scholarly journals 414 Ventricular-arterial interaction predicts response to cardiac resynchronization therapy: a link with improvement of endothelial function and arterial elastic properties

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
N Karamichalakis ◽  
I Ikonomidis ◽  
J Parissis ◽  
P Simitsis ◽  
S Xydonas ◽  
...  

Abstract Background Endothelial dysfunction (ED) is a hall mark of chronic heart failure and has been linked to disease progression, hospitalizations and mortality. Purpose to evaluate the impact of cardiac resynchronization therapy (CRT) in ED and to determine predictors of response to CRT Methods CRT recipients from 19/07/2016 until 19/10/2018 were studied at baseline and 3 months after. In each visit we evaluated a 12 lead ECG, carotid to femoral pulse wave velocity (cfPWV), flow-mediated dilatation of the brachial artery (FMD), left ventricle ejection fraction (LVEF) and left ventricle (LV) global longitudinal strain (GLS). We evaluated arterial elastance (Ea) to ventricular elastance (Ees) ratio (Ea/Ees) by echocardiography and the ratio of cfPWV to GLS, as valid markers of ventricular-arterial interaction. We also assessed the layer of endothelial glycocalyx by measurement of Perfused Boundary Region (PBR) of the sublingual microvessel range:5-25 microns. Results 32 patients with a mean age 65.5 (±10.9) years and severe LV systolic dysfunction were enrolled. During follow-up, LVEF, GLS, LVESV and all ED markers exhibited significant improvement (table 1). 23 patients were responders. Among the baseline vascular function markers, only the ratio cfPWV/GLS predicted response to CRT (OR: 0.245, 95%CI: 0.042-0.759, p = 0.044).Threshold analysis showed that the best threshold of cfPWV/GLS for response to CRT was 2.75 (specificity: 0.67%, sensitivity: 0.94%). Conclusions After 3 months of CRT, endothelial function, arterial elasticity and ventricular arterial interaction are improved. The baseline ratio cfPWV/GLS, a novel marker of ventricular arterial interaction, can be applied to predict response to CRT. table 1 Baseline Follow-up Change Measurement mean (sd) mean (sd) mean (sd) p-value SBP (mmHg) 126 (19) 128 (16) 2.18 (11.98) 0,465 DBP (mmHg) 79 (9) 80 (9) 1.06 (8.58) 0,618 LVEF (%) 27 (7) 35 (9) 7.50 (4.77) <0.001 LVESV (mL) 151 (42) 120 (46) -26.91 (17.20) <0.001 GLS (%) 6.47 (2.89) 9.33 (4.18) 2.85 (2.28) <0.001 FMD (%) 5.88 (2.79) 10.25 (3.67) 4.37 (3.34) <0.001 Ea/Ees 2.81 (1.10) 2.04 (0.99) -0.77 (0.47) <0.001 cfPWV 11.11 (2.61) 10.01 (2.45) -1.10 (1.56) 0,003 PBR 5-25(microns) 2.26 (0.20) 2.14 (0.24) -0.13 (0.25) 0,028 cfPWV/GLS 2.18 (1.46) 1.45 (1.11) -0.73 (0.55) <0.001 Measurements at baseline, follow-up and their change during study Abstract 414 Figure. picture 1

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
N D Karamichalakis ◽  
I Ikonomidis ◽  
J Parissis ◽  
P Simitsis ◽  
S Xydonas ◽  
...  

