A randomized controlled trial of cardiac resynchronization therapy in patients with prolonged atrioventricular interval: the REAL-CRT pilot study

EP Europace ◽  
2019 ◽  
Vol 22 (2) ◽  
pp. 299-305 ◽  
Author(s):  
Giovanni Luca Botto ◽  
Assunta Iuliano ◽  
Eraldo Occhetta ◽  
Giuseppina Belotti ◽  
Giovanni Russo ◽  
...  
Keyword(s):  
Ejection Fraction ◽  
Cardiac Resynchronization Therapy ◽  
Diastolic Function ◽  
Lower Risk ◽  
Left Atrial ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Pr Interval ◽  
New Onset

Abstract Aims A prolonged PR interval is known to be associated with increased mortality and a higher risk of developing atrial fibrillation (AF). We tested the hypothesis that cardiac resynchronization therapy (CRT) is superior to conventional dual-chamber pacing with algorithms for right ventricular pacing avoidance (DDD-VPA) in preserving systolic and diastolic function and in preventing new-onset AF in patients with normal systolic function, indication for pacing and prolonged atrioventricular conduction (PR interval ≥220 ms). Methods and results We randomly assigned 82 patients with ejection fraction >35%, indication for pacing and PR interval ≥220 ms to CRT or to DDD-VPA. On 12-month follow-up examination, the study and control arms did not differ in terms of left ventricular end-systolic volume (44 ± 17 mL vs. 47 ± 16 mL, P = 0.511) or ejection fraction (55 ± 6% vs. 57 ± 8%, P = 0.291). The E to A mitral wave amplitude ratio was higher in the CRT arm (1.3 ± 1.3 vs. 0.8 ± 0.4, P = 0.046) and the E wave deceleration time was longer (262 ± 83 ms vs. 205 ± 51 ms, P = 0.027). Left atrial volume was smaller in the CRT arm (64 ± 17 mL vs. 84 ± 25 mL, P = 0.035). Moreover, the functional class was lower in CRT patients (1.4 ± 0.6 vs. 1.8 ± 0.5, P = 0.010). During follow-up, CRT was associated with a lower risk of new-onset AF [hazard ratio = 0.37 (0.13–0.98), P = 0.046]. Conclusion Cardiac resynchronization therapy proved superior to DDD-VPA in terms of better diastolic function, less left atrial enlargement and lower risk of new-onset AF, at 12 months. These data need to be confirmed in a larger trial with longer follow-up. Clinical trial registration URL: http://clinicaltrials.gov/ Identifier: NCT02150538

NISAR-F SCORE: a simple risk stratification tool for patients implanted with cardiac resynchronization therapy

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
J Correia ◽  
L Goncalves ◽  
I Pires ◽  
J Santos ◽  
V Neto ◽  
...  
Keyword(s):  
Ejection Fraction ◽  
Cardiac Resynchronization Therapy ◽  
Cox Regression ◽  
Nyha Class ◽  
Prognostic Score ◽  
Roc Curves ◽  
Cardiac Resynchronization ◽  
Class Iii ◽  
Resynchronization Therapy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Individualized estimation of prognosis after cardiac resynchronization therapy (CRT) remains challenging. Outcomes in this group of patients are influenced by multiple factors and a comprehensive and customized approach to estimate prognosis after CRT is lacking Aims To develop and validate a simple prognostic score for patients implanted with CRT (NISAR-F score), based on readily available clinical and echocardiographic variables to predict the combined endpoints of death or hospitalization in 24 months. Methods A single-centre retrospective study was conducted with inclusion of all consecutive patients who underwent CRT implantation between 2012 and 2019. Follow-up started after CRT implantation and ended upon death, hospitalization or 24 months after study entry. Survival analysis was performed using a multivariate Cox regression model, in order to analyze the effect on survival /hospitalization in 24 months of the following factors: age, gender, NYHA Class III-IV, ischemic heart failure, type 2 diabetes, arterial hypertension, dyslipidemia and ejection fraction < 21%. According to the analysis, points were attributed to each factor. Afterwards, the NISAR-F score was calculated for each patient, summing the points of each variable. The authors finally created ROC curves for the NISAR-F score to predict the occurrence of the combined endpoint in 2 groups of patients: CRT responders (ejection fraction increase of at least 10% after CRT implantation) and CRT non-responders. The statistical analysis was performed in SPSS. Results 102 patients were included in the study (75.4% male, mean age 68 ± 10.46 years). 10(9.8%) of the patients were re-hospitalized and 8 (7.8%) died during the 24-month follow-up.  After calculating NISAR-F score for each patient, area under ROC curves were obtained. The analysis of the ROC curves allows us to confirm the good performance of the score created [responders group (AUC 0.812) vs non-responders (AUC 0.721)]. Conclusion The NISAR-F score is a useful tool to predict the combined endpoint (mortality and hospitalization in 24 months) after CRT implantation, in both responders and non-responders, revealing good performance of this new and simple score based only on clinical and echocardiographic variables.

