Cardiac Resynchronisation Therapy in Heart Failure Patients with Atrial Fibrillation

Cardiac resynchronisation therapy (CRT) is an important device-based, non-pharmacological approach that has been shown to improve left ventricular (LV) function and reduce both morbidity and mortality rates in selected patients affected by advanced heart failure (HF), with New York Heart Association (NYHA) functional class III–IV, ejection fraction (EF) ≤35%, QRS duration ≥120ms and on optimal medical therapy. Patients with atrial fibrillation (AF), who constitute an important subgroup of HF patients, are nowadays considered eligible for receiving CRT as described in the latest European Society of Cardiology (ESC) and American Heart Association/American College of Cardiology/Heart Rhythm Society (AHA/ACC/HRS) guidelines, with some relevant differences in terms of how to manage the interference of natural rhythm and biventricular pacing. In this article, the authors explain how AF may interfere with adequate CRT delivery and how to manage different AF burdens, trying to obtain the best effects of CRT in AF patients.

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Emerging Cardiac Resynchronisation Therapy Indications

European Cardiology Review ◽

10.15420/ecr.2011.7.1.29 ◽

2011 ◽

Vol 7 (1) ◽

pp. 29

Author(s):

Charlotte Eitel ◽

Gerhard Hindricks ◽

Christopher Piorkowski ◽

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...

Keyword(s):

Heart Failure ◽

Systolic Heart Failure ◽

Cardiac Resynchronisation Therapy ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Current Evidence ◽

Class Iii ◽

Ventricular Ejection Fraction ◽

Cardiac Resynchronisation ◽

Resynchronisation Therapy

Cardiac resynchronisation therapy (CRT) is an efficacious and cost-effective therapy in patients with highly symptomatic systolic heart failure and delayed ventricular conduction. Current guidelines recommend CRT as a class I indication for patients with sinus rhythm, New York Heart Association (NYHA) functional class III or ambulatory class IV, a QRS duration ≥120ms, and left ventricular ejection fraction (LVEF) ≤35%, despite optimal pharmacological therapy. Recent trials resulted in an extension of current recommendations to patients with mild heart failure, patients with atrial fibrillation, and patients with an indication for permanent right ventricular pacing with the aim of morbidity reduction. The effectiveness of CRT in patients with narrow QRS, patients with end-stage heart failure and cardiogenic shock, and patients with an LVEF >35% still needs to be proved. This article reviews current evidence and clinical applications of CRT in heart failure and provides an outlook on future developments.

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Scar burden is an independent and incremental predictor of cardiac resynchronisation therapy response

Open Heart ◽

10.1136/openhrt-2019-001067 ◽

2019 ◽

Vol 6 (2) ◽

pp. e001067 ◽

Cited By ~ 1

Author(s):

Serge C Harb ◽

Saleem Toro ◽

Jennifer A Bullen ◽

Nancy A Obuchowski ◽

Bo Xu ◽

...

Keyword(s):