Abstract Background Cardiac resynchronization therapy (CRT) is a well-established therapy in heart failure (HF) patients with prolonged QRS. In HF patients, reduced nitric oxide availability and increased oxidative stress promote endothelial dysfunction (ED) and arterial stiffness. Purpose To investigate the pathophysiologic changes in endothelium and arterial elastic properties in CRT patients and their correlation to therapy. Methods We studied 32 HF patients before and 3 months after CRT implantation. In each visit we performed a 12-lead ECG and assessed markers of endothelial function. Specifically, we examined flow-mediated dilatation of the brachial artery (FMD), carotid to femoral pulse wave velocity (cfPWV), as well as the layer of endothelial glycocalyx using the Perfused Boundary Region (PBR) of the sublingual microvessel range: 5–25 microns. We also evaluated left ventricle ejection fraction (LVEF), left ventricle (LV) global longitudinal strain (GLS) and arterial elastance (Ea) to ventricular elastance (Ees) ratio (Ea/Ees) by echocardiography. Results 32 HF CRT patients, at age 65.5 (±10.9) years, with reduced LVEF (baseline LVEF: 27±7%, LVESV: 151±42 ml, GLS: 6.47±2.89%) were followed-up for a median of 115 days (IQR: 36). During follow up, all markers of ED demonstrated significant change: FMD was increased by 4.37±3.34% (p<0.001), cfPWV and PBR 5–25 were reduced by 1.10±1.56 (p=0.003) and 0.13±0.25 microns (p=0.028) respectively. LVEF was significantly increased (mean change: 7.50±4.77%) and LVESV was significantly reduced (mean change: −26.91±17.20 ml). 16 of 32 patients were responders (LVESV change ≥15% compared to baseline). Among the changes of the examined markers during follow-up, response to CRT correlated with the change of FMD (OR: 3.10, 95% CI: 1.47–15.51, p=0.039) and change of Ea/Ees (OR: 0.000, 95% CI: 0.000–0.061, p=0,0239). Effect of change in measurements during follow-up on response to CRT Measurement OR (95% CI) Main effect p-value FMD change 3.100 (1.470–15.513) 0.0397 cfPWV change 0.669 (0.295–1.354) 0.0622 PBR 5–25 change 1.773 (0.008–455.458) 0.828 Ea/Ees change 0.000 (0.000–0.061) 0.0239 Conclusion Improvement in endothelial function and arterial elastic properties evaluated by FMD and Ea/Ees respectively are related with effective CRT.


2020 ◽  
Author(s):  
Gonçalo Cristóvão ◽  
James Milner ◽  
Pedro Sousa ◽  
Miguel Ventura ◽  
João Cristóvão ◽  
...  

Abstract Background Recent studies suggest that circulating endothelial progenitor cells (EPCs) may influence the response to cardiac resynchronization therapy (CRT). The aim of this study was to evaluate the effect of CRT on EPCs levels and to assess the impact of EPCs on long-term clinical outcomes. Population and methods Prospective study of 50 patients submitted to CRT. Two populations of circulating EPCs were quantified previously to CRT implantation: CD34 + KDR + and CD133 + KDR + cells. EPCs levels were reassessed 6 months after CRT. Endpoints during the long-term follow-up were all-cause mortality, heart transplantation and hospitalization for heart failure (HF) management. Results The proportion of non-responders to CRT was 42% and tended to be higher in patients with an ischemic vs non-ischemic etiology (64% vs 35%, p=0.098). Patients with ischemic cardiomyopathy (ICM) showed significantly lower CD34+KDR+ EPCs levels when compared to non-ischemic dilated cardiomyopathy patients (DCM) (0.0010 ± 0.0007 vs 0.0030 ± 0.0024 cells/100 leukocytes, p=0.032). There were no significant differences in baseline EPCs levels between survivors and non-survivors nor between patients who were rehospitalized for HF management during follow-up or not. At 6-month follow-up, circulating EPCs levels were significantly higher than baseline levels (0.0024 ± 0.0023 vs 0.0047 ± 0.0041 CD34 + KDR + cells/100 leukocytes, p=0.010 and 0.0007 ± 0.0004 vs 0.0016 vs 0.0013 CD133 + /KDR + cells/100 leukocytes, p=0.007). Conclusions Patients with ICM showed significantly lower levels of circulating EPCs when compared to their counterparts. CRT seems to improve the pool of endogenously circulating EPCs and reduced baseline EPCs levels seem not influence long-term outcomes after CRT.


Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Bhupendar Tayal ◽  
Antonia Delgado-Montero ◽  
Akiko Goda ◽  
Samir Saba ◽  
Niels Risum ◽  
...  