Abstract 2285: Acute and Chronic Improvement in Left Ventricular Diastolic Function Following Cardiac Resynchronization Therapy

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Glen Miske ◽  
Masaki Tanabe ◽  
Nini C Thomas ◽  
David Schwartzman ◽  
John Gorcsan
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Diastolic Function ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Control Group ◽  
Resynchronization Therapy ◽  
Beneficial Effects ◽  
Lv Diastolic Function ◽  
Deceleration Time

Background: Cardiac resynchronization therapy (CRT) has been shown to result in improvements in left ventricular (LV) systolic function, but its effects on diastolic function are not well understood. Our aim was to test the hypothesis that CRT acutely improves LV diastolic function and that these benefits are sustained in chronic follow-up. Methods: We studied 40 NYHA Class III–IV heart failure patients (65±10 yrs, ejection fraction 24±7%, QRS duration 166±26 ms, 62% ischemic) at baseline, 24 hours after CRT, and 6±3 mo. after CRT. A control group of 10 normal subjects were also studied. Quantitative pulsed wave and tissue Doppler measures of diastolic function included: mitral inflow peak E and A wave velocity, E deceleration time, mitral annular E′ velocity (septal and lateral sites) and estimation of LV filling pressure by E/E′. Results: All CRT patients had baseline diastolic dysfunction, as expected: Deceleration Time = 163±53 ms, E′ = 3.4±1.6 cm/sec, E/E′ = 40±20, peak E wave = 1.11±0.3 m/sec, peak A wave = 0.5±.3 m/sec, (all p < 0.05 vs. controls). Diastolic function acutely improved following CRT: Deceleration Time = 218±52 ms*, E′= 4.3±1.8 cm/sec*, and E/E′ = 29±19*, peak E wave = 1.01±0.26 m/sec*, peak A wave = 0.7±.34 m/sec* (all p < 0.05 vs. baseline). These beneficial effects of CRT were sustained 6±3 month following CRT (all p < 0.05 vs. baseline). Conclusion: CRT was associated with acute improvements in LV diastolic function. These improvements were sustained through chronic follow-up. These findings extend the understanding of beneficial effects of CRT on LV function.

Abstract 13444: Complete Left-Sided Reverse Remodeling in Cardiac Resynchronization Therapy and Clinical Implications: a MADIT-CRT Long-term Follow-up Sub-study

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Andrew M Mathias ◽  
Scott D Solomon ◽  
Arthur J Moss ◽  
Dorit Knappe ◽  
Anne-Catherine Pouleur ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Lower Risk ◽  
Left Atrial ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Long Term Follow Up ◽  
Median Change

