many patients with continuous-flow left ventricular assist devices (CF-LVAD) have other, co-existing implantable cardiac devices. While such devices often function appropriately, there is potential for electromagnetic interference (EMI). A literature review was performed to identify cases of EMI between CF-LVAD and other implanted cardiac devices to better understand their etiology, outcomes, and the strategies used to overcome such interference. The cases identified included interference between CF-LVAD and pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy. The EMI reported in the current literature can be broken down into two general categories: interference leading to difficulty establishing telemetry and interference leading to impaired electrical signal sensing. Such interference led to inappropriate shock delivery in some cases. The type of interference, and thus treatments, differed and were device dependent. The strategies employed to reduce interference included metal shielding, physical manipulation to increase the distance between devices, and even exchange of the implanted device with another brand of the same class. To avoid such EMI in the future, physicians must be aware of the reported interference between certain devices, and manufacturers must work more closely to increase the compatibility of implanted cardiac devices.
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Cardiac resynchronisation therapy pacemaker implant in a patient with ARTO mitral device in situ.
Pacing Clin Electrophysiol2021 Jan;():. doi: 10.1111/pace.14169.
Nguyen Thomas, Williams Steven E, Falkner Gillian, Shetty Anoop K,
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Validity and Reliability of the Japanese Version of the Florida Patient Acceptance Survey.
J Nurs Meas2021 Jan;():. doi: JNM-D-20-00091.
Umeda Aya, Mizuno So, Suzuki Makoto, Iizuka Hiromi,
Abstract
BACKGROUND AND PURPOSE:
Patient acceptance of implantable cardioverter defibrillators (ICDs) is one of the factors influencing clinical outcomes. This study aimed to develop a Japanese version of the Florida Patient Acceptance Survey (FPAS; a measure of acceptance of ICDs), examine its reliability and validity, and test instrument reliability and ability to generate valid data in a new population.
METHODS:
122 outpatients with ICD, cardiac resynchronization therapy defibrillator (CRTD) completed the FPAS, the 12-Item Short-Form Health Survey developed for the Medical Outcomes Study, and the Hospital Anxiety and Depression Scale.
RESULTS:
Confirmatory and exploratory factor data analyses yielded a three-factor model with nine items. This version of the FPAS had high internal consistency, both for the single factor scale and all other subscales; Cronbach's ? ranged from .78 to. 84.
CONCLUSION:
The scale was shown to be valid and reliable for assessing device acceptability in Japanese patients with ICD.
© Copyright 2021 Springer Publishing Company, LLC.
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Clinical and prognostic implications of phenomapping in patients with heart failure receiving cardiac resynchronization therapy.
Arch Cardiovasc Dis2021 Jan;():. doi: S1875-2136(20)30261-8.
Riolet Clémence, Menet Aymeric, Verdun Stéphane, Altes Alexandre, Appert Ludovic, Guyomar Yves, Delelis François, Ennezat Pierre Vladimir, Guerbaai Raphaelle A, Graux Pierre, Tribouilloy Christophe, Marechaux Sylvestre,
Abstract
BACKGROUND:
Despite having an indication for cardiac resynchronization therapy according to current guidelines, patients with heart failure with reduced ejection fraction who receive cardiac resynchronization therapy do not consistently derive benefit from it.
AIM:
To determine whether unsupervised clustering analysis (phenomapping) can identify distinct phenogroups of patients with differential outcomes among cardiac resynchronization therapy recipients from routine clinical practice.
METHODS:
We used unsupervised hierarchical cluster analysis of phenotypic data after data reduction (55 clinical, biological and echocardiographic variables) to define new phenogroups among 328 patients with heart failure with reduced ejection fraction from routine clinical practice enrolled before cardiac resynchronization therapy. Clinical outcomes and cardiac resynchronization therapy response rate were studied according to phenogroups.
