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.

Cathodic-anodal left ventricular stimulation during cardiac resynchronization therapy: haemodynamic evaluation and electrocardiographic analysis

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Gravellone ◽  
G Dell' Era ◽  
F De Vecchi ◽  
E Boggio ◽  
E Prenna ◽  
...  
Keyword(s):  
Ejection Fraction ◽  
Arterial Pressure ◽  
Cardiac Resynchronization Therapy ◽  
Right Ventricle ◽  
Single Point ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Biventricular Stimulation ◽  
Qrs Duration

Abstract Background Cardiac resynchronization therapy (CRT) is an established treatment for heart failure with reduced ejection fraction (HFrEF). However, one third of patients are “non responders”. Cathodic-anodal (CA) left ventricle (LV) capture is a multisite pacing occurring during CRT using both bipolar and quadripolar LV lead. It allows depolarization to arise simultaneously from the cathode and the anode of the bipole located on the LV epicardium, activating a larger volume of myocardium than cathodal pacing alone, thus potentially improving electromechanical synchrony (figure 1). We have previously proven that CA-LV stimulation is feasible and similar to bicathodic multipoint pacing (MPP) in terms of QRS wavefront activation. Purpose We aimed to evaluate both the acute intraprocedural haemodynamic and electrical effects of CA biventricular stimulation (CA-BS), comparing it with right-ventricle only pacing (Right Ventricle-Stimulation: RV-S), single-point CRT (Single Point-Biventricular Stimulation: SP-BS) and multipoint bicathodic biventricular stimulation (Multi Point-Biventricular Stimulation:MP-BS) in de novo CRT implants. Methods Ten patients candidates to CRT (LV ejection fraction ≤35% and left bundle branch block) received a quadripolar LV lead. Four pacing configurations were tested: RV-S, SP-BS, MP-BS and CA-BS, where cathode and the anode were the same electrodes used as cathodes in MP-BS. QRS duration by 12-lead ECG was defined as the time from the earliest ventricular deflection until the return to the isoelectric line. Haemodynamic assessment by radial artery catheterization using Pressure Recording Analytical Method processed the following parameters: dP/dT max (mmHg/msec), systolic arterial pressure (aPsys, mmHg), diastolic arterial pressure (aPdia, mmHg), mean arterial pressure (aPmean, mmHg), Cardiac Index (CI, l/min/m2), Stroke Volume Index (SVI, ml/min/m2). Results dP/dT max and aPmean increased significantly from RV-S to SP-BS (mean dP/dT max 0,82±0,28 versus 0,87±0,29 mmHg/msec, p=0,02; mean aPmean 89±19 versus 93±20 mmHg, p=0,01), but not from RV-S to MP-BS. Comparing RV-S to CA-BS, only aPmean exhibited a significant increase (mean aPmean 89±19 versus 92±20 mmHg, p=0,01). There were no haemodynamic differences between SP-BS, MP-BS and CA-BS. QRS duration reduced significantly from RV-S (167±10 msec) to each biventricular stimulation (135±14 msec, p=0,0002 for SP-BS; 130±17 msec, p=0,0001 for MP-BS; 129±18 msec, p=0,0002 for CA-BS) and from SP-BS to MP-BS and CA-BS (p=0,03 for both), whereas there were no difference comparing MP-BS and CA-BS. Conclusions CA-LV stimulation is not superior to single-point CRT in terms of acute haemodynamic performance, whereas it reduces the duration of ventricular electrical activation, showing an electrohaemodynamic mismatch. Long-term studies are needed to evaluate if acute electrical benefits of CA stimulation can predict chronic benefits, in terms of reverse cardiac remodelling. Cathodic-anodal left ventricular capture Funding Acknowledgement Type of funding source: None

Abstract 12722: Cardiac Resynchronization Therapy in Pacing Induced Cardiomyopathy: A Higher Right Ventricle Pacing Percentage Predicts Greater Improvement in Left Ventricle Ejection Fraction

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Sean Lacy ◽  
Jonathan Chandler ◽  
NACHIKET MADHAV APTE ◽  
Seth Sheldon ◽  
Madhu Reddy ◽  
...  
Keyword(s):  
Left Ventricle ◽  
Ejection Fraction ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Left Ventricle Ejection Fraction ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Qrs Duration ◽  
Rv Pacing ◽  
The Impact

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.

scholarly journals Predictive value of QRS duration normalized to left ventricular volume for responding to cardiac resynchronization therapy in patients with mid-QRS duration enrolled in the multicenter registry

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
N Yamamoto ◽  
M Nakano ◽  
H Hayashi ◽  
Y Hasebe ◽  
N Ueda ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Risk Stratification ◽  
Cardiac Resynchronization Therapy ◽  
Predictive Value ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
End Diastolic Volume ◽  
Qrs Duration