Introduction: Heart failure (HF) patients have an increased risk for ventricular arrhythmias (VA) and in particular patients with ischemic cardiomyopathy (ICM) have a worse prognosis after cardiac resynchronization therapy with defibrillator (CRT-D) compared with non-ischemic patients. Hypothesis: We hypothesize that global longitudinal strain (GLS) at baseline has the ability to identify ICM patients at higher risk for VA after CRT-D. Methods: We prospectively studied 175 consecutive HF patients implanted with CRT-D from a single center. All of them had class II-IV HF symptoms, LV ejection fraction (≤35%), QRS≥120 ms. GLS was measured from the three standard apical views and presented as absolute values. Outcome event was defined as VA (anti-tachycardia pacing or appropriate shock) after CRT in the first 2 years of follow-up. Results: Of 175 patients aged 65±11 years, 135 (77%) were male and 115 (66%) had ICM. They suffered 34 (19%) VA events over 2 years. Mean GLS of the population was 8.1±3.0. GLS (< 6.5%) was associated with VA events after CRT-D with a sensitivity of 70% and specificity of 56%. A cutoff of GLS<6.5% was associated with greater VA events in the ICM patients with HR 2.92 (95% confidence interval 1.48 to 5.77, p=0.002). A similar significant association of GLS was not seen in the non ICM patients (p=0.12). Conclusions: Low GLS (<6.5% in absolute values) in ICM patients is associated with increased risk for VA after CRT-D and might represent more extensive myocardial scarring and has prognostic implications.


Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sean Lacy ◽  
Jonathan Chandler ◽  
NACHIKET MADHAV APTE ◽  
Seth Sheldon ◽  
Madhu Reddy ◽  
...  

Introduction: Cardiac resynchronization therapy (CRT) upgrade is indicated for improvement of cardiac function in patients with chronic right ventricular (RV) pacing burden >40% and heart failure with reduced ejection fraction. It is uncertain whether the CRT response is different among patients with high (≥90%) versus intermediate (<90%) burden of baseline RV pacing. Hypothesis: To assess the impact of baseline RV pacing percent on ECG and echocardiographic response after CRT upgrade for pacing induced cardiomyopathy. Methods: We conducted a retrospective study of all CRT upgrades for pacing induced cardiomyopathy at our hospital from January 2017 to December 2018. Cohorts were grouped by RV pacing burden ≥90% or <90%. QRS duration, left ventricle ejection fraction (LVEF), and left ventricular internal dimension systolic (LVIDs) were assessed at baseline and 3-12 months post CRT upgrade. Results: We included 82 patients (age 74 ± 12 yr., 71% male) who underwent CRT upgrade for pacing induced cardiomyopathy. The RV pacing burden was ≥90% [median 99% (IQR 98-99%)] in 61 patients, and <90% [median 79% (IQR 69-88%)] in 21 patients. There was a trend towards greater reduction in QRS duration in the ≥90% RV pacing group (28 ± 29 ms vs. 22 ± 38 ms, p=0.5). Improvement in LVEF was greater in ≥90% vs. <90% RV pacing group (14.3 ± 10.1% vs. 6.3 ± 10.1%, p=0.003). The association persisted on multivariable adjustment for age, sex and baseline LVEF (p=0.004). There was a trend towards greater % reduction in LVIDs in the ≥90% vs. <90% RV pacing group (6.4 ± 15.5 % vs. 3.9 ± 14.3 %, p=0.5) [Figure]. Conclusions: A higher baseline RV pacing burden predicts a greater improvement in LVEF after CRT upgrade for pacing induced cardiomyopathy.


2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
J Duchenne ◽  
J M Aalen ◽  
M Cvijic ◽  
C K Larsen ◽  
E Galli ◽  
...  