RESULTS:
Although all patients met the recommended criteria for cardiac resynchronization therapy implantation, phenomapping analysis classified study participants into four phenogroups that differed distinctively in clinical, biological, electrocardiographic and echocardiographic characteristics and outcomes. Patients from phenogroups 1 and 2 had the most improved outcome in terms of mortality, associated with cardiac resynchronization therapy response rates of 81% and 78%, respectively. In contrast, patients from phenogroups 3 and 4 had cardiac resynchronization therapy response rates of 39% and 59%, respectively, and the worst outcome, with a considerably increased risk of mortality compared with patients from phenogroup 1 (hazard ratio 3.23, 95% confidence interval 1.9-5.5 and hazard ratio 2.49, 95% confidence interval 1.38-4.50, respectively).
CONCLUSIONS:
Among patients with heart failure with reduced ejection fraction with an indication for cardiac resynchronization therapy from routine clinical practice, phenomapping identifies subgroups of patients with differential clinical, biological and echocardiographic features strongly linked to divergent outcomes and responses to cardiac resynchronization therapy. This approach may help to identify patients who will derive most benefit from cardiac resynchronization therapy in "individualized" clinical practice.
Copyright © 2020 Elsevier Masson SAS. All rights reserved.
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Clinical outcome of cardiac resynchronization therapy in patients randomized to an active fixation bipolar left ventricular lead a passive quadripolar lead.
Scand Cardiovasc J2021 Jan;():1-7. doi: 10.1080/14017431.2020.1869299.
Keilegavlen Havard, Schuster Peter, Hovstad Thomas, Faerestrand Svein,
Abstract
To compare the clinical outcome of cardiac resynchronization therapy (CRT) in patients receiving a bipolar left ventricular (LV) lead with a side helix for active fixation to the outcome in patients receiving a quadripolar passive fixation LV lead. Sixty-two patients (mean age 72?±?11 years) were blindly and randomly assigned to the active fixation bipolar lead group (?=?31) or to the quadripolar lead group (=?31). The LV leads were targeted to the basal LV segment in a vein concordant to the LV segment with the latest mechanical contraction chosen on the basis of preoperative radial strain (RS) echocardiography. At the 6-month follow-up (FU), the reduction in LV end-systolic volume and LV reverse remodelling responder rate, defined as LV end-systolic volume reduction >15%, was 77% in the active fixation group and 83% in the quadripolar group, which was not significantly different. At the 12-month FU, the LV ejection fraction (LVEF) did not differ between the groups. There were no significant differences between the two groups in changes in New York Heart Association (NYHA) functional class or Minnesota Living with Heart Failure Questionnaire score. The occurrence of phrenic nerve stimulation (PNS) was 19% in the active fixation group versus 10% in the quadripolar group (=.30), and all cases were resolved by reprogramming the device. All patients were alive at the 12-month FU. There was no device infection. There were no significant differences between the active fixation group of patients and the quadripolar group of patients concerning improvement in echocardiographic parameters or clinical symptoms. ClinicalTrials.gov number, NCT04632472.
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First experience in quadripolar active fixation coronary sinus lead extraction: a case report.
Eur Heart J Case Rep2020 Aug;4(4):1-5. doi: 10.1093/ehjcr/ytaa184.
Guella Elhosseyn, Brack Michael, Abozguia Khalid, Cassidy Christopher John,
Abstract
Background:
The Attain Stability Quadripolar 4798 lead is a relatively new quadripolar active fixation coronary sinus (CS) lead. No cases of extraction of a chronically implanted 4798 lead have been published to date.
Case summary:
A 52-year-old man with a history of previous cardiac resynchronization therapy pacemaker (CRT-P) insertion and atrioventricular node ablation presented to our institution with a pocket infection 69 weeks after implantation. Directed intravenous antibiotic therapy was commenced and an extraction was performed the following day. Extraction of the right atrial and right ventricular leads was simple and achieved with gentle manual traction. Extraction of the CS lead was more difficult. Significant traction was required due to the formation of adhesions inside the CS but extraction of the lead was eventually successful without complication. Specialized extraction equipment was not required. A new contralateral CRT-P device was implanted, and the patient was discharged home. He remains well at 3 months of follow-up.
