A Predictive Model for Super-Response to Cardiac Resynchronization Therapy: The QQ-LAE Score

Objectives. It is important to identify super-responders who can derive most benefits from cardiac resynchronization therapy (CRT). We aimed to establish a scoring model that can be used for predicting super-response to CRT. Methods. We retrospectively reviewed 387 CRT patients. Multivariate logistic regression analysis was performed to identify predictors for super-response (defined as an absolute increase in left ventricular ejection fraction of ≥15% at 6-month follow-up) and to create a score model. Multivariate Cox proportional-hazard regression analysis was conducted to assess associations with the long-term endpoint (defined as cardiac death/heart transplant, heart failure (HF) hospitalization, or all-cause death) across the score categories at follow-up. Results. Among 387 patients, 109 (28.2%) met super-response. In multivariable analysis, 5 independent predictors (QQ-LAE) were identified: prior no fragmented QRS (odds ratio (OR) = 3.10 (1.39, 6.94)), QRS duration ≥170 ms (OR = 2.37 (1.35, 4.12)), left bundle branch block (OR = 2.57 (1.04, 6.37)), left atrial diameter <45 mm (OR = 3.27 (1.81, 5.89)), and left ventricular end-diastolic dimension <75 mm (OR = 4.11 (1.99, 8.48)). One point was attributed to each predictor, and three score categories were identified. The proportion of super-response after 6-month CRT implantation in patients with scores 0–3, 4, and 5 was 14.6%, 40.3%, and 64.1%, respectively (P<0.001). Patients with score 5 had an 88% reduction in the risk of cardiac death/heart transplant (P=0.042), a 71% reduction in the risk of HF hospitalization (P=0.048), and an 89% reduction in the risk of all-cause mortality (P=0.028) compared to patients with scores 0–3. Conclusions. The QQ-LAE score can be used for prediction of super-response to CRT and selection of most suitable patients in clinical practices.

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Feasibility and efficacy of left bundle branch area pacing in patients indicated for cardiac resynchronization therapy

EP Europace ◽

10.1093/europace/euaa271 ◽

2020 ◽

Vol 22 (Supplement_2) ◽

pp. ii54-ii60

Author(s):

Yuqiu Li ◽

Lirong Yan ◽

Yan Dai ◽

Yu’an Zhou ◽

Qi Sun ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

Resynchronization Therapy ◽

Bundle Branch Block ◽

Ventricular Ejection Fraction ◽

Intraventricular Conduction ◽

Lead Placement

Abstract Aims The present study was to evaluate the feasibility and clinical outcomes of left bundle branch area pacing (LBBAP) in cardiac resynchronization therapy (CRT)-indicated patients. Methods and results LBBAP was performed via transventricular septal approach in 25 patients as a rescue strategy in 5 patients with failed left ventricular (LV) lead placement and as a primary strategy in the remaining 20 patients. Pacing parameters, procedural characteristics, electrocardiographic, and echocardiographic data were assessed at implantation and follow-up. Of 25 enrolled CRT-indicated patients, 14 had left bundle branch block (LBBB, 56.0%), 3 right bundle branch block (RBBB, 12.0%), 4 intraventricular conduction delay (IVCD, 16.0%), and 4 ventricular pacing dependence (16.0%). The QRS duration (QRSd) was significantly shortened by LBBAP (intrinsic 163.6 ± 29.4 ms vs. LBBAP 123.0 ± 10.8 ms, P < 0.001). During the mean follow-up of 9.1 months, New York Heart Association functional class was improved to 1.4 ± 0.6 from baseline 2.6 ± 0.6 (P < 0.001), left ventricular ejection fraction (LVEF) increased to 46.9 ± 10.2% from baseline 35.2 ± 7.0% (P < 0.001), and LV end-diastolic dimensions (LVEDD) decreased to 56.8 ± 9.7 mm from baseline 64.1 ± 9.9 mm (P < 0.001). There was a significant improvement (34.1 ± 7.4% vs. 50.0 ± 12.2%, P < 0.001) in LVEF in patients with LBBB. Conclusion The present study demonstrates the clinical feasibility of LBBAP in CRT-indicated patients. Left bundle branch area pacing generated narrow QRSd and led to reversal remodelling of LV with improvement in cardiac function. LBBAP may be an alternative to CRT in patients with failure of LV lead placement and a first-line option in selected patients such as those with LBBB and heart failure.

