Duration of the preejection phase is less preload dependent and therefore a better marker of acute response to cardiac resynchronization therapy than maximum pressure rise

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): EU’s Horizon 2020 research and innovation program under the Marie Sklodowska-Curie Background There is no consensus on which haemodynamic marker should be used to quantify acute response to cardiac resynchronization therapy (CRT) during implantation of the device. CRT has been shown to acutely reduce left ventricular (LV) end systolic as well as end-diastolic volume (EDV), precluding the use of preload dependent markers such as LV maximum pressure rise (dP/dtmax). Purpose As resynchronization will abolish the uncoordinated regional early systolic contractions of the LV, it will shorten the time to maximal pressure rise and aortic valve opening. For this reason, the purpose of this study was to investigate if duration from the time-point of ventricular pacing to dP/dtmax is less preload dependent and a better marker of acute response to CRT than dP/dtmax by comparing how the 2 markers reflected LV function during different CRT configurations. Methods LV pressure by micromanometer and volume by sonomicrometry were measured in 6 anaesthetized canines with left bundle branch block. Transient caval constrictions were performed to vary preload. Preload dependency of the 2 markers was compared by normalizing their values and calculating their relations to EDV. In 4 of the animals, biventricular pacing was performed at 3 different pacing sites with variations in atrioventricular delays that provided a range of response to CRT. To correct for acute changes in preload by CRT, stroke volume (SV) at identical EDV found from transient caval constrictions, were assessed and used as reference to grade improved LV function. Linear regression analysis was used to assess the correlation of both the duration of the preejection phase and dP/dtmax with SV. Results The duration of the preejection phase varied less with changes in preload compared to dP/dtmax: the slopes of their relation to EDV were -0.6 ± 0.7 %/ml and 4.8 ± 2.1 %/ml (p = 0.004), respectively. Turning CRT on, acutely reduced EDV from 74 ± 16 to 69 ± 17 ml (p < 0.001) at the best pacing configuration. For the different pacing sites and settings, there was a consistent relation in all animals where the preejection phase shortened as SV increased (average r2 = 0.75) (Figure A). dP/dtmax showed no clear relation to SV (average r2 = 0.22) and included cases with both negative and positive slopes (Figure B). Conclusions The duration of the preejection phase correlated with changes in LV function induced by CRT while dP/dtmax performed poorly as preload was changed. Hence, the novel timing parameter was less preload dependent and may be a better marker for assessing acute response to CRT. Abstract Figure.

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Biventricular pacing-induced acute response in baroreflex sensitivity has predictive value for midterm response to cardiac resynchronization therapy

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.00113.2009 ◽

2009 ◽

Vol 297 (1) ◽

pp. H233-H237 ◽

Cited By ~ 9

Author(s):

Maaike G. J. Gademan ◽

Rutger J. van Bommel ◽

C. Jan Willem Borleffs ◽

SumChe Man ◽

Joris C. W. Haest ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Predictive Value ◽

Baroreflex Sensitivity ◽

Biventricular Pacing ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Arterial Baroreflex ◽

Resynchronization Therapy ◽

Acute Response

In a previous study we demonstrated that the institution of biventricular pacing in chronic heart failure (CHF) acutely facilitates the arterial baroreflex. The arterial baroreflex has important prognostic value in CHF. We hypothesized that the acute response in baroreflex sensitivity (BRS) after the institution of cardiac resynchronization therapy (CRT) has predictive value for midterm response. One day after implantation of a CRT device in 33 CHF patients (27 male/6 female; age, 66.5 ± 9.5 yr; left ventricular ejection fraction, 28 ± 7%) we measured noninvasive BRS and heart rate variability (HRV) in two conditions: CRT device switched on and switched off (on/off order randomized). Echocardiography was performed before implantation (baseline) and 6 mo after implantation (follow-up). CRT responders were defined as patients in whom left ventricular end-systolic volume at follow-up had decreased by ≥15%. Responders (69.7%) and nonresponders (30.3%) had similar baseline characteristics. In responders, CRT increased BRS by 30% ( P = 0.03); this differed significantly ( P = 0.02) from the average BRS change (−2%) in the nonresponders. CRT also increased HRV by 30% in responders ( P = 0.02), but there was no significant difference found compared with the increase in HRV (8%) in the nonresponders. Receiver-operating characteristic curve analysis revealed that the percent BRS increase had predictive value for the discrimination of responders and nonresponders (area under the curve, 0.69; 95% confidence interval, 0.51–0.87; maximal accuracy, 0.70). Our study demonstrates that a CRT-induced acute BRS increase has predictive value for the echocardiographic response to CRT. This finding suggests that the autonomic nervous system is actively involved in CRT-related reverse remodeling.