Discussion:
We present the first case of extraction of a chronically implanted active fixation Attain Stability Quadripolar lead. Our experience demonstrates that this has been performed successfully without specialist tools and with preservation of the CS branch. Significant adhesion was noted at the site of active fixation, however. Potential difficulty with this lead's extraction should therefore be considered when contemplating its use.
© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.
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Morphometric Characterization of Human Coronary Veins and Subvenous Epicardial Adipose Tissue-Implications for Cardiac Resynchronization Therapy Leads.
Front Cardiovasc Med2020 ;7():611160. doi: 10.3389/fcvm.2020.611160.
Keiler Jonas, Meinel Felix G, Ortak Jasmin, Weber Marc-André, Wree Andreas, Streckenbach Felix,
Abstract
Subvenous epicardial fat tissue (SEAT), which acts as an electrical insulation, and the venous diameter (VD) both constitute histomorphological challenges for optimal application and lead design in cardiac synchronization therapy (CRT). In this study, we characterized the morphology of human coronary veins to improve the technical design of future CRT systems and to optimize the application of CRT leads. We retrospectively analyzed data from cardiac computed tomography (CT) of 53 patients and did studies of 14 human hearts using the postmortem freeze section technique and micro CT. Morphometric parameters (tributary distances, offspring angles, luminal VD, and SEAT thickness) were assessed. The left posterior ventricular vein (VVSP) had a mean proximal VD of 4.0 ± 1.4 mm, the left marginal vein (VMS) of 3.2 ± 1.5 mm and the anterior interventricular vein (VIA) of 3.9 ± 1.3 mm. More distally (5 cm), VDs decreased to 2.4 ± 0.6 mm, 2.3 ± 0.7 mm, and 2.4 ± 0.6 mm, respectively. In their proximal portions (15 mm), veins possessed mean SEAT thicknesses of 3.2 ± 2.4 (VVSP), 3.4 ± 2.4 mm (VMS), and 4.2 ± 2.8 mm (VIA), respectively. More distally (20-70 mm), mean SEAT thicknesses decreased to alternating low levels of 1.3 ± 1.1 mm (VVSP), 1.7 ± 1.1 mm (VMS), and 4.3 ± 2.6 mm (VIA), respectively. In contrast to the VD, SEAT thicknesses alternated along the further distal vein course and did not display a continuous decrease. Besides the CRT responsiveness of different areas of the LV myocardium, SEAT is a relevant electrophysiological factor in CRT, potentially interfering with sensing and pacing. A sufficient VD is crucial for successful CRT lead placement. Measurements revealed a trend toward greater SEAT thickness for the VIA compared to VVSP and VMS, suggesting a superior signal-to-noise-ratio in VVSP and VMS.
Copyright © 2020 Keiler, Meinel, Ortak, Weber, Wree and Streckenbach.
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Segment length in cine (SLICE) strain analysis: a practical approach to estimate potential benefit from cardiac resynchronization therapy.
J Cardiovasc Magn Reson2021 Jan;23(1):4. doi: 10.1186/s12968-020-00701-4.
Zweerink Alwin, Nijveldt Robin, Braams Natalia J, Maass Alexander H, Vernooy Kevin, de Lange Frederik J, Meine Mathias, Geelhoed Bastiaan, Rienstra Michiel, van Gelder Isabelle C, Vos Marc A, van Rossum Albert C, Allaart Cornelis P,
Abstract
BACKGROUND:
Segment length in cine (SLICE) strain analysis on standard cardiovascular magnetic resonance (CMR) cine images was recently validated against gold standard myocardial tagging. The present study aims to explore predictive value of SLICE for cardiac resynchronization therapy (CRT) response.