Heart Failure ◽

Characteristic Curve ◽

Cardiac Resynchronisation Therapy ◽

Left Ventricular ◽

Lv Function ◽

Prognostic Impact ◽

Clinical Events ◽

Cardiac Resynchronisation ◽

Resynchronisation Therapy ◽

Heart Failure Admission

ObjectiveDetermine the prognostic impact of scar quantification (scar %) by cardiac magnetic resonance (CMR) in predicting heart failure admission, death and left ventricular (LV) function improvement following cardiac resynchronisation therapy (CRT), after controlling for the presence of left bundle branch block (LBBB), QRS duration (QRSd) and LV lead tip location and polarity.MethodsConsecutive patients who underwent CMR between 2002 and 2014 followed by CRT were included. The primary endpoint was death or heart failure admission. The secondary endpoint was change in ejection fraction (EF) ≥3 months after CRT. Cox proportional hazards, linear regression models and change in the area under the receiver operating characteristic curve (AUC) were used.ResultsA total of 84 patients were included (63% male, 51% with ischaemic cardiomyopathy). After adjusting for clinical factors, presence of LBBB and QRSd and LV lead tip location and polarity, greater scar % remained associated with a higher risk for clinical events (HR=1.06; 95% CI 1.02 to 1.10; p<0.001) and a smaller improvement in EF (slope: −0.61%; 95% CI −0.93% to 0.29%; p<0.001). When adding scar % to QRSd and LBBB, there was significant improvement in predicting clinical events at 3 years (AUC increased to 0.831 from 0.638; p=0.027) and EF increase ≥10% (AUC 0.869 from 0.662; p=0.007).ConclusionScar quantification by CMR has an incremental value in predicting response to CRT, in terms of heart failure admission, death and EF improvement, independent of the presence of LBBB, QRSd, LV lead tip location and polarity.

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Developments in Cardiac Resynchronisation Therapy

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2015.04.02.122 ◽

2015 ◽

Vol 04 (2) ◽

pp. 122 ◽

Cited By ~ 5

Author(s):

Geoffrey F Lewis ◽

Michael R Gold ◽

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Keyword(s):

Heart Failure ◽

Ejection Fraction ◽

New Technologies ◽

Cardiac Resynchronisation Therapy ◽

Left Ventricular ◽

Conduction Delay ◽

Lv Function ◽

Qrs Prolongation ◽

Cardiac Resynchronisation ◽

Resynchronisation Therapy

Cardiac resynchronisation therapy (CRT) is an important therapy for patients with heart failure with a reduced ejection fraction and interventricular conduction delay. Large trials have established the role of CRT in reducing heart failure hospitalisations and improving symptoms, left ventricular (LV) function and mortality. Guidelines from major medical societies are consistent in support of CRT for patients with New York Health Association (NYHA) class II, III and ambulatory class IV heart failure, reduced LV ejection fraction and QRS prolongation, particularly left bundle branch block. The current challenge facing practitioners is to maximise the rate of patients who respond to CRT and the magnitude of that response. Current areas of interest for achieving these goals include tailoring patient selection, individualising LV lead placement and application of new technologies and techniques for CRT delivery.

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Optimisation of Cardiac Resynchronisation Therapy with MultiPoint™ Pacing

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2015.4.3.sup1 ◽

2015 ◽

Vol 4 (3) ◽

pp. 3

Author(s):

Antonio Curnis ◽

David O’Donnell ◽

Axel Kloppe ◽

Žarko Calovic ◽

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...

Keyword(s):

Systolic Function ◽

Biventricular Pacing ◽

Heart Rhythm ◽

Cardiac Resynchronisation Therapy ◽

Left Ventricular ◽

Optimal Placement ◽

Jude Medical ◽

Number Of Patients ◽

Cardiac Resynchronisation ◽

Resynchronisation Therapy

Cardiac resynchronisation therapy (CRT) using biventricular pacing is an established therapy for impairment of left ventricular (LV) systolic function in patients with heart failure (HF). Although technological advances have improved outcomes in patients undergoing biventricular pacing, the optimal placement of pacing leads remains challenging, and approximately one third of patients have no response to CRT. This may be due to patient selection and lead placement. Electrical mapping can greatly improve outcomes in CRT and increase the number of patients who derive benefit from the procedure. MultiPoint™ pacing (St Jude Medical, St Paul, MN, US) using a quadripolar lead increases the possibility of finding the best pacing site. In clinical studies, use of MultiPoint pacing in HF patients undergoing CRT has been associated with haemodynamic and clinical benefits compared with conventional biventricular pacing, and these benefits have been sustained at 12 months. This article describes the proceedings of a satellite symposium held at the European Heart Rhythm Association (EHRA) Europace conference held in Milan, Italy, in June 2015.