Background: Left ventricular and left atrial remodeling (defined as a reduction in left ventricular end-systolic volume [LVESV] and left atrial volume [LAV] respectively) have both been shown to be associated with better clinical outcome in patients with cardiac resynchronization therapy (CRT). However, a portion of CRT patients exhibit discordant remodeling (e.g. improvement in LVESV but not in LAV or vice versa). Whether combined assessment of LA and LV remodeling predicts clinical outcome is unknown. Objectives: We aimed to evaluate the predictive value of a combined assessment of LAV and LVESV change in CRT patients with left bundle branch block (LBBB) enrolled in MADIT-CRT. We hypothesized that combined assessment better predicts outcome than LAV or LVESV reduction alone. Methods: The study population comprised 533 CRT-D LBBB patients assigned to lesser remodeling (below median LAV and LVESV change), discordant remodeling (above median change in only LAV or LVESV), or complete left-sided remodeling (above median change in both LAV and LVESV). The end point was heart failure (HF) during follow-up. Results: At 1-year follow-up, 206 patients had lesser remodeling, 115 had discordant remodeling and 212 had complete left-sided remodeling. Patients with complete left-sided remodeling had less HF than those with discordant remodeling or lesser remodeling (Figure, p=0.002). Multivariate analysis confirmed that complete left-sided remodeling is associated with lower risk of HF than discordant remodeling and discordant remodeling is better than lesser remodeling (HR=0.62 per each group, 95% CI: 0.44-0.86, p = 0.004). Conclusions: A combined assessment of LAV and LVESV reduction predicts HF in CRT patients with LBBB. Patients with complete left-sided remodeling had a significantly lower risk of HF during long-term follow-up.

Minimally Invasive Surgical Cardiac Resynchronization Therapy: An Intermediate-Term Follow-Up Study

2007 ◽  
Vol 2 (1) ◽  
pp. 40-47 ◽  
Author(s):  
Joel S. Corvera ◽  
John D. Puskas ◽  
Vinod H. Thourani ◽  
Robert A. Guyton ◽  
Omar M. Lattouf
Keyword(s):  
Ejection Fraction ◽  
Minimally Invasive ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Inotropic Support ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Minimally Invasive Surgical ◽  
Qrs Duration

Background Cardiac resynchronization therapy (CRT) improves symptoms, quality of life, and ejection fraction in selected patients with congestive heart failure (CHF) and interventricular conduction delay. Transvenous insertion of left ventricular (LV) pacing leads via the coronary sinus is unsuccessful in 8–10% of patients. This study describes intermediate-term follow up of minimally invasive surgical techniques for CRT as a viable alternative after failed transvenous lead insertion. Methods From March 2001 to October 2005, fifty-four patients with NYHA Class III–IV symptoms, QRS duration 181 ± 40 milliseconds, and LV ejection fraction 19.7 ± 8.0% underwent a total of 56 minimally invasive LV lead placements via thoracoscopic video assistance (n = 38) or minithoracotomy (n = 17). One patient required full thoracotomy after a previous video-assisted thoracoscopic procedure. Intraoperative transesophageal echocardiography was used to assess changes in LV function. Results Acute thresholds for the active lead measured 1.10 ± 0.62 V, with R-wave amplitude of 12.3 ± 6.6 mV and impedance of 631 ± 185 Ohm. Thirty-day mortality was 5%. There were no perioperative myocardial infarctions or strokes. Five patients required transfusion, 3 had exacerbation of prior renal insufficiency, 5 had pulmonary complications, and 8 required inotropic support for more than 48 hours. Intermediate-term follow up (mean 20 ± 16 months, range 11 days to 55 months) revealed 3 patients with lead failure requiring additional surgical intervention. Hospitalization due to worsening CHF occurred in 5 patients, and 2 of these patients required intravenous inotropic support. QRS duration decreased to 146 ± 36 milliseconds postoperatively (P < 0.001). Conclusion Minimally invasive surgical lead placement safely and effectively accomplishes cardiac resynchronization using either thoracoscopic or minithoracotomy techniques.

scholarly journals Electrical Reverse Remodeling of the Native Cardiac Conduction System after Cardiac Resynchronization Therapy

2020 ◽  
Vol 9 (7) ◽  
pp. 2152
Author(s):  
Hee-Jin Kwon ◽  
Kyoung-Min Park ◽  
Seong Soo Lee ◽  
Young Jun Park ◽  
Young Keun On ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Ventricular Remodeling ◽  
Left Ventricular ◽  
Conduction System ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
Resynchronization Therapy ◽  
Pr Interval ◽  
Crt Response