METHODS AND RESULTS:
Fifty-seven patients with heart failure and left bundle branch block (LBBB) were prospectively enrolled in this multi-center study and underwent CMR examination before CRT implantation. Circumferential strains of the septal and lateral wall were measured by SLICE on short-axis cine images. In addition, timing and strain pattern parameters were assessed. After twelve months, CRT response was quantified by the echocardiographic change in left ventricular (LV) end-systolic volume (LVESV). In contrast to timing parameters, strain pattern parameters being systolic rebound stretch of the septum (SRS), systolic stretch index (SSI), and internal stretch factor (ISF) all correlated significantly with LVESV change (R - 0.56; R - 0.53; and R - 0.58, respectively). Of all strain parameters, end-systolic septal strain (ESS) showed strongest correlation with LVESV change (R - 0.63). Multivariable analysis showed ESS to be independently related to LVESV change together with age and QRS.
CONCLUSION:
The practicable SLICE strain technique may help the clinician to estimate potential benefit from CRT by analyzing standard CMR cine images without the need for commercial software. Of all strain parameters, end-systolic septal strain (ESS) demonstrates the strongest correlation with reverse remodeling after CRT. This parameter may be of special interest in patients with non-strict LBBB morphology for whom CRT benefit is doubted.
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Importance of systematic right ventricular assessment in cardiac resynchronization therapy candidates: a machine-learning approach.
J Am Soc Echocardiogr2021 Jan;():. doi: S0894-7317(21)00003-1.
Galli E, Le Rolle V, Smiseth O A, Duchenne J, Aalen J M, Larsen C K, Sade E, Hubert A, Anilkumar S, Penicka M, Cecilia Linde, Leclercq C, Hernandez A, Voigt J-U, Donal E,
Abstract
BACKGROUND:
Despite all having systolic heart failure and broad QRS, patients screened for cardiac resynchronization therapy (CRT) are highly heterogeneous, and it remains extremely challenging to predict the impact of the device on left ventricular (LV) function and outcomes.
OBJECTIVES:
We sought to evaluate the relative impact of clinical, electrocardiographic, and echocardiographic data on the left ventricular (LV) remodeling and prognosis of CRT-candidates by the application of machine learning (ML) approaches.
METHODS:
193 patients with systolic heart failure undergoing CRT according to current recommendations were prospectively included in this multicentre study. We used a combination of the Boruta algorithm and random forest methods to identify features predicting both CRT volumetric response and prognosis. The model performance was tested by the area under the receiver operating curve (AUC). We also applied the K-medoid method to identify clusters of phenotypically similar patients.
RESULTS:
From 28 clinical, electrocardiographic, and echocardiographic-derived variables, 16 features were predictive of CRT response, and 11 features were predictive of prognosis. Among the predictors of CRT-response, 8 variables (50%) pertained to right ventricular (RV) size or function. Tricuspid annular plane systolic excursion was the main feature associated with prognosis. The selected features were associated with a particularly good prediction of both CRT response (AUC 0.81, 95% CI: 0.74-0.87) and outcomes (AUC 0.84, 95% CI: 0.75-0.93). An unsupervised ML approach allowed the identifications of two phenogroups of patients who differed significantly in clinical variables and parameters of biventricular size, and RV function. The two phenogroups had significant different prognosis (HR 4.70, 95% CI: 2.1-10.0, p<0.0001; log-rank p<0.0001).
CONCLUSIONS:
Machine learning can reliably identify clinical and echocardiographic features associated with CRT-response and prognosis. The evaluation of both RV-size and function parameters has pivotal importance for the risk stratification of CRT-candidates and should be systematically assessed in patients undergoing CRT.
Copyright © 2021. Published by Elsevier Inc.
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Intermediate Term Performance and Safety of His Bundle Pacing Leads: A Single Center Experience.
Heart Rhythm2021 Jan;():. doi: S1547-5271(20)31226-1.