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Cardiac Resynchronisation Therapy – Evolving Strategies to Enhance Response

European Cardiology Review ◽

10.15420/ecr.2010.6.1.83 ◽

2010 ◽

Vol 6 (1) ◽

pp. 83

Author(s):

Jagmeet P Singh ◽

Keyword(s):

Heart Failure ◽

Systolic Heart Failure ◽

Cardiac Resynchronisation Therapy ◽

Left Ventricular ◽

Patient Specific ◽

Cardiac Resynchronisation ◽

Clinical Benefits ◽

Pacing Lead ◽

Resynchronisation Therapy ◽

Physiological Impact

Cardiac resynchronisation therapy (CRT) has gained widespread acceptance as a safe and effective therapeutic strategy for congestive heart failure (CHF) refractory to optimal medical therapy. The use of implantable devices has substantially altered the natural history of systolic heart failure. These devices exert their physiological impact through ventricular remodelling, associated with a reduction in left ventricular (LV) volumes and an improvement in ejection fraction (EF). Several prospective randomised studies have shown that this in turn translates into long-term clinical benefits such as improved quality of life, increased functional capacity and reduction in hospitalisation for heart failure and overall mortality. Despite these obvious benefits, there remain more than a few unresolved concerns, the most important being that up to one-third of patients treated with CRT do not derive any detectable benefit. There are several determinants of successful delivery and response to CRT, including selecting the appropriate patient, patient-specific optimal LV pacing lead placement and appropriate post-implant device care and follow-up. This article highlights the importance of collectively working on all of these aspects of CRT to enhance and maximise response.

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Atrial Fibrillation in Heart Failure Patients

European Cardiology Review ◽

10.15420/ecr.2009.5.1.41 ◽

2009 ◽

Vol 5 (1) ◽

pp. 41

Author(s):

Michalis Efremidis ◽

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Rate Control ◽

Clinical Trial Data ◽

Cardiac Resynchronisation Therapy ◽

Controlled Clinical Trial ◽

Cardiac Resynchronisation ◽

Resynchronisation Therapy ◽

Randomised Controlled ◽

Near Future

There is a sinister synergism between atrial fibrillation (AF) and heart failure (HF). These common cardiovascular conditions often co-exist and result in significant morbidity and mortality. Despite the extensive amount of research and literature about each of these disorders separately, randomised controlled clinical trial data concerning the management of AF in patients with HF are lacking. The recently published Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial elucidated the matter of rhythm versus rate control. In addition, non-pharmacological treatment approaches such as catheter ablation of AF and cardiac resynchronisation therapy are rapidly growing and are likely to alter AF management in HF patients in the near future.

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Acute recoordination rather than functional hemodynamic improvement determines reverse remodelling by cardiac resynchronisation therapy

The International Journal of Cardiovascular Imaging ◽

10.1007/s10554-021-02174-7 ◽

2021 ◽

Author(s):

Philippe C. Wouters ◽

Geert E. Leenders ◽

Maarten J. Cramer ◽

Mathias Meine ◽

Frits W. Prinzen ◽

...

Keyword(s):