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Resynchronization therapy in end-stage heart failure

Russian Medical Inquiry ◽

10.32364/2587-6821-2021-5-4-206-211 ◽

2021 ◽

Vol 5 (4) ◽

pp. 206-211

Author(s):

D.V. Shumakov ◽

◽

D.I. Zybin ◽

M.A. Popov ◽

V.V. Dontsov ◽

...

Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

Cardiac Resynchronization Therapy ◽

Heart Transplant ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

Resynchronization Therapy ◽

End Stage Heart Failure ◽

End Stage

Heart failure (HF) is a common condition, and its overall prevalence is constantly growing. HF ultimately progresses to end-stage disease that is refractory to optimal medical therapy and requires implantable devices or heart transplant. In recent years, cardiac resynchronization therapy (CRT) has been generally accepted in patients with NYHA class III or IV, reduced left ventricular ejection fraction (less than 35%), and the wide QRS complex (>120 msec). CRT improves the efficacy of heart ventricle function and, as a result, physical performance and quality of life. Reverse cardiac remodeling occurs at a pathophysiological level that improves systolic function. Patients with end-stage HF who are on the heart transplant list are a specific group in whom CRT is considered a “bridge” to surgery. This review paper discusses state-of-the-art, advances, and unresolved issues in this area. KEYWORDS: cardiac resynchronization therapy, heart failure, left ventricular remodeling, ejection fraction, heart transplant. FOR CITATION: Shumakov D.V., Zybin D.I., Popov M.A. et al. Resynchronization therapy in end-stage heart failure. Russian Medical Inquiry. 2021;5(4):206–211 (in Russ.). DOI: 10.32364/2587-6821-2021-5-4-206-211.

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Sex-Specific Patterns of Mortality Predictors Among Patients Undergoing Cardiac Resynchronization Therapy: A Machine Learning Approach

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.611055 ◽

2021 ◽

Vol 8 ◽

Author(s):

Márton Tokodi ◽

Anett Behon ◽

Eperke Dóra Merkel ◽

Attila Kovács ◽

Zoltán Tősér ◽

...

Keyword(s):

Machine Learning ◽

Cardiac Resynchronization Therapy ◽

Left Ventricular ◽

Conditional Inference ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

Resynchronization Therapy ◽

All Cause Mortality ◽

Test Sets

Background: The relative importance of variables explaining sex-related differences in outcomes is scarcely explored in patients undergoing cardiac resynchronization therapy (CRT). We sought to implement and evaluate machine learning (ML) algorithms for the prediction of 1- and 3-year all-cause mortality in CRT patients. We also aimed to assess the sex-specific differences in predictors of mortality utilizing ML.Methods: Using a retrospective registry of 2,191 CRT patients, ML models were implemented in 6 partially overlapping patient subsets (all patients, females, or males with 1- or 3-year follow-up). Each cohort was randomly split into training (80%) and test sets (20%). After hyperparameter tuning in the training sets, the best performing algorithm was evaluated in the test sets. Model discrimination was quantified using the area under the receiver-operating characteristic curves (AUC). The most important predictors were identified using the permutation feature importances method.Results: Conditional inference random forest exhibited the best performance with AUCs of 0.728 (0.645–0.802) and 0.732 (0.681–0.784) for the prediction of 1- and 3-year mortality, respectively. Etiology of heart failure, NYHA class, left ventricular ejection fraction, and QRS morphology had higher predictive power, whereas hemoglobin was less important in females compared to males. The importance of atrial fibrillation and age increased, while the importance of serum creatinine decreased from 1- to 3-year follow-up in both sexes.Conclusions: Using ML techniques in combination with easily obtainable clinical features, our models effectively predicted 1- and 3-year all-cause mortality in CRT patients. Sex-specific patterns of predictors were identified, showing a dynamic variation over time.