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Cardiac Resynchronization Therapy using Left-Bundle-Branch Area and Left Ventricular Pacing

10.22541/au.160692129.90149450/v1 ◽

2020 ◽

Author(s):

Xiang-Fei Feng ◽

Ling-Chao Yang ◽

Rui Zhang ◽

Yi Yu ◽

Bo Liu ◽

...

Keyword(s):

New York ◽

Cardiac Resynchronization Therapy ◽

Biventricular Pacing ◽

Operation Time ◽

Heart Association ◽

Left Ventricular ◽

Functional Class ◽

Cardiac Resynchronization ◽

Lv Function ◽

Resynchronization Therapy

Introduction: Cardiac resynchronization therapy via biventricular pacing is an established therapy for patients with heart failure. However, high nonresponder rates and inability to predict response remains a challenge. Recently left bundle branch area pacing (LBBAP) has been shown to be feasible and may also improve clinical outcomes. In this article we describe sequential LBBAP followed by left ventricular (LV) pacing (LOT-CRT) and assess the feasibility of LOT-CRT. Methods: The RV implantation site was positioned and the LBBAP lead was implanted using our methods. The QRS duration (QRSd) at baseline, during LBBAP, biventricular pacing, and LOT-CRT was measured. Results: LOT-CRT was successful in 5 patients (age 71.8 ± 5.1 years, men 3, ischemic 3). The QRSd at baseline was 158.0 ± 13.0 ms and significantly narrowed to 117.0 ± 6.7 ms during LOT-CRT (P < 0.01). During 3-month follow-up, LV ejection fraction improved from 32.8 ± 5.2 % to 45.0 ± 5.1% (P < 0.01), and New York Heart Association functional class changed from 3.25 ± 0.5 to 2.5 ± 0.6 (P < 0.05). A decrease in left ventricular end-diastolic dimension was observed, with widening from (68.2 ± 12.3) mm at baseline to (62.2 ± 11.3) mm at pacing (P < 0.05). The length of operation time was (152.0 ± 31.1) min. Conclusions: The study demonstrates that LOT-CRT is clinically feasible in patients with systolic HF and LBBB. LOT-CRT was associated with significant narrowing of QRSd and improvement in LV function, especially in patients with ischemic cardiomyopathy.

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Cardiac Resynchronization Therapy using Left-Bundle-Branch Area and Left Ventricular Pacing

10.21203/rs.3.rs-123532/v1 ◽

2020 ◽

Author(s):

Xiang-Fei Feng ◽

Ling-Chao Yang ◽

Rui Zhang ◽

Mei Yang ◽

Bo Liu ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Biventricular Pacing ◽

Operation Time ◽

Left Ventricular ◽

Functional Class ◽

Cardiac Resynchronization ◽

Lv Function ◽

Ventricular Pacing ◽

Resynchronization Therapy ◽

Left Ventricular Pacing

Abstract Background: Cardiac resynchronization therapy via biventricular pacing is an established therapy for patients with heart failure. However, high nonresponder rates and inability to predict response remains a challenge. Recently left bundle branch area pacing (LBBAP) has been shown to be feasible and may also improve clinical outcomes. In this article we describe the new technique (sequential LBBAP followed by left ventricular pacing, LOT-CRT) and assess the feasibility of LOT-CRT.Methods: The RV implantation site was positioned and the LBBAP lead was implanted using our methods. The QRS duration (QRSd) at baseline, during LBBAP, biventricular pacing, and LOT-CRT was measured. Results: LOT-CRT was successful in 5 patients (age 71.8 ± 5.1 years, men 3, ischemic 3). The QRSd at baseline was 158.0 ± 13.0 ms and significantly narrowed to 117.0 ± 6.7 ms during LOT-CRT (P < 0.01). During 3-month follow-up, LV ejection fraction improved from 32.8 ± 5.2 % to 45.0 ± 5.1% (P < 0.01), and New York Heart Association functional class changed from 3.25 ± 0.5 to 2.5 ± 0.6 (P < 0.05). A decrease in left ventricular end-diastolic dimension was observed, with widening from (68.2 ± 12.3) mm at baseline to (62.2 ± 11.3) mm at pacing (P < 0.05). The length of operation time was (152.0 ± 31.1) min. Conclusions: The study demonstrates that LOT-CRT is clinically feasible in patients with systolic HF and LBBB. LOT-CRT was associated with significant narrowing of QRSd and improvement in LV function, especially in patients with ischemic cardiomyopathy.

