scholarly journals A rapid electromechanical model to predict reverse remodeling following cardiac resynchronization therapy

2021 ◽  
Author(s):  
Pim J. A. Oomen ◽  
Thien-Khoi N. Phung ◽  
Seth H. Weinberg ◽  
Kenneth C. Bilchick ◽  
Jeffrey W. Holmes
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
Resynchronization Therapy ◽  
Electromechanical Model

P536Reverse remodeling after cardiac resynchronization therapy is associated with improvement of contractile asymmetry in the area of left ventricular lead position

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
T Zaremba ◽  
B Tayal ◽  
A M Thogersen ◽  
S Riahi ◽  
P Sogaard
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Spline Interpolation ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
Lead Target ◽  
Target Area ◽  
Resynchronization Therapy ◽  
Lead Position ◽  
Ventricular Lead

Abstract Background One third of patients receiving cardiac resynchronization therapy (CRT) do not respond to the treatment, possibly due to suboptimal lead position and persistent dyssynchronous left ventricular (LV) contraction. Purpose To assess the influence of LV lead position on improvement of contractile asymmetry and its significance for LV reverse remodeling after CRT. Methods Patients with heart failure and left bundle branch block undergoing CRT implantation were studied retrospectively. Assessment of mechanical delay within the LV was assessed using a recently developed index of contractile asymmetry (ICA). ICA was calculated as standard deviation of differences in systolic strain rate in the opposing LV walls derived from curved anatomical M-mode plots. LV was divided into 12 equally sized 30-degree sectors. Spline interpolation was used to estimate ICA in six opposing sector pairs permitting quantification of regional contractile asymmetry in the entire LV. Position of LV lead tip was assessed by thoracic computed tomography (CT). Response to CRT was defined as a reduction of LV end-systolic volume (ESV) ≥15% after 6 months. Results Study population (n= 26) consisted of 65.4% males, 68 ± 10 years, ischemic etiology in 42.3%, LV ejection fraction 24.1 ± 5.8%, QRS duration 171 ± 22 ms. CRT response was present in 18 (69.2%) patients. Pre-implantation ICA in the LV sector containing LV lead was 0.75 ± 0.24 s-1 in responders vs. 0.46 ± 0.16 s-1 in non-responders (p = 0.003). Reduction of ICA in the LV sector with LV lead was directly correlated with reduction of LV ESV after CRT (r = 0.46, p = 0.02) (Figure 1). ICA reduction in the LV sector with LV lead was -0.24 ± 0.28 s-1 in responders and -0.05 ± 0.16 s-1 in non-responders (p = 0.03). Meanwhile, reduction of ICA in the LV sectors located 60 degrees clockwise and 60 degrees counterclockwise away from the LV sector with LV lead (remote LV sectors) did not differ significantly between responders and non-responders: -0.12 ± 0.15 s-1 vs. -0.06 ± 0.1 s-1 (p = 0.28). Likewise, no significant correlation between reduction of ICA in remote LV sectors and LV ESV reduction was observed (p = 0.11). Conclusion Pre-implantation contractile asymmetry in the LV lead target area is associated with a positive response to CRT. Simultaneously, the degree of LV reverse remodeling after CRT seems to correlate with the magnitude of improvement of contractile asymmetry specifically in the region of LV lead location. Abstract Figure 1

scholarly journals Excitation and Contraction of the Failing Human Heart In Situ and Effects of Cardiac Resynchronization Therapy: Application of Electrocardiographic Imaging and Speckle Tracking Echo-Cardiography

Hearts ◽  
2021 ◽  
Vol 2 (3) ◽  
pp. 331-349
Author(s):  
Christopher M. Andrews ◽  
Gautam K. Singh ◽  
Yoram Rudy
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Cardiac Electrophysiology ◽  
Speckle Tracking ◽  
Contractile Function ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
Resynchronization Therapy ◽  
Electromechanical Delay ◽  
Electrocardiographic Imaging ◽  
Activation Sequence