Background: Little is known about electrical remodeling of the native conduction systems, particularly how the PR interval changes, after cardiac resynchronization therapy (CRT). We investigated the effects of CRT on the intrinsic PR interval (i-PRi) and QRS duration (i-QRSd). Methods and results: In 100 consecutive CRT recipients with sinus rhythm and long-term follow-up (>1 year), the i-PRi and i-QRSd were measured at baseline and at the last echocardiographic follow-up (33.4 ± 17.9 months) with biventricular pacing temporarily withdrawn. The relative decrease in the left ventricular end-systolic volume (LVESV) was measured to define CRT-responders (≥15%) and super-responders (≥30%). Following CRT, the left ventricular (LV) ejection fraction increased significantly (p < 0.001). In CRT-responders (n = 71), the LVESV and i-QRSd decreased markedly (170 ± 39 to 159 ± 24 ms, p = 0.012). However, the i-PRi was not shortened with CRT response and was actually likely to increase, even in the super-responder group (n = 33). Moreover, lengthening of the i-PRi was observed consistently irrespective of the CRT response status, beta-blocker use, or amiodarone use. CRT non-responders were associated with a remarkable PR prolongation (p = 0.005) and QRS widening (p = 0.001), along with positive ventricular remodeling. Conclusion: LV volume and i-QRSd decreased markedly with CRT response. However, the i-PRi was not shortened, but rather increased regardless of the degree of CRT response. CRT non-response was associated with a considerable increase in the i-PRi and i-QRSd, along with positive ventricular remodeling. CRT-induced electrical reverse remodeling might occur preferentially in the intraventricular, but not the atrioventricular, conduction system.

scholarly journals Pacemaker optimization guided by echocardiography in cardiac resynchronization therapy

2009 ◽  
Vol 137 (7-8) ◽  
pp. 416-422
Author(s):  
Danijela Trifunovic ◽  
Milan Petrovic ◽  
Goran Milasinovic ◽  
Bosiljka Vujisic-Tesic ◽  
Marija Boricic ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Delay Optimization ◽  
Mitral Flow ◽  
Av Delay

Introduction. Cardiac resynchronization therapy (CRT) or biventricular pacing is a contemporary treatment in the management of advanced heart failure. Echocardiography plays an evolving and important role in patient selection for CRT, follow-up of acute and chronic CRT effects and optimization of device settings after biventricular pacemaker implantation. In this paper we illustrate usefulness of echocardiography for successful AV and VV timing optimization in patients with CRT. A review of up-to-date literature concerning rationale for AV and VV delay optimization, echocardiographic protocols and current recommendations for AV and VV optimization after CRT are also presented. Outline of Cases. The first case is of successful AV delay optimization guided by echocardiography in a patient with dilated cardiomyopathy treated with CRT is presented. Pulsed blood flow Doppler was used to detect mitral inflow while programming different duration of AV delay. The AV delay with optimal transmittal flow was established. The optimal mitral flow was the one with clearly defined E and A waves and maximal velocity time integral (VTI) of the mitral flow. Improvement in clinical status and reverse left ventricle remodelling with improvement of ejection fraction was registered in our patient after a month. The second case presents a patient with heart failure caused by dilated cardiomyopathy; six months after CRT implantation the patient was still NYHA class III and with a significantly depressed left ventricular ejection fraction. Optimization of VV interval guided by echocardiography was undertaken measuring VTI of the left ventricular outflow tract (LVOT) during programming of different VV intervals. The optimal VV interval was determined using a maximal LVOT VTI. A month after VV optimization our patient showed improvement in LV ejection fraction. Conclusion. Optimal management of patients treated with CRT integrate both clinical and echocardiographic follow-up with, if needed, echocardiographically guided optimization of AV and VV delays, which offers the possibility of additional clinical improvement in such patients.

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