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Abstract 12717: Improvement of Longitudinal Function is Closely Related to Reverse Remodeling in Cardiac Resynchronization Therapy

Circulation ◽

10.1161/circ.130.suppl_2.12717 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Nina E Hasselberg ◽

Kristina H Haugaa ◽

Anne Bernard-Brunet ◽

Erik Kongsgård ◽

Erwan Donal ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Resynchronization Therapy ◽

Biventricular Pacing ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Reverse Remodeling ◽

Lv Function ◽

Resynchronization Therapy ◽

Heart Failure Patients ◽

Longitudinal Function

Introduction: Response to cardiac resynchronization therapy (CRT) is often defined as reverse remodeling as a reduction in left ventricular (LV) end systolic volume (ESV). How myocardial mechanics are affected by biventricular pacing is not fully clarified. We tested the hypothesis that longitudinal and circumferential function are affected differently by biventricular pacing. Methods: Echocardiography (two dimensional) was performed before and 6 months after CRT implantation in heart failure patients with LV ejection fraction (EF) ≤ 35% and QRS ≥ 120 ms. LV function was assessed by EF and by global longitudinal (GLS) and global circumferential (GCS) strain from 16 LV segments by speckle tracking technique. CRT responders were defined as patients with reverse remodeling with a reduction in ESV ≥ 15% at 6 months. Results: We included 138 heart failure patients (65±10 years, 22% women, NYHA functional class 2.8±0.4, 48% ischemic cardiomyopathy). In the total population, GLS did not change (-8.5±3.9% to -8.9±4.7%, p=0.31) after 6 months with biventricular pacing, while GCS (-11.3±3.3% to -14.2±4.5%, p<0.001) and EF (27±9% to 36±12%, p<0.001) improved. Analyzing CRT responders (62%) and non-responders separately, GLS improved in responders (-8.4±3.8% to -9.5±3.8%, p=0.02) but not in non-responders (-8.7±4.1% to -7.9±4.5%, p=0.30) (Figure). GCS improved in both groups (-11.3±3.0% to -15.0±4.3%, p<0.001 and -11.4±3.8% to 13.0±4.7%, p=0.01). ΔGLS was a predictor of CRT response (OR 0.84 (0.75-0.95), p=0.009) and of ΔESV (1.62 (0.45-2.79), p=0.007) independently of ΔGCS. Conclusions: Biventricular pacing by CRT generally induced less changes in GLS than in GCS and EF. Importantly, GLS improved only in CRT responders with reverse remodeling. We suggest that reverse remodeling is more dependent on improved longitudinal function than circumferential function.

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Abstract 2819: Identification and Characterization of Super-Responders to Cardiac Resynchronization Therapy: An Echocardiographic Study

Circulation ◽

10.1161/circ.118.suppl_18.s_781 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Amira Zaroui ◽

Patricia Reant ◽

Erwan Donal ◽

Aude Mignot ◽

Pierre Bordachar ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Longitudinal Strain ◽

Global Longitudinal Strain ◽

Strain Analysis ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Lv Function ◽