Despite the success of cardiac resynchronization therapy (CRT) for treating heart failure (HF), the rate of nonresponders remains 30%. Improvements to CRT require understanding of reverse remodeling and the relationship between electrical and mechanical measures of synchrony. The objective was to utilize electrocardiographic imaging (ECGI, a method for noninvasive cardiac electrophysiology mapping) and speckle tracking echocardiography (STE) to study the physiology of HF and reverse remodeling induced by CRT. We imaged 30 patients (63% male, mean age 63.7 years) longitudinally using ECGI and STE. We quantified CRT-induced remodeling of electromechanical parameters and evaluated a novel index, the electromechanical delay (EMD, the delay from activation to peak contraction). We also measured dyssynchrony using ECGI and STE and compared their effectiveness for predicting response to CRT. EMD values were elevated in HF patients compared to controls. However, the EMD values were dependent on the activation sequence (CRT-paced vs. un-paced), indicating that the EMD is not intrinsic to the local tissue, but is influenced by factors such as opposing wall contractions. After 6 months of CRT, patients had increased contraction in native rhythm compared to baseline pre-CRT (baseline: −8.55%, 6 months: −10.14%, p = 0.008). They also had prolonged repolarization at the location of the LV pacing lead. The pre-CRT delay between mean lateral LV and RV electrical activation time was the best predictor of beneficial reduction in LV end systolic volume by CRT (Spearman’s Rho: −0.722, p < 0.001); it outperformed mechanical indices and 12-lead ECG criteria. HF patients have abnormal EMD. The EMD depends upon the activation sequence and is not predictive of response to CRT. ECGI-measured LV activation delay is an effective index for CRT patient selection. CRT causes persistent improvements in contractile function.

scholarly journals Diagnostic value of electrocardiographic markers of left bundle branch block in predicting left ventricular reverse remodeling in patients receiving cardiac resynchronization therapy

2021 ◽  
Vol 26 (9) ◽  
pp. 4500
Author(s):  
L. M. Malishevsky ◽  
V. A. Kuznetsov ◽  
V. V. Todosiychuk ◽  
N. E. Shirokov ◽  
D. S. Lebedev
Keyword(s):  
Mathematical Model ◽  
Cardiac Resynchronization Therapy ◽  
Predictive Value ◽  
Diagnostic Value ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
Resynchronization Therapy ◽  
Bundle Branch Block ◽  
T Wave

Aim. To analyze the prognostic value of 18 electrocardiographic (ECG) markers of left bundle branch block (LBBB) in predicting left ventricular (LV) reverse remodeling in patients receiving cardiac resynchronization therapy (CRT).Material and methods. The study included 98 patients. Depending on the presence of reverse remodeling during CRT, defined as a decrease in LV endsystolic volume ≥15%, the patients were divided into two groups: non-responders (n=33) and responders (n=65). We selected and analyzed 18 ECG markers included in 9 LBBB criteria.Results. Among the ECG markers significantly associated with reverse remodeling during CRT, the absence of q wave in leads V5-V6 demonstrated the highest sensitivity (92,31%), a negative predictive value (70,59%) and overall accuracy (73,47%). Normal internal deviation interval of the R wave in leads V1-V3 was also associated with the best sensitivity (92.31%), while QS with a positive T in lead aVR — the best specificity (69,7%). Discordant T wave demonstrated the highest positive predictive value (80,33%). Multivariate analysis revealed following ECG signs independently associated with reverse remodeling during CRT: QRS complex duration (odds ratio (OR)=1,022; 95% confidence interval (CI): 1,001-1,043; p=0,040); absence of q wave in leads V5-V6 (OR=4,076; 95% CI: 1,071-15,51; p=0,039); discordant T wave (OR=4,565; 95% CI: 1,708-12,202; p=0,002). These ECG findings were combined into a mathematical model that demonstrated high predictive power (AUC=0,81 [0,722-0,898], p<0,001). Once the cut-off point was determined, a binary variable was obtained that showed higher sensitivity, negative predictive value, and overall accuracy when compared with the actual LBBB criteria. The 5-year survival rate among patients with a model value above the cut-off point was 84,4%, while in patients with a value below the cut-off point — 50% (Log-rank test, p=0,001). To improve usability of the model, a mobile application was developed.Conclusion. For the first time, the diagnostic value of ECG markers of LBBB were analyzed and a mathematical model with ECG signs was proposed to predict reverse remodeling in patients receiving CRT.

