Cardiac Resynchronization Therapy Device Implantation Research Articles

Short-term cost-utility analysis of biventricular cardiac resynchronization therapy in comparison with left bundle branch area pacing cardiac resynchronization therapy

Abstract Background Cardiac resynchronisation therapy (CRT) is a well-established form of treatment for patients with heart failure and cardiac dyssynchrony. Recently, left bundle branch area pacing (LBBAP) has emerged as a more physiological alternative for biventricular pacing (BiVP) cardiac resynchronization therapy (1,2). Purpose The purpose of this study was to conduct a cost-utility analysis for LBBAP CRT, compared to BiVP CRT in a cohort of patients with heart failure from the Spanish health system perspective. Methods A multicenter prospective quasi-experimental study in which 44 consecutive patients underwent CRT was conducted. According to the study protocol, the four centers would perform their usual clinical practice: two out of them would perform conventional BiVP-CRT while the other half LBBAP-CRT. Intention-to-treat analysis was carried-out. Health outcomes were quality-adjusted life years (QALYs), measured by the EuroQol-5D-5L questionnaire, which the patients were asked to complete at baseline and 12 weeks after the CRT device implantation. The total direct costs include device, leads, guidewires, introducer kits, sheats and operating theater time. The results were expressed as the incremental cost-utility ratio (ICUR). In order to analyze the uncertainty of ICUR results, we performed a non-parametric bootstrapping with 1000 replications. Results The LBBAP procedure was attempted for a total of 26 consecutive patients (1 patient underwent rescue BiVP), while BiVP was attempted for 18 patients (2 patients switched to LBBAP). Mean QALYs over 3 months were 0.1914 ± 0.009 in the LBBAP CRT group and 0.1904 ± 0.0112 in the BiVP CRT. Improvements from baseline were greater in the LBBA CRT group but not statistically significant. The total costs at the end of the intervention were 7546.6 €± 602.15€ in the LBBAP CRT group and 16064.56€ ± 723.7€ in the BiVP CRT group. When excluding from the analysis the cases in which ICD was implanted, the mean difference in QALYs is 0.002; 95% confidence interval [95%CI]: -0.03 to 0.036) and the mean saving is -3.510.38 €. The LBBAP CRT leads to cost savings for the health system and similar QALYs outcomes; 95%CI: -6.660 to -360.71. Based on 1000 bootstrapping replication, the cost savings of using LBBAP vs BiVP occur in 99% of the simulations. Conclusion LBBAP CRT is an efficient alternative to BiVP CRT for cardiac resynchronization in patients with heart failure with similar results in terms of QALYs but with significant average savings per patient.Cost-utility plane for 1000 bootstrappedBaseline characteristics of patients

Health-related quality of life among patients after cardiac resynchronization therapy: a comparison between biventricular and left bundle branch area pacing