Resynchronization Therapy ◽

Systolic Volume ◽

End Systolic Volume

In some patients, cardiac resynchronization therapy (CRT) has been recently shown to induce a spectacular effect on left ventricular (LV) function and inverted remodeling with nearby normalization of LV contraction. Objectives: To analyze and characterize super-responders (CRTSR) by echocardiography before CRT. 186 patients have been investigated before and 6 months after implantation of a CRT device with conventional indication according to ESC guidelines. Echocardiographies including measurements of LV dimensions, and contraction by 2-dimensional strain, and pressure assessment, mitral valve analysis were performed at baseline and at 6 months in an independent core-center lab. CRTSR were defined as a reduction of end-systolic volume of at least 15% and an ejection fraction (EF)>50% and were compared to normal responder patients (CRTNo, patients with a reduction of end-systolic volume of at least 15% but an EF <50%). 17/186 patients (9.1%) were identified as CRTSR, only 2 with ischemic cardiomyopathy (p<0.01). No difference was observed regarding NYHA status, EKG duration or EF between CRTSR and CRTNo at baseline. CRTSR presented with significant lower end-diastolic and end-systolic diameters (64±9mm vs 73±9mm (p<0.01) and 53±7.4mm vs 63±8.4mm (p<0.01), respectively), and end-diastolic and end-systolic volumes 161±44ml vs 210±76ml (p<0.02) and 123±43ml vs 163±69ml (p<0.01)) as well as a higher LV dP/dt max (714±251mmHg.s −1 vs 527±188 mmHg.s −1 (p<0.05)). Regarding strain analysis, CRTSR had significantly higher longitudinal values than CRTNo (−12.8±3% vs −9±2.6%, p<0.001) whereas no difference was observed for other components (p ns). Global longitudinal strain obtained by ROC curves was identified as the best parameter for predicting CRTSR with a cut-off value of −11% (Se=80%, Spe=87%, AUC=0.89, p<0.002) and was confirmed as an independent predictor by the logistic regression (RR: 21.3, p<0.0001). In a large multicenter study, CRT super-responders (EF>50%) were observed in 9% of the population and were associated with less-depressed LV function as determined by strain analysis. Global longitudinal strain appears to be the best predictor of CRTSR.

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Echocardiographic evaluation of cardiac resynchronization therapy

Srpski arhiv za celokupno lekarstvo ◽

10.2298/sarh0612488p ◽

2006 ◽

Vol 134 (11-12) ◽

pp. 488-491 ◽

Cited By ~ 1

Author(s):

Milan Petrovic ◽

Goran Milasinovic ◽

Bosiljka Vujisic-Tesic ◽

Vera Jelic ◽

Zarko Calovic ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Diastolic Filling ◽

Lv Function ◽

Mitral Insufficiency ◽

Stroke Index ◽

Resynchronization Therapy ◽

Filling Time ◽

The Mean

Introduction: Cardiac resynchronization therapy (CRT) is relatively new tool in treatment of chronic heart failure (HF), especially in dilated cardiomyopathy (DCM) with the left bundle branch block (LBBB). Objective: The Objective of our study was to assess the success of CRT in treatment of severe HF and the role of echocardiography in the evaluation of Results of such therapy. Method: The group consisted of 19 patients, 13 males and 6 females, mean age 58.0?8.22 years (47-65 years) with CRT applied for DCM, severe HF (NYHA III-IV), LBBB and ejection fraction (EF) <35%. The mean follow up was 17 months (6.5-30). Standard color Doppler echocardiography examination was performed in all patients before and after CRT. The parameters of systolic and diastolic left ventricular function, mitral insufficiency and the right ventricular pressure were evaluated. Results: Following the CRT, statistically significant improvement of the end-systolic LV dimension, cardiac output, cardiac index, myocardial performance index (p<0.01) and stroke index (p<0.05) was recorded. The mean value of EFLV was increased by 10% and LV fractional shortening improved by 6% in 10/16 (62%) patients. CRT resulted in decreased MR (p<0.01), prolonged LV diastolic filling time (p<0.02) and reduced RV pressure (p<0.05). Interventricular mechanical delay was shortened by 28% (18 msec) Conclusion: CRT has an important role in improvement of LV function and correction of ventricular asynchrony. The echocardiography is a useful tool for evaluation of HF treatment with CRT.