Teigeler Todd, Kolominsky Jeffrey, Vo Chau, Shepard Richard K, Kalahasty Gautham, Kron Jordana, Huizar Jose F, Kaszala Karoly, Tan Alex Y, Koneru Jayanthi N, Ellenbogen Kenneth A, Padala Santosh K,
Abstract
BACKGROUND:
The short-term safety, feasibility, and performance of the His bundle pacing (HBP) leads have been reported, however, their longer-term performance beyond 1 year remains unclear.
OBJECTIVE:
The objective of this study was to examine the intermediate-term performance and safety of HBP.
METHODS:
All HBP lead implants at Virginia Commonwealth University between 01-2014 and 01-2019 were analyzed. HBP was performed using a SelectSecure 3830-69 cm pacing lead (Medtronic, Minneapolis, MN).
RESULTS:
Of 295 attempts, successful HBP implantation (selective or non-selective) was seen in 274 (93%) cases. The mean follow-up duration was 22.8±19.5 months (median 19.5 months, IQR 11-33 months). Mean age was 69±15 years, 58% were males, and ejection fraction <50% was noted in 30%. Indications for pacemaker included sick sinus syndrome in 41%, atrioventricular block in 36%, cardiac resynchronization therapy in 7%, and refractory atrial fibrillation in 15%. Selective HBP was achieved in 33%. The mean HBP capture threshold at implant was 1.1±0.9V at 0.8±0.2ms which significantly increased at chronic follow-up to 1.7±1.1V at 0.8±0.3ms (P<0.001). Threshold was ?2.5V in 24% patients, and 28% had an increase in HBP threshold ?1V. Loss of His bundle capture at follow-up (septal RV pacing) was seen in 17%. There was a total of 31 (11%) lead revisions, primarily for unacceptably high thresholds.
CONCLUSION:
While HBP can prevent or improve pacing induced cardiomyopathy, the elevated capture thresholds, loss of His bundle capture, and lead revision rates at intermediate follow-up are concerning. Longer-term follow-up data from multiple centers are needed.
Copyright © 2021. Published by Elsevier Inc.
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Predicted benefit of an implantable cardioverter-defibrillator: the MADIT-ICD benefit score.
Eur Heart J2021 Jan;():. doi: ehaa1057.
Younis Arwa, Goldberger Jeffrey J, Kutyifa Valentina, Zareba Wojciech, Polonsky Bronislava, Klein Helmut, Aktas Mehmet K, Huang David, Daubert James, Estes Mark, Cannom David, McNitt Scott, Stein Kenneth, Goldenberg Ilan,
Abstract
AIMS:
The benefit of prophylactic implantable cardioverter-defibrillator (ICD) is not uniform due to differences in the risk of life-threatening ventricular tachycardia (VT)/ventricular fibrillation (VF) and non-arrhythmic mortality. We aimed to develop an ICD benefit prediction score that integrates the competing risks.
METHODS AND RESULTS:
The study population comprised all 4531 patients enrolled in the MADIT trials. Best-subsets Fine and Gray regression analysis was used to develop prognostic models for VT (?200 b.p.m.)/VF vs. non-arrhythmic mortality (defined as death without prior sustained VT/VF). Eight predictors of VT/VF (male, age??75 b.p.m., systolic blood pressure?
CONCLUSIONS:
We propose the novel MADIT-ICD benefit score that predicts the likelihood of prophylactic ICD benefit through personalized assessment of the risk of VT/VF weighed against the risk of non-arrhythmic mortality.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.
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Left ventricular regional glucose metabolism in combination with septal scar extent identifies CRT responders.
Eur J Nucl Med Mol Imaging2021 Jan;():. doi: 10.1007/s00259-020-05161-7.
Degtiarova Ganna, Claus Piet, Duchenne Jürgen, Bogaert Jan, Nuyts Johan, Vöros Gabor, Willems Rik, Larsen Camilla Kjellstad, Aalen John M, Fjeld Jan Gunnar, Stokke Caroline, Hopp Einar, Smiseth Otto Armin, Voigt Jens-Uwe, Gheysens Olivier,
Abstract
BACKGROUND:
Cardiac resynchronization therapy (CRT) is effective in selective heart failure (HF) patients, but non-response rate remains high. Positron emission tomography (PET) may provide a better insight into the pathophysiology of left ventricular (LV) remodeling; however, its role for evaluating and selecting patients for CRT remains uncertain.