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Merits of Different Ventricular Lead Locations on Left Ventricular Myocardial Strain and Dyssynchrony in Patients with Cardiac Resynchronization Therapy

Cardiology ◽

10.1159/000503953 ◽

2019 ◽

Vol 145 (1) ◽

pp. 13-20

Author(s):

Alaa S. Algazzar ◽

Mohamed M. Elbably ◽

Azza A. Katta ◽

Neama Elmeligy ◽

Khaled Elrabbat ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Circumferential Strain ◽

Nyha Class ◽

Myocardial Strain ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

Resynchronization Therapy ◽

Short Term

Background: The idea behind cardiac resynchronization therapy (CRT) is to pace both ventricles resulting in a synchronized electro-mechanical coupling of the left ventricle (LV), meaning every effort should be made to improve the percentage of CRT responders. Objectives: This study aimed at demonstrating the short-term effect of right ventricular apical (RVA) and mid-septal (RVS) lead locations combined with different LV lead positions on LV myocardial strain, dyssynchrony, and clinical outcomes. Methods: We examined 60 patients with indication for CRT before and after 6 months of implantation for clinical outcome and CRT response (6-min walk test [6MWT], NYHA class, decrease in left ventricular end systolic volume [LVESV] by >15%), dyssynchrony, and myocardial strain. Results: After 6 months of follow-up, the two RV lead locations represented a significant improvement in 6MWT, left ventricular ejection fraction, and LVESV in comparison to baseline values, but no significant difference was found between both groups. With regards to NYHA class improvement, p values were insignificant between the groups (0.44 and 0.88) at baseline and 6 months after implantation, respectively. The mean 6MWT was 273.8 m in the RVA group compared to 279.0 m in the RVS group (p = 0.84) at baseline. After 6 months of CRT implantation, the 6MWT mean was 326.5 m in the RVA group compared to 316.2 m in the RVS group (p = 0.74). The posterolateral cardiac vein site showed a significant improvement when combined with RVS location in interventricular and intraventricular dyssynchrony, global longitudinal strain, global circumferential strain, and apical circumferential strain (p = 0.01 0.032, 0.02, 0.005, and 0.049), respectively. Conclusion: RVS is not inferior and provides a good alternative to RVA pacing in short-term follow-up. However, the QRS duration, myocardial strain, and dyssynchrony varies depending on RV and LV stimulation sites. Long-term morbidity and mortality outcomes according to LV lead location in coronary sinus need more assessment.

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P1240Is resynchronization therapy really efficient in laminopathy?

European Heart Journal ◽

10.1093/eurheartj/ehz748.0198 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

J Burdeau ◽

G Viart ◽

E Gandjbakhch ◽

A Savoure ◽

B Godin ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Heart Transplantation ◽

Nyha Class ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

P Value ◽

Resynchronization Therapy ◽

Ventricular Ejection Fraction

Abstract Introduction Laminopathy (LMNA) is a group of rare disease caused by a mutation of lamin A/C genes. Heart transplantation (HT) is often required. Cardiac resynchronization therapy (CRT) may be an option to postpone HT. Purpose To describe characteristics and outcome of LMNA patients receiving CRT. Methods All consecutive LMNA patients implanted with a CRT device for conventional indications were included in the study. Clinical and echocardiographic (TTE) data were collected during the follow-up period. Results From 2002 to 2017, 68 LMNA patients had CRT implantation. Despite CRT, 30/68 patients (44%) had HT. Population divided into two groups according to response to CRT. Patients were considered without benefit (WHOB-CRT group) if they experienced severe events (inscription on heart transplantation list or death) within two years after CRT implantation. Other patients were in the WB-CRT group. TTE and clinical parameters are described in Table 1. Table 1 Parameters WB-CRT (n=33) WHOB-CRT (n=35) P-value At implantation Age (years) 52.3±9.7 50.6±9.5 0.27 Women 9 (27%) 13 (37%) 0.45 NYHA class 2.7±0.6 2.8±0.7 0.45 LVEF (%) 33.2±8.8 31.3±7 0.64 LVEDD (mm) 60±6.9 60±6.9 0.96 TAPSE (mm) 23±3.7 14±4.8 0.002 At last follow up NYHA class 2.2±0.6 2.9±0.7 <0.001 LVEF (%) 36.4±11 27±9 <0.001 LVEDD (mm) 59±5.5 59±7.7 0.98 TAPSE (mm) 19.9±5.5 12.3±3.3 0.003 Left ventricular ejection fraction (LVEF); Left ventricular end diastolic diameter (LVEDD); Tricuspid annular plane systolic excursion (TAPSE). Conclusion Cardiac resynchronization therapy is less efficient in LMNA patients. An impaired right ventricular stroke function seems to be the only predictive factor leading to poor response to CRT.

