Right ventricular contractility as a measure of optimal interventricular pacing setting in cardiac resynchronization therapy

Abstract Funding Acknowledgements Type of funding sources: None. Background Despite having all a systolic heart failure and broad QRS, patients proposed for cardiac resynchronization therapy (CRT) are highly heterogeneous and it remains extremely complicated 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 (Figure 1). 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; 11 features were predictive of prognosis. Among the predictors of CRT-response, 7 variables (44%) 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 very 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) (Figure 1, Supervised Machine Learning Panel). An unsupervised ML approach allowed the identifications of two phenogroups of patients who differed significantly in clinical and parameters, 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; Figure 1, Unsupervised Machine Learning Panel). 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. Abstract Figure 1

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Abstract P64: Right Ventricular Outflow Septal Pacing as Cardiac Resynchronization Therapy in Patients with Right Bundle-Branch Block: Results in 62 Patients

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.4.suppl_2.ap64 ◽

2011 ◽

Vol 4 (suppl_2) ◽

Author(s):

Phillip E Schrumpf ◽

Michael Giudici ◽

Deborah Paul ◽

Roselyn Krupa ◽

Cynthia Meirbachtol

Keyword(s):

Cardiac Resynchronization Therapy ◽

Right Ventricular ◽

Right Bundle Branch Block ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Qrs Complex ◽

Resynchronization Therapy ◽

Ventricular Performance ◽

Bundle Branch Block ◽

Qrs Duration

Background: Cardiac resynchronization therapy has been shown to improve left ventricular performance in patients with left ventricular dysfunction and a left-sided interventricular conduction delay. This is performed by placing a pacing lead on the lateral left ventricular wall to stimulate the area normally stimulated by the left bundle branch. In patients with right bundle branch block (RBBB), pacing the right bundle branch could also result in resynchronization. Previous studies have shown that right ventricular outflow septal (RVOS) pacing does, in fact, utilize the native conduction system. Methods: 62 consecutive patients, 46 male/16 female, aged 75 +/− 10.5 yr, with RBBB and indications for pacing, underwent RVOS lead placement using commercially available pacing systems. The patients subsequently underwent bedside A-V optimization to achieve the narrowest QRS duration and most “normal” QRS complex. Echocardiography was performed to evaluate changes in wall motion comparing baseline with optimal pacing. Results: Baseline mean QRS duration 146 +/− 20.9 ms Optimized mean QRS duration 111 +/− 20.5 ms Average decrease in QRS duration -35 +/− 21.5 ms p < 0.001 Echocardiography demonstrated improvement in septal contraction abnormalities. Conclusions: 1) RVOS pacing in RBBB patients can significantly narrow the QRS complex on ECG. 2) Septal contraction abnormalities due to RBBB can be improved with RVOS pacing and optimal A-V timing. 3) Further studies are warranted to evaluate this therapy in a heart failure population.

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Heart failure and right ventricular pacing – how to avoid the need for cardiac resynchronization therapy

Expert Review of Medical Devices ◽

10.1080/17434440.2019.1552133 ◽

2018 ◽

Vol 16 (1) ◽

pp. 35-43

Author(s):

Maria F. Paton ◽

Klaus K. Witte

Keyword(s):

Heart Failure ◽

Cardiac Resynchronization Therapy ◽

Right Ventricular ◽

Cardiac Resynchronization ◽

Ventricular Pacing ◽

Resynchronization Therapy ◽

Right Ventricular Pacing

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394 The influence of cardiac resynchronization therapy on right ventricular systolic function in heart failure patients with right ventricular impairment

European Journal of Echocardiography ◽

10.1016/s1525-2167(06)60184-4 ◽

2006 ◽

Vol 7 ◽

pp. S51-S51

Author(s):

M SZULIK ◽

W STREB ◽

R LENARCZYK ◽

P PRUSZKOWSKASKRZEP ◽

O KOWALSKI ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Resynchronization Therapy ◽

Right Ventricular ◽

Systolic Function ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

Ventricular Systolic Function ◽

Heart Failure Patients ◽

Right Ventricular Systolic Function

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Effect of cardiac resynchronization therapy on right ventricular function

International Journal of Cardiology ◽

10.1016/j.ijcard.2016.02.034 ◽

2016 ◽

Vol 209 ◽

pp. 34-36 ◽

Cited By ~ 3

Author(s):

Abhishek Sharma ◽

Jerome J. Bax ◽

Ajay Vallakati ◽

Sunny Goel ◽

Carl J. Lavie ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Right Ventricular ◽

Ventricular Function ◽

Right Ventricular Function ◽

Cardiac Resynchronization ◽

Resynchronization Therapy

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P797 Assessment of right ventricular systolic function with 3D echocardiography following cardiac resynchronization therapy

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.453 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

C Jenei ◽

E Papp ◽

M Clemens ◽

Z Csanadi

Keyword(s):

Cardiac Resynchronization Therapy ◽

Right Ventricular ◽

Systolic Function ◽

Left Ventricular ◽

3D Echocardiography ◽

Cardiac Resynchronization ◽

Resynchronization Therapy ◽

S Wave ◽

Ventricular Systolic Function ◽

Significant Difference

Abstract Background In approximately 30-40% of cases, the left ventricular systolic function does not improve following cardiac resynchronization therapy (CRT; non-responders). Currently, the role of right ventricular (RV) systolic function is not yet completely clear in the background. Our aim was to assess the RV systolic function with 3D echocardiography in CRT patients. Methods We selected 19 patients who received CRT in our department between May and June 2017, and whose 1-year follow-up data were available. We characterized several 2D parameters of RV systolic function, such as RV free wall strain (RV GLSFW), annular s’ wave velocity (TDI s), tricuspid annulus plane systolic excursion (TAPSE), RV fractional area change (RV FAC). A number of 3D parameters were also assessed, such as RV ejection fraction (EF), end-diastolic (EDV) and end-systolic (ESV) volumes, using a dedicated RV analysis software. Moreover, we measured the LV EF and considered the patients "responder", when the LV EF improved with at least 10% after CRT implantation. Results From 19 patients, 12 was identified as responders (R) and 7 as non-responders (NR). No significant difference was seen in the mean age of patients in the two groups (NR: 68 ± 6 year; R: 67 ± 9 year, p = 0.76), however, the proportion of male individuals was higher in the NR group (8/12 vs. 1/7). The RV EF was higher in the R group (41 ± 8% vs.29 ± 10%; p = 0.012), while the EDV or ESV did not differ between the two groups. The RV GLSFW (–21.2 ± 7% vs.–13.9 ± 7%, p = 0.045) and the TAPSE (16.8 ± 5 mm vs.11.4 ± 3 mm, P = 0.03) values were significantly different between the two groups. Based on logistic regression analysis, the RV EF was an independent predictor of non-respondence. Conclusions The lower RV EF indicates non-respondence to CRT, however, it is not associated with RV dilation, i.e.adverse remodelling. These results suggest mechanical abnormality of RV function in the background of impaired EF.

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