Systolic Function ◽

Cardiac Resynchronisation Therapy ◽

Left Ventricular ◽

Lv Function ◽

Peak Strain ◽

Cardiac Resynchronisation ◽

Reverse Remodelling ◽

Resynchronisation Therapy ◽

Lv Systolic Function

AbstractPurpose: Cardiac resynchronisation therapy (CRT) improves left ventricular (LV) function acutely, with further improvements and reverse remodelling during chronic CRT. The current study investigated the relation between acute improvement of LV systolic function, acute mechanical recoordination, and long-term reverse remodelling after CRT. Methods: In 35 patients, LV speckle tracking longitudinal strain, LV volumes & ejection fraction (LVEF) were assessed by echocardiography before, acutely within three days, and 6 months after CRT. A subgroup of 25 patients underwent invasive assessment of the maximal rate of LV pressure rise (dP/dtmax,) during CRT-implantation. The acute change in dP/dtmax, LVEF, systolic discoordination (internal stretch fraction [ISF] and LV systolic rebound stretch [SRSlv]) and systolic dyssynchrony (standard deviation of peak strain times [2DS-SD18]) was studied, and their association with long-term reverse remodelling were determined. Results: CRT induced acute and ongoing recoordination (ISF from 45 ± 18 to 27 ± 11 and 23 ± 12%, p < 0.001; SRS from 2.27 ± 1.33 to 0.74 ± 0.50 and 0.71 ± 0.43%, p < 0.001) and improved LV function (dP/dtmax 668 ± 185 vs. 817 ± 198 mmHg/s, p < 0.001; stroke volume 46 ± 15 vs. 54 ± 20 and 52 ± 16 ml; LVEF 19 ± 7 vs. 23 ± 8 and 27 ± 10%, p < 0.001). Acute recoordination related to reverse remodelling (r = 0.601 and r = 0.765 for ISF & SRSlv, respectively, p < 0.001). Acute functional improvements of LV systolic function however, neither related to reverse remodelling nor to the extent of acute recoordination. Conclusion: Long-term reverse remodelling after CRT is likely determined by (acute) recoordination rather than by acute hemodynamic improvements. Discoordination may therefore be a more important CRT-substrate that can be assessed and, acutely restored.

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DIAGNOSIS OF ATRIAL FIBRILLATION IN HEART FAILURE PATIENTS WITH IMPLANTABLE CARDIOVERTER DEFIBRILLATOR OR CARDIAC RESYNCHRONISATION THERAPY.

Archives of Medical Science ◽

10.5114/aoms/114977 ◽

2021 ◽

Author(s):

Barbara Dominik ◽

Mitkowski Przemyslaw ◽

Wojciech Zorawski ◽

Ilona Kowalik ◽

Adam Ciesielski

Keyword(s):

Heart Failure ◽

Atrial Fibrillation ◽

Implantable Cardioverter Defibrillator ◽

Cardiac Resynchronisation Therapy ◽

Predisposing Factors ◽

Study Group ◽

Cardioverter Defibrillator ◽

Cardiac Resynchronisation ◽

Resynchronisation Therapy

IntroductionImplantable cardioverter defibrillators register various types of arrhythmias. Thus they can be exploited to better identify patients with atrial fibrillation episodes and increase the proportion of patients who may benefit from implementation of pharmacological prophylaxis of thromboembolic events, most of which it turns out are asymptomatic.Material and methodsAssessment of the frequency, symptoms and predisposing factors for the occurrence of atrial fibrillation episodes in patients with implanted ICD (implantable cardioverter defibrillator) and CRT-D (cardiac resynchronisation therapy with defibrillator) based on the analysis of intracardiac electrocardiograms (IEGM) records. The study included 174 consecutive outpatient cases with heart failure, sinus rhythm and Implanted Cardioverter Defibrillator and Cardiac Resynchronisation Therapy with Defibrillator. Control visits with analysis of IEGM records occurred every three months. During mean follow-up of 20 months, 901 visits were carried out. 147 patients had at least one year of follow-up.ResultsAtrial fibrillation episodes in the study group occurred in 54 (31.0%) of patients and 71.4% were asymptomatic. Predisposing factors were: history of paroxysmal atrial fibrillation (37.0% vs 13.3%, p ˂ 0.001), atrioventricular conduction abnormalities (42.6% vs. 20.0%, p = 0.002), intraventricular conduction abnormalities (59.3% vs 40.8%, p = 0.02) and more severe mitral regurgitation (7.4% vs 0.8%, p = 0.04). Chronic renal disease was a risk factor for death in the study group. No stroke occurred during the study.ConclusionsEpisodes of paroxysmal AF in patients with systolic heart failure and implanted cardioverter-defibrillator systems are quite common. The majority of the episodes recorded in the study were asymptomatic.

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