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Sudden cardiac death after implantation of a cardiac resynchronization therapy pacemaker: a case report illustrating that not always less is more

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa540 ◽

2021 ◽

Vol 5 (2) ◽

Author(s):

Dirk Vollmann ◽

Claudius Hansen ◽

Peter Hunold ◽

Lars Lüthje

Keyword(s):

Heart Failure ◽

Sudden Cardiac Death ◽

Cardiac Resynchronization Therapy ◽

Cardiac Death ◽

Patient Characteristics ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

Resynchronization Therapy ◽

Less Is More

Abstract Background Cardiac resynchronization therapy (CRT) improves symptoms and survival in selected patients with systolic heart failure and ventricular conduction delay. In subjects without prior life-threatening ventricular arrhythmia, clinicians have to select between implanting a CRT pacemaker (CRT-P) or a more complex device with additional defibrillator capability (CRT-D). This individual decision can be challenging in light of the available evidence and the potential risks and benefits. Case summary A 76-year-old male with non-ischaemic cardiomyopathy, heart failure New York Heart Association Class III, left bundle branch block (QRS duration 185 ms) and a left ventricular ejection fraction of 30% despite optimal medical therapy was indicated for CRT. In light of the patient characteristics and clinical condition, a CRT-P device was implanted. No complication occurred, and the patient was discharged after an appropriate device function was confirmed. Despite the clinical improvement, he died suddenly without prior symptoms approximately 2 months thereafter. Post-mortem device interrogation provided no evidence for device malfunction and confirmed sudden cardiac death (SCD) due to spontaneous ventricular fibrillation. Discussion Patients indicated for CRT often have overlapping internal cardioverter defibrillator indication for the primary prevention of SCD. By weighing individual risks and potential benefits, clinicians have to decide whether to implant a CRT-P (less is more) or a more complex and costly CRT-D device. Despite careful consideration of patient characteristics and clinical conditions, however, SCD can occur in subjects categorized as low risk and implanted with a CRT-P. More data from randomized clinical trials are needed to better support physicians in the often challenging process of selecting the most appropriate device for CRT.

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Chagas disease is associated with a poor outcome at 1-year follow-up after cardiac resynchronization therapy

Revista da Associação Médica Brasileira ◽

10.1590/1806-9282.65.11.1391 ◽

2019 ◽

Vol 65 (11) ◽

pp. 1391-1396

Author(s):

Luiz Carlos Santana Passos ◽

Rodrigo Morel Vieira de Melo ◽

Yasmin Menezes Lira ◽

Natalia Ferreira Cardoso de Oliveira ◽

Thiago Trindade ◽

...

Keyword(s):

Cardiac Resynchronization Therapy ◽

Chagas Disease ◽

Univariate Analysis ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

Resynchronization Therapy ◽

Ventricular Ejection Fraction ◽

The Mean

SUMMARY BACKGROUND: Cardiac resynchronization therapy (CRT) is a therapeutic modality for patients with heart failure (HF). The effectiveness of this treatment for event reduction is based on clinical trials where the population of patients with Chagas' disease (DC) is underrepresented. OBJECTIVE: To evaluate the prognosis after CRT of a population in which CD is an endemic cause of HF. METHODS: A retrospective cohort conducted between January 2015 and December 2016 that included patients with HF and left ventricular ejection fraction (LVEF) of less than 35% and undergoing CRT. Clinical and demographic data were collected to search for predictors for the combined outcome of death or hospitalization for HF at one year after CRT implantation. RESULTS: Fifty-four patients were evaluated, and 13 (24.1%) presented CD as the etiology of HF. The mean LVEF was 26.2± 6.1%, and 36 (66.7%) patients presented functional class III or IV HF. After the mean follow-up of 15 (±6,9) months, 17 (32.1%) patients presented the combined outcome. In the univariate analysis, CD was associated with the combined event when compared to other etiologies of HF, 8 (47%) vs. 9 (13,5%), RR: 3,91 CI: 1,46–10,45, p=0,007, as well as lower values of LVEF. In the multivariate analysis, CD and LVEF remained independent risk factors for the combined outcome. CONCLUSION: In a population of HF patients undergoing CRT, CD was independently associated with mortality and hospitalization for HF.