Abstract Background Cardiac resynchronization therapy (CRT) with biventricular pacing (BiVP) has the potential to improve cardiac function in patients with heart failure (HF). However, a portion of patients do not respond to therapy. Recently, left bundle branch area pacing (LBBAP) has emerged as a more physiological alternative for CRT in selected cases (1,2). Quality of life (QoL) tools measures subjective experience and its results are relevant as they may help to assessed the impact that medical interventions have in patient's health. Purpose The authors sought to measure and compare the quality of life in a cohort of patients after the implantation of either a BiVP or a LBBaP CRT device. Methods A multicenter prospective quasi-experimental study in which consecutive patients underwent CRT was conducted. According to the study protocol, the four centers would perform their usual clinical practice: two out of them would perform conventional BiVP-CRT while the other half LBBAP-CRT. The health related QoL was measured by the Spanish version of the EuroQol Group’s five-level EuroQol five-dimensional questionnaire (EQ-5D-5L), which the patients were asked to complete at baseline and 12 weeks after the CRT device implantation. The descriptive system section of the EQ-5D-5L questionnaire produces a 5-digit health state profile that can be converted into a single index value. The EQ-5D-5L Spanish index values range from -0.225 to 1.0 (full health). The EQ-5D visual analogue scale (EQ-VAS) is a vertical scale numbered from 0 to 100 (the worst and the best health you can imagine). Both groups (BiVP and LBBaP) were compared with data from the general population of Spain for the EQ-5D-5L and EQ-VAS (n=20.587) according to the national survey (3). Results The study included 44 consecutive patients (31 males, mean age 66 ± 11 years, LVEF 28.9% ± 6.9%). The LBBAP procedure was finally performed in 27 patients, while BiVP was the therapy performed in the other 17 patients. Crossover rate was less than 12% (1 patient underwent rescue BiVP and 2 patients switched to LBBAP). The basal characteristics of included patients are presented in Table 1. Among the individuals with BiVP the mean EQ-5D-5L index score and the EQ-VAS score were 0.74±0.24 and 65.71±17.90 respectively at baseline while they were 0.83±0.19 [+0.08±0.16, p 0.054, CI 95%] and 76.59±15.76 three months later [+10.80±15.38, p 0.01, CI 95%]. In the LBBAP group, the mean EQ-5D-5L index score and the EQ-VAS score were 0.71±0.25 and 50.04±25.49 respectively at baseline while they were 0.80±0.19 [+0.09±0.22, p 0.044, CI 95%] and 69.30±23.53 [+19.26±22.83, p 0.0001, CI 95%] three months later. Conclusion It was found that the EQ-5D-5L index value and EQ-VAS improved in the LBBAP group. In the BiVP group only EQ-VAS improved although there was also a non-statistically significant trend in EQ-5D-5L index score. The main limitation of the study was the small sample size.Table 1Figure 1

Comparative analysis of clinical outcomes in patients undergoing primary CRT implantation versus CRT upgrade: single center experience

Abstract Background As heart failure (HF) management evolves, cardiac resynchronization therapy (CRT) has emerged as a cornerstone intervention, improving left ventricular (LV) function and reducing morbidity and mortality. The Budapest trial specifically addressed upgrading from permanent pacemaker (PPM) to CRT, emphasizing the potential for improved clinical outcomes and quality of life in this population. The findings highlighted the impact of CRT upgrade and contribute valuable insights to the cardiac device strategies for HF patients. This study aims to compare clinical outcomes between patients undergoing primary CRT implantation and those undergoing CRT upgrade. Methods A retrospective analysis was conducted on a cohort of heart failure patients who received CRT devices between 2015 and 2019. Patients were categorized into two groups: those undergoing primary CRT implantation and those undergoing CRT upgrade. Clinical outcomes, including mortality rate, hospitalization for HF exacerbation, and improvements in left ventricular ejection fraction (LVEF), were assessed and compared between the two groups. Results A total of 847 patients were included in the study, with 74,5% (n=631) undergoing primary CRT implantation and 13,5% (n=114) receiving CRT upgrades. The mean age was 72±10 years-old and 57% (n=485) were women, and a mean follow-up time of 23±8 months. 33.7% (n=285) of the total were of ischemic etiology. The primary CRT implantation group demonstrated a mortality of 34% (n=215) and 13% (n=84) of hospitalization due to HF; NYHA functional class improvement in 58% (n=369), and 35,7% (n=225) were CRT responders with a mean LV ejection fraction (EF) improvement of ±10%, while the CRT upgrade group had a 31% (n=36) mortality and 19% (n=22) of hospitalization due to HF; NYHA functional class improvement in 60% (n=68), and 27% (n=31) were CRT responders with a mean LV EF improvement of 8,7%. There were no statistically significant differences regarding each endpoint, namely mortality, HF hospitalizations, NYHA functional class improvement, CRT responders and mean LVEF improvement. Conclusion A clear benefit from implantation of a primary CRT device implantation has already been demonstrated. However, recent trials revealed there was also benefit in upgrading from PPM to CRT patients with decrease LVEF, comparing with PPM. This study showed that the benefits from primary CRT were similar to the benefits from upgrading CRT, in terms of mortality reduction, HF hospitalizations, NYHA functional class improvement, CRT responders and mean LVEF improvement. Once again, just like in the most recent trials, this study demonstrates the clear benefit of upgrading from a PPM to CRT in patients with decreased LVEF.