Abstract Background In patients with dilated cardiomyopathy and left bundle branch block (LBBB), different regions of the left ventricle (LV) have been shown to perform different amounts of work. In this study, we investigate the acute impact of cardiac resynchronization therapy (CRT) on regional LV work distribution and its relation to long-term reverse-remodelling. Methods We recruited 140 heart failure patients, referred for CRT. Regional myocardial work was calculated from non-invasive echocardiographic segmental stress-strain-loop-area before and immediately after CRT. The magnitude of volumetric reverse-remodelling was determined from the change in LV end-systolic volume (ESV), 11 ± 3 months after implantation. Characteristics of patients with the lowest and highest quartile of LV ESV reverse remodelling (LV ESV reduction of less than 10% and LV ESV reduction of more than -48%) were compared. Results Before CRT, myocardial work showed significant differences among the walls of the LV (Figure A). CRT caused an acute re-distribution of myocardial work, on average with most increase in the septum and most decrease laterally (all walls p &lt; 0.05) and lead to a homogeneous work distribution (Figure B). The acute change in the difference between lateral and septal wall work (Δ Lateral-to-septal work) correlated significantly with LV ESV reverse-remodelling (r = 0.63, p &lt; 0.0001). The smallest changes in work were seen in the patients with the least LV ESV reverse remodelling (Figure C, red markers), while patients with the most LV ESV reverse remodelling showed the largest changes in work (Figure C, green markers). In multivariate linear regression analysis, including conventional parameters such as pre-implant QRS duration, LV ejection fraction, LV end-diastolic volume and global longitudinal strain, the re-distribution of work across the septal and lateral walls appeared as the strongest determinant of volumetric reverse-remodelling after CRT (R²=0.393, p &lt; 0.0001). Conclusions The acute re-distribution of regional myocardial work between the septal and lateral wall of the left ventricle is an important determinant of long term reverse-remodelling after CRT-implantation. Our data suggest that modification of regional loading is the mode of action of CRT treatment. Abstract 553 Figure.


2021 ◽  
Vol 8 ◽  
Author(s):  
Zhongkai Wang ◽  
Pan Li ◽  
Bili Zhang ◽  
Jingjuan Huang ◽  
Shaoping Chen ◽  
...  

Background: The patient-tailored SyncAV algorithm shortens the QRS duration (QRSd) beyond what conventional biventricular (BiV) pacing can. However, evidence of the ability of SyncAV to improve the cardiac resynchronization therapy (CRT) response is lacking. The aim of this study was to evaluate the impact of CRT enhanced by SyncAV on echocardiographic and clinical responses.Methods and Results: Consecutive heart failure (HF) patients from three centers treated with a quadripolar CRT system (Abbott) were enrolled. The total of 122 patients were divided into BiV+SyncAV (n = 68) and BiV groups (n = 54) according to whether they underwent CRT with or without SyncAV. Electrocardiographic, echocardiographic, and clinical data were assessed at baseline and during follow-up. Echocardiographic response to CRT was defined as a ≥15% decrease in left ventricular end-systolic volume (LVESV), and clinical response was defined as a NYHA class reduction of ≥1. At the 6-month follow-up, the baseline QRSd and LVESV decreased more significantly in the BiV+SyncAV than in the BiV group (QRSd −36.25 ± 16.33 vs. −22.72 ± 18.75 ms, P &lt; 0.001; LVESV −54.19 ± 38.87 vs. −25.37 ± 36.48 ml, P &lt; 0.001). Compared to the BiV group, more patients in the BiV+SyncAV group were classified as echocardiographic (82.35 vs. 64.81%; P = 0.036) and clinical responders (83.82 vs. 66.67%; P = 0.033). During follow-up, no deaths due to HF deterioration or severe procedure related complications occurred.Conclusion: Compared to BiV pacing, BiV combined with SyncAV leads to a more significant reduction in QRSd and improves LV remodeling and long-term outcomes in HF patients treated with CRT.


2020 ◽  
Author(s):  
Gonçalo Cristóvão ◽  
James Milner ◽  
Pedro Sousa ◽  
Miguel Ventura ◽  
João Cristóvão ◽  
...  