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Efficacy of left bundle branch area pacing in patients with indication for cardiac resynchronization therapy

European Heart Journal ◽

10.1093/eurheartj/ehab724.0400 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

G Elvira Ruiz ◽

P Penafiel-Verdu ◽

C Munoz-Esparza ◽

J Martinez-Sanchez ◽

J J Sanchez-Munoz ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Resynchronization Therapy ◽

Left Ventricular ◽

Cardiac Resynchronization ◽

Left Ventricular Ejection ◽

Conduction Delay ◽

Resynchronization Therapy ◽

Ventricular Ejection Fraction ◽

Ventricular Activation

Abstract Background Cardiac resynchronization therapy (CRT) with biventricular pacing has demonstrated clinical benefits in heart failure patients with left bundle branch block (LBBB) and ventricular dysfunction. Left bundle branch area pacing (LBBAP) results in a relatively short QRS duration (QRSd) with fast left ventricular activation and could be considered as an alternative to conventional CRT. Purpose The aim of the present study was to evaluate the feasibility and outcomes of LBBAP in patients with indications for CRT. Methods Consecutive patients with indications for CRT were included. LBBAP was performed via transventricular septal approach (1–3). We aimed to achieve a paced QRS with right bundle branch conduction delay morphology, a stimulus to peak left ventricular activation time (S-LVAT) <100ms and/or a QRSd ≤130ms. AV delay programming was individualized in patients in sinus rhythm, taking consideration of the AV conduction, programming the one that generated the shortest QRSd at rest. Rate adaptive AV was also activated in these patients. Pacing electrical and echocardiographic parameters were recorded at baseline and during follow-up. Results LBBAP was achieved in 19 of 21 (90.5%) patients with indication for CRT. Indications were heart failure with LBBB and left ventricular ejection fraction (LVEF) ≤35% in 8 (42%), AV node ablation or AV block with LVEF <50% and high expected RV pacing burden in 9 (47%), 1 pacing-induced cardiomyopathy and 1 patient with biventricular pacemaker malfunction (high LV capture threshold). The mean follow-up was 4.6±1.7 months and the percentage of ventricular pacing was 93.4±13.9%. There were no device-related complications during this period. LBBA capture threshold was 0.6±0.3V at 0.4ms at the implantation, and remained stable (0.7±0.1 V, p=0.17). The lead impedance and R-wave amplitude at implantation were 636±106 ohms and 13.4±6.8 mV, and 541±88 ohms and 13.0±5.1 mV during the follow-up (p<0.001 and p=0.27, respectively). Mean S-LVAT was 85.5±13.9 ms, and mean QRSd was 122±9 ms, that remained stable during follow-up (122 vs 124 ms, p=0.21). In patients with LBBB, a significant narrowing of paced QRSd was achieved (160.9±16.7 vs. 123.9±9.7 ms, p<0.001). Mean LVEF increased by 15.9%, from 35.4±8.9% at baseline to 51.3±9.8% at follow-up (p<0.001) in the overall population, and 14.5% (from 32.7±4.8% to 47.2±10.7%, p=0.001) in patients with LBBB. After one month, estimated time for elective replacement was 11.9±0.4 years. Conclusions LBBPA was successfully achieved in 90.5% of the patients with indication for CRT, with good and stable pacing electrical parameters, long estimated battery longevity and relatively narrow QRS, and was associated with improvement in cardiac function. LBBAP may be considered as a first-line option for patients with indications for CRT. FUNDunding Acknowledgement Type of funding sources: None.

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