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Cardiac resynchronization therapy: optimization and follow-up

The ESC Textbook of Cardiovascular Imaging ◽

10.1093/med/9780198703341.003.0031 ◽

2015 ◽

pp. 420-431

Author(s):

Marta Sitges ◽

Genevieve Derumeaux

Keyword(s):

Cardiac Resynchronization Therapy ◽

Imaging Techniques ◽

Biventricular Pacing ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Functional Mitral Regurgitation ◽

Cardiac Imaging Techniques ◽

Resynchronization Therapy

Cardiac imaging techniques have an important role in the follow-up of patients undergoing cardiac resynchronization therapy (CRT) as they provide objective evidence of changes in cardiac dimensions and function. The role of echocardiography is well established in the assessment of left ventricular reverse remodelling and the evaluation of secondary (functional) mitral regurgitation. Additionally, echocardiography might be used for optimizing the programming of atrio-ventricular (AV) and inter-ventricular (VV) delays of current CRT devices. Acute benefits from this optimization have been demonstrated, but longer follow-up studies have failed to show a clear benefit of optimized CRT on top of simultaneous biventricular pacing on the outcome of patients with CRT. This chapter reviews the role of imaging in assessing follow-up and outcome of patients undergoing CRT, as well as the rationale, the methods used, and the clinical impact of optimization of the programming of CRT devices.

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45Improving the optimization of cardiac resynchronization therapy: Does multipoint left ventricular pacing shorten the paced-QRS duration compared to the fusion-optimized intervals method?

EP Europace ◽

10.1093/europace/euaa162.032 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

R San Antonio ◽

M Pujol-Lopez ◽

R Jimenez-Arjona ◽

A Doltra ◽

F Alarcon ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Biventricular Pacing ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Reverse Remodeling ◽

Prospective Clinical Study ◽

Battery Life ◽

Resynchronization Therapy ◽

Qrs Duration ◽

Phrenic Stimulation

Abstract Funding Acknowledgements Cardiac Pacing Scholarship from the Spanish Society of Cardiology (SEC) Background Electrocardiogram-based optimization of cardiac resynchronization therapy (CRT) using the fusion-optimized intervals (FOI) method has demonstrated to improve both acute hemodynamic response and left ventricle (LV) reverse remodeling compared to nominal programming of CRT. FOI optimizes the atrioventricular (AV) and ventriculo-ventricular (VV) intervals to achieve the shortest paced-QRS duration. The recent development of multipoint pacing (MPP) enables the activation of the LV from 2 locations, also shortening the QRS duration compared to conventional biventricular pacing. Purpose To determine if MPP reduces the paced-QRS duration compared to FOI optimization. Methods This prospective clinical study included 25 consecutive patients who successfully received a CRT with MPP pacing capability. All patients were in sinus rhythm and had an PR interval below 250 ms. The QRS duration was measured with a 12-lead digital electrocardiography (screen speed of 200 mm/s) at baseline and using 3 different configurations: MPP, FOI and a combined FOI-MPP strategy. In MPP, the intervals were (based on previous studies): 1) AV 130 ms, 2) Right ventricular (RV)-LV2 (Δ1) 5 ms, and 3) LV1-LV2 (Δ2) 5 ms. In FOI, AV and VV intervals were optimized to achieve fusion between intrinsic conduction and biventricular pacing. In FOI-MPP, the Δ2 was set at 5 ms, while AV and Δ1 intervals were optimized using the FOI method. The CRT device was programmed with the configuration that achieved a greater paced-QRS shortening. After 45 days, battery life was estimated. Results Mean age was 65 ± 10 years, 20 were men (80%) and baseline QRS duration was 177 ± 17 ms. The FOI method bested nominal MPP (QRS shortened by 58 ± 16 ms vs 43 ± 16 ms, respectively, p = 0.002). Adding MPP to the narrowest QRS by FOI did not result in further shortening (FOI: 58 ± 16 ms vs FOI-MPP: 59 ± 13 ms, p = 0.81). The final configuration was FOI method alone in most cases (n = 16, 64%) and FOI-MPP in all others (n = 9, 36%; figure). In total, 10 out of 25 patients (40%) were not candidates to MPP due to: 1) pacing thresholds exceeding 3.5 V/0.4 ms at the distal or proximal electrode (8, 32%), and 2) phrenic stimulation (2, 8%). Estimated battery longevity was longer in patients receiving FOI as compared to MPP (8.3 ± 2.1 years vs. 6.2 ± 2.2 years, p = 0.04). Conclusion In CRT, the FOI method is not improved by coupling with MPP. Up to 40% of patients are not candidates for MPP due to high thresholds or phrenic stimulation. The use of MPP in unselected patients would result in a decrease of battery longevity, without any additional benefit over FOI. Abstract Figure.

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