Predictors of responders to cardiac resynchronization therapy in patients with non-left bundle branch block with mid-wide QRS duration

Abstract Background Cardiac resynchronization therapy (CRT) is useful for patients with severe heart failure with dyssynchrony of left ventricular contraction, significantly reducing total mortality or heart failure rehospitalization. In patient with left bundle branch block (LBBB) or QRS duration (QRSd) ≥ 150 ms, CRT is a well-established therapy at guidelines in Japan and other countries. However, CRT may be more useful and effective in Asian patients with middle range wide QRSd, because of smaller body size than in the West. Few reports have shown the usefulness and efficacy of CRT in patients with non-LBBB and middle range wide QRS duration (mid-wide QRSd). Purpose To evaluate the predictors of CRT responders in heart failure patients with non LBBB and mid wide QRSd. Methods We retrospectively studied 174 consecutive patients who underwent a denovo CRT device implantation at two institutions between September 2013 and March 2023. Follow up echocardiography examination could be performed after 150 days postoperatively. CRT responders were defined as a decrease in left ventricular end systolic volume ≥15% on echocardiography. We plotted thereceiver operating characteristic (ROC) curve for predicting CRT responders. The area under the curve (AUC) was calculated to determine the best cut off value. Results A total of 34 patients with non LBBB and 120≤ QRSd <150 ms were enrolled in this study. Sixteen of 34 (47%) patients were the responders for CRT. There was no significant difference in gender between the responder and non responder groups (p=0.274). Non ischemic cardiomyopathy was more prevalent in the responder group (p=0.046). The ROC curve analysis confirmed that 0.809 was the better optimal cut off value of QRSd/left ventricular end diastolic volume (LVEDV) for predicting CRT responders (AUC = 0.688). The multivariate analysis demonstrated that QRSd/LVEDV was significantly associated with CRT responders [odds ratio (OR) 9.88, 95% confidence interval 1.51 64.90, p = 0.017]. Conclusion The corrected QRSd for heart size using LVEDV could be the independent predictor of CRT responders in Japanese patients with non LBBB and mid wide QRSd.

Abstract 16146: A Scoping Review of Adverse Outcomes Associated With Cardiac Resynchronization Therapy Device Implantation: Implications for Informed Consent

Background/Objectives: Cardiac Resynchronization Therapy (CRT) is a treatment option for many adults with heart failure with reduced ejection fraction (HFrEF). While the benefits of CRT are well-established, the downstream implications of adverse events are not well-characterized. We sought to better understand the ramifications of CRT-related adverse events on length of hospital stay (LOS) and mortality—information relevant for patients and clinicians to make informed decisions about pursuing CRT. Design: Scoping Review Methods: We conducted an initial PubMed search using terms including “Congestive Heart Failure” or “Heart Failure” and "Cardiac resynchronization" or "Cardiac re-synchronization" or "Biventricular pacing.” We reviewed resulting articles that were written in English, studied CRT devices, and outlined adverse events related to CRT device placement. We separately searched PubMed for additional articles outlining individual adverse events identified using search terms “event name,” “mortality,” and “hospital stay.” We read articles and summarized data regarding the impact of reported adverse events on hospital LOS and mortality. Results: Our search identified 18 full length articles with relevant data. The most common adverse events included device implant failure/non-response, lead dislodgment, coronary sinus dissection, and pocket hematoma. The LOS and mortality rates of each event are shown in Table 1. Of note, LOS for implantation in the ambulatory setting is up to 1 day; LOS for uncomplicated implantation during hospitalization is 4.6 days. Implantation during hospitalization with complication is mean 13.6 days. Conclusion: While absolute risks for adverse events associated with CRT implantation are low, several have important implications on hospital LOS and mortality. These findings warrant inclusion in discussion regarding the risks of CRT when clinicians and patients engage in informed decision making related to CRT.