scholarly journals Analysis of Risk Factors for Acute Heart Failure in Patients with Dilated Cardiomyopathy and Persistent Severe Functional Mitral Regurgitation Despite Cardiac Resynchronization Therapy

2020 ◽  
pp. 35-39
Author(s):  
R. V. Buriak ◽  
K. V. Rudenko ◽  
O. A. Krykunov
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Mitral Regurgitation ◽  
Cardiac Resynchronization Therapy ◽  
Dilated Cardiomyopathy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Functional Mitral Regurgitation ◽  
Reverse Remodeling ◽  
Resynchronization Therapy

Congestive heart failure resulting from non-ischemic dilated cardiomyopathy (DCM) with secondary functional mitral regurgitation (FMR) is associated with poor prognosis. Medical treatment results in a 1-year survival of 52% to 87% and a 5-year survival of 22% to 54%, with highest survivals observed in more recent years, probably reflecting improvements in medical therapy. Non-surgical interventions involve cardiac resynchronization therapy. In addition to medical treatment, cardiac resynchronization therapy (CRT) should be considered in patients with New York Heart Association (NYHA) class II– IV HF, left ventricular ejection fraction (LVEF) =35%, normal sinus rhythm and left bundle branch block with QRS >150 ms. In these patients, CRT can also facilitate left ventricular (LV) reverse remodeling and reduce associated FMR. The aim of this study was to investigate the features of symptomatology and to analyze the risk factors for acute heart failure (AHF) in patients with DCM and persistent severe functional mitral regurgitation despite CRT and optimal guideline-directed medical therapy (GDMT). Materials and methods. After providing informed consent, 144 patients with severe FMR were involved in the study. Concomitant tricuspid valve regurgitation was registered in 142 (98.6%) cases. The median LVEF was 27.0 (23.0-31.6)%. 40 (27.8%) patients had a permanent form of atrial fibrillation, and 24 (16.7%) patients had a first-degree atrioventricular node block. The median NT-proBNP was 2600 (2133-3200) pg/ml, indicating the presence of severe chronic heart failure. Results. The median term after CRT device implantation was 36 (3.5-60) months. A comparative analysis between DCM patients with and without CRT revealed statistically significant differences between clinical characteristics, namely: age (p=0.020), lower heart rate (p=0.004), lower hemoglobin (p=0.017), higher erythrocyte sedimentation rate (ESR) (p=0.000) and more frequent AHF at the hospital stage (p=0.030). The incidence of AHF at the hospital stage was 13.8% in patients with CRT and 3.5% in those without CRT. The calculated odds ratio of AHF was 4.44 (95% confidence interval (CI) 1.039-18.971), and the relative risk of AHF was 3.966 (95% CI 1.054-14.915). Discussion. FMR has been reported to persist in about 20% to 25% of CRT patients and, in an additional 10% to 15%, it may actually worsen after CRT. In this subset of CRT non-responders, reduced reverse remodeling, increased morbidity, and increased mortality have been reported compared with CRT patients in whom FMR was significantly reduced or abolished. Conclusions. The results of our study demonstrate that severe functional mitral regurgitation despite cardiac resynchronization therapy in patients with dilated cardiomyopathy is a significant risk factor for AHF and subsequent hospitalizations for heart failure.