PURPOSE:
We investigated if regional LV glucose metabolism in combination with myocardial scar could predict response to CRT.
METHODS:
Consecutive CRT-eligible HF patients underwent echocardiography, cardiac magnetic resonance (CMR), and F-fluorodeoxyglucose (FDG) PET within 1 week before CRT implantation. Echocardiography was additionally performed 12 months after CRT and end-systolic volume reduction ??15% was defined as CRT response. Septal-to-lateral wall (SLR) FDG uptake ratio was calculated from static FDG images. Late gadolinium enhancement (LGE) CMR was analyzed semi-quantitatively to define scar extent.
RESULTS:
We evaluated 88 patients (67?±?10 years, 72% males). F-FDG SLR showed a linear correlation with volumetric reverse remodeling 12 months after CRT (r?=?0.41, p?=?0.0001). In non-ischemic HF patients, low FDG SLR alone predicted CRT response with sensitivity and specificity of more than 80%; however, in ischemic HF patients, specificity decreased to 46%, suggesting that in this cohort low SLR can also be caused by the presence of a septal scar. In the multivariate logistic regression model, including low FDG SLR, presence and extent of the scar in each myocardial wall, and current CRT guideline parameters, only low FDG SLR and septal scar remained associated with CRT response. Their combination could predict CRT response with sensitivity, specificity, negative, and positive predictive value of 80%, 83%, 70%, and 90%, respectively.
CONCLUSIONS:
FDG SLR can be used as a predictor of CRT response and combined with septal scar extent, CRT responders can be distinguished from non-responders with high diagnostic accuracy. Further studies are needed to verify whether this imaging approach can prospectively be used to optimize patient selection.
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R-Wave Singularity: A New Morphological Approach to the Analysis of Cardiac Electrical Dyssynchrony.
Front Physiol2020 ;11():599838. doi: 10.3389/fphys.2020.599838.
Zhan Ping, Li Tao, Shi Jinlong, Wang Guojing, Wang Buqing, Liu Hongyun, Wang Weidong,
Abstract
R-wave singularity (RWS) measures the intermittence or discontinuousness of R waves. It has been broadly used in QRS (QRS complex of electrocardiogram) detection, electrocardiogram (ECG) beats classification, . In this article, we novelly developed RWS to the analysis of QRS morphology as the measurement of ventricular dyssynchrony and tested the hypothesis that RWS could enhance the discrimination between control and acute myocardial infarction (AMI) patients. Holter ECG recordings were obtained from the Telemetric and Holter ECG Warehouse database, among which database Normal was extracted as normal controls ( = 202) and database AMI ( = 93) as typical subjects of autonomic nervous system dysfunction and cardiac electrical dyssynchrony with high risk for cardiac arrhythmias and sudden cardiac death. Experimental results demonstrate that RWS measured by Lipschitz exponent calculated from 5-min Holter recordings was significantly less negative in early AMI and late AMI than that in Normal subjects for overall, elderly, and elderly male groups, which suggested the heterogeneous depolarization of the ventricular myocardium during AMI. Receiver operating characteristic curve analyses show that combined with heart rate variability parameters, Lipschitz exponent provides higher accuracy in distinguishing between the patients with AMI and healthy control subjects for overall, elderly, elderly male, and elderly female groups. In summary, our study demonstrates the significance of using RWS to probe the cardiac electrical dyssynchrony for AMI. Lipschitz exponent may be valuable and complementary for existing cardiac resynchronization therapy and autonomic nervous system assessment.
Copyright © 2020 Zhan, Li, Shi, Wang, Wang, Liu and Wang.
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