Implications of ventricular arrhythmia after cardiac resynchronization therapy

Conflicting data are available on whether ventricular arrhythmia (VA) or shock therapy increases mortality. Although cardiac resynchronization therapy (CRT) reduces the risk of VA, little is known about the prognostic value of VA among patients with CRT devices. The purpose of this study was to evaluate the implications of VA as a prognostic marker for CRT. We investigated 330 CRT patients within 1 year after CRT device implantation. The primary endpoint was the composite endpoint of all-cause death or hospitalization for heart failure. Forty-three patients had VA events. These patients had a significantly higher risk of the primary endpoint, even among CRT responders (P = .009). Fast VA compared to slow VA was associated with an increased risk of the primary endpoint (hazard ratio [HR] 2.14; 95% confidence interval [CI] 1.06-4.34; P = .035). Shock therapy was not associated with a primary endpoint (shock therapy vs antitachycardia pacing: HR 1.49; 95% CI 0.73-3.03; P = .269). The patients with VA had a lower prevalence of response to CRT (23 [53%] vs 202 [70%]; P = .031) and longer left ventricular paced conduction time (174 ± 23 ms vs 143 ± 36 ms; P = .003) than the patients without VA. VA occurrence within 1 year was related to paced electrical delay and poor response to CRT. VA could be associated with poor prognosis among CRT patients.

Electrocardiographic Predictors of Complete Heart Block During Right Ventricular Lead Implantation in Patients Who Underwent Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT) device procedures have their own complications in addition to the complications associated with standard pacemaker implantations. This study aimed to analyze the predictors of the right bundle branch injury resulting in complete heart block (CHB) during right ventricular (RV) lead implantation in patients who underwent CRT with defibrillator. We conducted an observational study of consecutive 790 patients who underwent CRT with defibrillator device implantation at our institution from 2010 to 2022. Relevant clinical information and complete data regarding the echocardiographic data, implantation procedure, and clinical follow-up were collected into a computerized database. A total of 29 patients (3.7%) had CHB during RV lead implantation. In multivariate analysis, left axis deviation (odds ratio [OR] 2.408, 95% confidence interval [CI] 1.025 to 5.658, p=0.044), QRS width (OR 1.022, 95% CI 1.001 to 1.043, p=0.035) and QRS alternans (OR 4.214, 95% CI 1.788 to 9.930, p=0.001) were found independently related to right bundle branch injury resulting in CHB development during RV lead implantation. In conclusion, left axis deviation, QRS width, and QRS alternans were associated with a higher rate of CHB, and these findings provide insight into optimal and safe CRT device implantation strategies based on preprocedural characteristics.

Significance of effective cardiac resynchronization therapy pacing for clinical responses: An analysis based on the effective cardiac resynchronization therapy algorithm

High percent ventricular pacing maximizes cardiac resynchronization therapy (CRT) response. An effective CRT algorithm classifies each left ventricular (LV) pace as effective or ineffective on the basis of the detection of QS or QS-r morphology on the electrogram; however, the relationship between percent effective CRT pacing (%e-CRT) and responses is unclear. We aimed to clarify the association between %e-CRT and clinical outcomes. Of the 136 consecutive CRT patients, 49 using the adaptive and effective CRT algorithm with percent ventricular pacing > 90% were evaluated. The primary and secondary outcomes were heart failure (HF) hospitalization and prevalence of CRT responders, defined as patients with an improvement in LV ejection fraction of ≥10% or a reduction in LV end-systolic volume of ≥15% after CRT device implantation, respectively. We divided the patients into the effective group (n = 25) and the less effective group (n = 24) by the median value of %e-CRT (97.4%). During the median follow-up period of 507 days (interquartile range 335-730 days), the effective group had a significantly lower risk of HF hospitalization than did the less effective group as revealed by Kaplan-Meier analysis (log-rank, P = .016). Univariate analysis revealed %e-CRT ≥ 97.4% (hazard ratio 0.12; 95% confidence interval 0.01-0.95; P = .045) as a predictor of HF hospitalization. The effective group had a higher prevalence of CRT responders than did the less effective group (23 [92%] vs 9 [38%]; P < .001). Univariate analysis revealed that %e-CRT ≥ 97.4% (odds ratio 19.20; 95% confidence interval 3.63-101.00; P < .001) was a predictor of CRT response. High %e-CRT is associated with high CRT responder prevalence and low HF hospitalization risk.