Abstract 13242: Insulin Treated Patients With Diabetes Derive Reduction in Mortality From Cardiac Resynchronization Therapy - Results From the Madit-Crt in Trial Experience

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Barbara Szepietowska ◽  
Valentina Kutyifa ◽  
Martin H Ruwald ◽  
Scott D Solomon ◽  
Anne-Christine H Ruwald ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Risk Reduction ◽  
Insulin Treatment ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
Diabetic Patients ◽  
Resynchronization Therapy ◽  
All Cause Mortality ◽  
Patients With Diabetes

Methods: We aimed to analyze the risk for death and HF and the effect of CRT on HF/death in diabetic patients with or without insulin treatment compared to none diabetic population. The study comprised 1278 patients with left bundle branch block in the MADIT-CRT trial with an average follow-up of 3.3y. We used time dependent survival analysis and Cox proportional hazards regression method. Results: In ICD arm patients with diabetes receiving insulin treatment had 2.4-fold higher risk of all-cause mortality (p=0.008), and 2.2-fold higher risk of HF (p<0.001) when compared to non diabetic patients, and 2.8-fold higher risk of death (p=0.01), and 1.6-fold higher risk of HF (p=0.06) when compared to patients with diabetes not treated with insulin. Treatment with CRT-D was associated with a significant 75% risk reduction in all-cause mortality (hazard ratio [HR ] 0.25; 95% confidence interval [CI]: 0.08-0.77; p=0.016) in patients with diabetes receiving insulin. Noteworthy, during the 3-year follow-up, reduction in all-cause mortality was not observed in patients not treated with insulin or in patients with no diabetes (interaction p-value=0.038). Significant risk reduction in HF and in HF/death after CRT treatment was observed across all three investigated groups. There were not significant differences in left ventricular reverse remodeling after CRT-D among diabetic patients with or without insulin treatment compared to the nondiabetic population. Conclusions: Patients with insulin treated diabetes derive significant reduction in mortality and heart failure after implantation of cardiac resynchronization therapy. Patients with diabetes and no insulin and patient without diabetes benefit from CRT by reduction of HF events.

Abstract 1606: High Specificity of Prolonged Isovolumic Contraction Time for Reverse Remodeling Associated with Cardiac Resynchronization Therapy

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Chinami Miyazaki ◽  
Charles J Bruce ◽  
Margaret M Redfield ◽  
Raul E Espinosa ◽  
David L Hayes ◽  
...  
Keyword(s):  
Mitral Valve ◽  
Cardiac Resynchronization Therapy ◽  
Roc Analysis ◽  
High Specificity ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
Contraction Time ◽  
Valve Closure ◽  
Resynchronization Therapy ◽  
Closure Time

Background: Isovolumic contraction time (ICT) and pre-ejection period (PEP) are altered by electrical conduction delay as well as impaired contractility. An abnormal PEP has been used to select patients for cardiac resynchronization therapy (CRT), however, the predictive value of PEP for reverse remodeling (RR) has not been reported. The purpose of this study is to determine the predictive value of ICT and PEP for the RR in a prospective, single center CRT registry. Methods: Prospective registry of all heart failure patients undergoing CRT with echo pre-implant and at 3 and 6 months after implant. PEP was measured from the ECG Q wave onset to the aortic valve opening from the left ventricular outflow tract pulsed-wave Doppler tracing. The timing interval from the QRS onset to mitral valve closure was measured (mitral valve closure time). ICT was calculated as PEP-mitral valve closure time. RR was defined as >15% reduction in end-systolic volume (ESV) measured by biplane Simpson’s method. Death due to cardiac cause and heart transplantation during the 6 month period were considered as a non-response in the receiver-operating characteristics (ROC)analysis. Results: Echocardiography data was available in 83 patients at 3 and 59 patients at 6 month after CRT. RR occurred in 42 patients (51%) at 3 months and in 32 (54%) patients at 6 months By ROC analysis, the area under the curve (AUC) for predicting RR was 0.74 for ICT (p<0.001) and 0.73 for PEP (p=0.001) (See table ). ICT>123 ms yielded a very high specificity of 90–93% to predict responders at 6 month after CRT either in entire population or after excluding the patients with atrial fibrillation. Conclusion: A prolonged ICT is highly specific for predicting reverse remodeling after CRT although it is found in a limited number of patients. A strategy employing a screening ICT measurement may identify patients highly likely to achieve reverse remodeling after CRT, but can not be used to exclude patients for CRT. ROC analysis

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