Abstract Background Recent studies suggest that circulating endothelial progenitor cells (EPCs) may influence the response to cardiac resynchronization therapy (CRT). The aim of this study was to evaluate the effect of CRT on EPCs levels and to assess the impact of EPCs on long-term clinical outcomes. Population and methods Prospective study of 50 patients submitted to CRT. Two populations of circulating EPCs were quantified previously to CRT implantation: CD34 + KDR + and CD133 + KDR + cells. EPCs levels were reassessed 6 months after CRT. Endpoints during the long-term follow-up were all-cause mortality, heart transplantation and hospitalization for heart failure (HF) management. Results The proportion of non-responders to CRT was 42% and tended to be higher in patients with an ischemic vs non-ischemic etiology (64% vs 35%, p=0.098). Patients with ischemic cardiomyopathy (ICM) showed significantly lower CD34+KDR+ EPCs levels when compared to non-ischemic dilated cardiomyopathy patients (DCM) (0.0010 ± 0.0007 vs 0.0030 ± 0.0024 cells/100 leukocytes, p=0.032). There were no significant differences in baseline EPCs levels between survivors and non-survivors nor between patients who were rehospitalized for HF management during follow-up or not. At 6-month follow-up, circulating EPCs levels were significantly higher than baseline levels (0.0024 ± 0.0023 vs 0.0047 ± 0.0041 CD34 + KDR + cells/100 leukocytes, p=0.010 and 0.0007 ± 0.0004 vs 0.0016 vs 0.0013 CD133 + /KDR + cells/100 leukocytes, p=0.007). Conclusions Patients with ICM showed significantly lower levels of circulating EPCs when compared to their counterparts. CRT seems to improve the pool of endogenously circulating EPCs and reduced baseline EPCs levels seem not influence long-term outcomes after CRT.


2018 ◽  
Vol 33 (2) ◽  
pp. 42-50
Author(s):  
N. E. Shirokov ◽  
V. A. Kuznetsov ◽  
A. M. Soldatova ◽  
S. M. Diachkov ◽  
D. V. Krinochkin

Aim. The aim is to assess clinical features of organism and morpho-functional properties of heart and to study the dynamics of mechanical dyssynchrony in patients with congestive heart failure and superresponse to cardiac resynchronization therapy.Material and Methods. 72 patients were examined (mean age 54.3±8.9 years) at baseline and during follow-up visits: 10.5±3.7 months, 52.0±21.4 months. Patients were divided into groups: I group (n=31) with decrease of left ventricle endsystolic volume ≥30% (superresponders) and II group (n=41) — decrease of left ventricle endsystolic volume <30% (nonsuperresponders).Results. At baseline there were differences in the presence of myocardial infarction (22.5% in I group vs 46.3% in II group; p=0.038), the groups were comparable in severity of electrical and mechanical dyssynchrony. Left ventricle pre-ejection period in I group was statistically significantly decreased at both control visits, in group II there was no significant change. Right ventricular pre-ejection period significantly increased only in I group at the second control visit compared to baseline values. The mechanical interventricular delay significantly decreased in I group at both control visits compared to baseline values, in II group only at first control visit. The Intraventricular dyssynchrony assessed by tissue doppler imaging significantly decreased in both groups compared to baseline values. The survival rate in I group was 87.1%, in group II was 65.9% (Log-Rank test p=0.038).Discussion. Based on the results of the subanalysis of the Echo-CRT study, it was shown that a decrease in mechanical dyssynchrony in patients with cardiac resynchronization therapy is associated with a lower incidence of hospitalization due to heart failure or death. Persistent or worsening dyssynchrony according to echocardiography may be a marker of a severity of the disease in patients with congestive heart failure and has a prognostic value. It is important to note that in our study the described facts confirm the preservation of cardiac resynchronization therapy effect with long follow-up in superresponders and limited cardiac resynchronization therapy effect with short follow-up in nonsuperresponders.Conclusion. Superresponse is associated with a decrease of mechanical dyssynchrony with a long-term follow-up also with a higher survival rate.


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