Machine learning–powered, device-embedded heart sound measurement can optimize AV delay in patients with CRT

Continuous optimization of atrioventricular (AV) delay for cardiac resynchronization therapy (CRT) is mainly performed by electrical means. The purpose of this study was to develop an estimation model of cardiac function that uses a piezoelectric microphone embedded in a pulse generator to guide CRT optimization. Electrocardiogram, left ventricular pressure (LVP), and heart sounds were simultaneously collected during CRT device implantation procedures. A piezoelectric alarm transducer embedded in a modified CRT device facilitated recording of heart sounds in patients undergoing a pacing protocol with different AV delays. Machine learning (ML) was used to produce a decision-tree ensemble model capable of estimating absolute maximal LVP (LVPmax) and maximal rise of LVP (LVdP/dtmax) using 3 heart sound-based features. To gauge the applicability of ML in AV delay optimization, polynomial curves were fitted to measured and estimated values. In the data set of ∼30,000 heartbeats, ML indicated S1 amplitude, S2 amplitude, and S1 integral (S1 energy for LVdP/dtmax) as most prominent features for AV delay optimization. ML resulted in single-beat estimation precision for absolute values of LVPmax and LVdP/dtmax of 67% and 64%, respectively. For 20-30 beat averages, cross-correlation between measured and estimated LVPmax and LVdP/dtmax was 0.999 for both. The estimated optimal AV delays were not significantly different from those measured using invasive LVP (difference -5.6 ± 17.1 ms for LVPmax and +5.1 ± 6.7 ms for LVdP/dtmax). The difference in function at estimated and measured optimal AV delays was not statiscally significant (1± 3 mm Hg for LVPmax and 9 ± 57 mm Hg/s for LVdP/dtmax). Heart sound sensors embedded in a CRT device, powered by a ML algorithm, provide a reliable assessment of optimal AV delays and absolute LVPmax and LVdP/dtmax.

The impact of intravenous ferric carboxymaltose on reverse electrical remodeling following cardiac resynchronization therapy

Abstract Funding Acknowledgements Type of funding sources: None. Background The effect of intravenous ferric carboxymaltose (FCM) on reverse electrical remodeling (RER) in patients with heart failure with reduced ejection fraction (HFrEF) following cardiac resynchronization therapy (CRT) implantation is unknown. Purpose The current study aims to examine the effect of iron replacement with intravenous FCM on RER in CRT-implanted patients with HFrEF and iron deficiency. Methods The present study retrospectively analyzed 65 patients with successful CRT-D device implantation between March 2017 and January 2020 with iron deficiency (defined as ferritin &amp;lt;100 μg/L) at implantation. Follow-up data were obtained from the 6-month routine follow-up visits of patients following CRT implantation. Demographic characteristics, laboratory results, medical history, medication details, functional status, information on whether intravenous FCM therapy was administered during CRT device implantation, echocardiographic left ventricular (LV) measurements, baseline electrocardiogram (ECG) recorded before CRT device implantation, and follow-up ECG were collected for analysis for each study patient. From baseline to 6-month follow-up, the change in intrinsic QRS duration (without biventricular pacing) was calculated as a primary endpoint, and the change in LV ejection fraction (LVEF) was assessed as a secondary endpoint of the study. Results Thirty-five of 65 patients were in the FCM group, while the remaining 30 study participants were in the non-FCM. The two study groups were similar regarding baseline characteristics, except for ferritin levels, which were minimally significantly lower in the FCM group (10.7±5.0μg/L vs 13.5 ±3.9μg/L, p= 0.012). At the 6-month follow-up, both mean ferritin levels increased significantly in the FCM group compared to baseline (from 10.7±5.0 to 86.5±7.6μg/L, p &amp;lt; 0.0001), while these levels were not significantly increased in the non-FCM group (from 13.5±3.9 to 14.1±4.2μg/L, p = 0.962). There was a significant reduction in intrinsic QRS durations compared to baseline at 6-month follow-up after CRT implantation in both FCM and non-FCM group (from 148.4±5.3 to 138.0±5.1ms, p &amp;lt; 0.0001; from 149.8±5.0 to 146.8±4.6ms, p &amp;lt; 0.0001, respectively). The change in intrinsic QRS duration from baseline to 6-month follow-up was significantly greater in the FCM group than in the non-FCM group (-10.4±2.2ms vs -3±2.9ms, p &amp;lt; 0.0001). At the 6-month follow-up, the change in LVEF from baseline was significantly higher in the FCM group than in the non-FCM group (+3.6±1.6% vs -0.1±1.7%, p &amp;lt; 0.0001). The change in ferritin level was negatively correlated with the change in intrinsic QRS duration (r = -0.725, p &amp;lt; 0.0001), whereas there was a positive correlation between the change in ferritin level and the change in LVEF (r = 0.712, p &amp;lt; 0.0001). Conclusions Treatment with FCM was induced RER and improvement in LVEF in HFrEF patients with iron deficiency following CRT implantation.