Abstract Background For cardiac resynchronization therapy (CRT), patients with chronic heart failure (HF) and wide (&gt;150msec) QRS duration (QRSd) received class I/A indication. However, its beneficial effect seemed to be limited for those with mid- (120–150msec) QRSd. Recent studies demonstrated that QRSd normalized to left ventricular end-diastolic volume (QRSd/ LVEDV) improved prediction of clinical outcome in patients with CRT. Therefore, we sought to investigate predictive value of QRSd/LVEDV for responding to CRT in patients with mid-QRSd. Methods This was retrospective multi-center observational cohort study. A total 506 consecutive patients who underwent CRT implantation in Tohoku University Hospital and National Cerebral and Cardiovascular Center were evaluated. Exclusion criteria were QRSd less than 120ms, upgrade procedures from other implanted non-CRT devices and bradycardia requiring pacing. We evaluated clinical variables, data of electrocardiogram and transthoracic echocardiography at baseline and 6 months after CRT implantation. Primary endpoint was a HF hospitalization after CRT implantation. Distribution of free from HF hospitalization during follow-up was calculated using Kaplan-Meier curves, and the effects of covariate on the time to endpoint were investigated using a Cox proportional hazards model. Results After 199 patients were excluded based on exclusion criterion, remaining 307 patients were included for the analysis. Mean age was 62±14 [SD] years, and 238 (77%) were male. Mean LVEF and LVEDV were 25±9% and 234±82ml, respectively, and 24% of patients had ischemic etiology of HF. During the median 948 days of follow-up, CRT patients with mid QRSd (n=126; 136±10msec), as compared with those with wide QRSd (n=181; 174±17msec), tended to have higher incidence of HF hospitalization (Wilcoxon p=0.03). Multivariate analysis showed that QRSd and QRSd/LVEDV were significant predictors for HF hospitalization in CRT patients with mid QRSd, and cut-off values (137msec of QRSd and 0.65 of QRSd/LVEDV), which was calculated by receiver operative curve analysis, was used for risk stratification. QRSd&lt;137msec was significant negative predictors for HF hospitalization (p=0.005), and Mid-QRSd patients with QRSd≥137msec demonstrated equivalent clinical outcome with those with wide QRSd. Moreover, patients with QRSd/LVEDV≥0.65 tended to have lower incidence of HF hospitalization as compared with those without it among patients with QRSd&lt;137msec (n=64, Figure). Conclusion The present study demonstrates that QRSd normalized to left ventricular end-diastolic volume (QRSd/ LVEDV) could be clinical value in predicting outcome in CRT patients with mid-QRSd. These findings indicate normalized QRSd reflects myocardial conduction properties and contribute to risk stratification. FUNDunding Acknowledgement Type of funding sources: None.

P602Septal function and viability determine response to cardiac resynchronization therapy

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
J Aalen ◽  
E Donal ◽  
C K Larsen ◽  
J Duchenne ◽  
E Kongsgaard ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Qrs Duration ◽  
Auc Value ◽  
Lge Cmr ◽  
Crt Response

Abstract Introduction Cardiac resynchronization therapy (CRT) has evolved as an important treatment in patients with symptomatic heart failure, reduced left ventricular (LV) ejection fraction and wide QRS. However, as one third of patients do not benefit from the therapy, there is need for better selection criteria. Previous studies have shown an association between recovery of septal function and response to CRT. Purpose To test the hypothesis that septal dysfunction in the absence of scar predicts response to CRT. Methods In 121 patients undergoing CRT implantation according to current European Society of Cardiology guidelines, we performed speckle-tracking echocardiography and estimated LV pressure non-invasively based on a method recently innovated in our lab. Pressure-strain analysis was used to calculate myocardial work. Septal dysfunction with asymmetric LV workload was calculated as the difference between LV lateral wall and septal work. Late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR) was performed to assess septal scar. CRT response was defined as ≥15% reduction of LV end systolic volume by echocardiography at 6 months follow-up. Results Eighty-eight patients (73%) responded to CRT at 6 months follow-up. Multivariate logistic regression analysis including lateral-to-septal work difference, septal scar, QRS duration and QRS morphology found that only lateral-to-septal work difference and septal scar were significant predictors of CRT response (both p<0.005). Using logistic regression and receiver operating characteristic (ROC) curve analysis, we found that the combined approach of these two parameters identified CRT responders with a sensitivity of 86% and a specificity of 82%. The area under the curve (AUC) for CRT response prediction was 0.85 (95% CI: 0.76–0.94) (Figure). In comparison, the AUC value for QRS duration was 0.63 (95% CI: 0.52–0.75). Furthermore, for the subgroup of patients with QRS duration 120–150 ms (n=27), the AUC value for lateral-to-septal work difference in combination with septal scar was 0.90 (95% CI: 0.78–1.00). Conclusions A multimodality approach with strain echocardiography and LGE-CMR was able to detect CRT responders with high accuracy, also in the subset of patients with intermediate QRS duration. A dysfunctional but viable septum appears to be an ideal target for CRT.

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.

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

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.

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 &lt; 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.

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