Prognostic value of nutritional status in post-implant CRT outcomes in patients with chronic heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Introduction There’s a close relationship between chronic heart failure (CHF) and malnutrition, and their main pathophysiological modifications are well known. Cardiac resynchronization therapy (CRT) has proven to be a promising therapy in symptomatic heart failure (HF) patients with broad QRS complexes and impaired systolic function with optimized medical therapy. However, there is still a considerable amount of non-responder patients. The role of nutritional status in CRT therapy response has yet still not been well assessed. Purpose Assess the prognostic value of nutritional status in post-op outcomes in patients with Chronic Heart Failure and (CRT) Methods Single-center retrospective study of patients submitted to CRT implantation between January 2007 and march 2021. Inclusion criteria were patients meeting criteria for CRT implantation, QRS duration ≥ 120ms, FEVE ≤ 35%, NYHA class II–IV and no adverse events during the follow up. Primary outcomes measured were all-cause mortality, cardiovascular mortality, and hospitalizations due to HF in a 1-year follow-up. To evaluate patient's nutritional status the CONUT score was used with patients being categorized in 2 groups: Low CONUT (Score 0-4: normal/low malnutrition) and Hight CONUT (Score 5-12: moderate/severe malnutrition). Results 198 patients (83%) exhibited Low CONUT status, and 41 patients (17%) exhibited High CONUT status. Patients with Hight CONUT were older (72.9 yrs vs 65.9 yrs, p&amp;lt;0.001), and exhibited higher percentage of chronic obstructive pulmonary disease (43.9% vs 27.3%, p=0.004), atrial fibrillation (72.9%, vs 25.3%, p&amp;lt;0.001), hypertension (78.1% vs 60.6%, p=0.038), chronic kidney disease (39.1% vs 21.2%, p=0.016) and NYHA IV (19.5% vs 5.1%, p&amp;lt;0.001). Cardiovascular mortality was 3.7% in the low CONUT group vs 29.3% in the Hight CONUT group (p&amp;lt;0.001; HR, 0.12; 95% CI, 0.05-0.29) and total HF hospitalizations were 16 and43, respectively (p=0.013; HR, 0.482, 95% CI, 0.27 to 0.86). The nutritional status prior to CRT assessed by the CONUT score showed to be an independent predictor of cardiovascular mortality (p=0.007; HR, 0.16 95% CI, 0.04-0,60). Conclusion Malnutrition was a common condition in our CRT patients showing that deficient nutrition status remains highly underdiagnosed. Patients with worse nutritional status before CRT device implantation presented higher morbidity and were more prone to worst outcomes such as cardiovascular mortality and mortality by all causes as well as higher incidence of hospitalizations secondary to HF decompensation. Assessment of nutritional status using screening tools may provide additional prognostic information in patients with HF and help early identification of those who may benefit from further assessment and nutritional intervention.

Spontaneous QRS complex narrowing predicts left ventricle reverse remodeling in CRT patients

Mechanical cardiac dyssynchrony is an important component of cardiac remodeling during heart failure with reduced ejection fraction. Furthermore, echocardiographic assessment of left ventricle reverse remodelingrepresents the major tool to evaluate cardiac resynchronization therapy (CRT) response. In contrast, according to major randomized trialsmechanical dyssynchrony assessment failed and electrocardiographic proof of dyssynchrony is needed to indicate CRT, therefore; electrical reverse remodeling was suggested by few clinical studies conducted with a small number of patients. Additional information is required on the relationship between electrical (ERR) and structural reverse remodeling (SRR) in patients treated with cardiac resynchronization therapy. We investigated whether ERR defined as narrowing of the native electrocardiographic QRS duration after CRT might predict improvement in echocardiographic outcome. We collected 75 patients who underwent successful CRT device implantation in our department. Clinical, electrocardiographic and echocardiographic parameters were collected before implantation and after a variable duration of follow up in the outpatient clinic. SRR was defined as an improvement of LVEF > 5% and/or a reduction in LVESV > 15%. ERR was defined as a decrease in native QRS duration > 10 milliseconds (was recorded after switching off biventricular pacing). After a mean follow up duration of 69 months from the time of implantation, 51 patients had an echocardiographic response (SRR) and among 45 patients who had demonstrated an electrocardiographic response (ERR), 75% developed SRR (vs. 55% for those without ERR P = 0.07) and only 7.5% of them were ischemic cardiomyopathy. Mean QRS reduction was at 16 milliseconds in patients with SRR versus 8 milliseconds in patients without SRR (P = 0.02). Reversal electric remodeling as assessed by native QRS narrowing was associated with greater improvements in mean LVEF (16% vs. 10%, P = 0.1), mean LVEDV (85 mL vs. 35 mL, P = 0.04) and mean LVESV (77 mL vs. 37 mL, P = 0.1). Native QRS narrowing after initiation of CRT in patients with HFrEF was positively correlated tostructural reverse remodeling parameters assessed by echocardiography and consequently to the echocardiographic outcome.

PO-05-055 A META-ANALYTIC COMPARISON OF OUTCOMES OF LEFT BUNDLE BRANCH AREA PACING (LBBP) VERSUS BI-VENTRICULAR PACING FOR CARDIAC RESYNCHRONIZATION THERAPY

Left bundle branch area pacing (LBBP), has emerged as a novel method to deliver cardiac resynchronization therapy (CRT), as an alternative to biventricular pacing (BVP). We aimed to evaluate the outcomes of LBBP as an alternative to BVP as a method of CRT. We aimed to evaluate the outcomes of LBBP as an alternative to BVP as a method of CRT. A systematic literature-based search was performed on various electronic databases, i.e., PubMed, Embase, Scopus, and Cochrane libraries, for studies that compared LBBP with BVP. The primary outcomes that were studied were changes in left ventricular end-diastolic diameter (LVEDD), New York Heart Association (NYHA) classification, left ventricular ejection fraction (LVEF) and paced QRS duration post CRT device implantation. Six articles (1 randomized trial and five observational studies) with a total of 399 patients (42% with LBBP as CRT) were included in the final analysis. A pooled random-effects analysis of the primary outcomes revealed that patients who underwent LBBP had a significantly greater reduction in left ventricular end-diastolic diameter [Mean Difference (MD) 0.40 (95% Confidence Interval (CI), 0.17-0.63); p < 0.001] and paced QRS duration [MD 1.03 (95% CI, 0.63-1.43); p < 0.001] as compared to the BVP group. There was also a significantly greater improvement in NYHA class [MD 0.64 (95% CI, 0.33-0.96); p < 0.001] and the LVEF [MD 0.83 (95% CI, 0.33-1.33); p < 0.001] in the LBBP group. (Figure 1 with the forest plots) LBBP has the potential to improve clinical outcomes over conventional BVP in patients undergoing CRT. This finding should be further confirmed by randomized trials with a larger sample size and well-defined outcome measures and feasibility indicators. Although limited by the observational nature of the included studies, our meta-analysis sets the stage towards the consideration of LBBP in patients who meet the indications for CRT.

Impact of Q wave in synthesized V7–9 lead on long-term outcomes after cardiac resynchronization therapy

BackgroundTo investigate the relationship between the Q wave in synthesized V7–9 leads of a baseline electrocardiogram and clinical outcomes in patients with heart failure after cardiac resynchronization therapy (CRT) device implantation. MethodsConsecutive patients with heart failure and a left ventricular (LV) ejection fraction <35 % were retrospectively analyzed. Patients with Q waves in the synthesized V7–9 lead were defined as the qV7–9 group and those without Q waves in the synthesized V7–9 lead were defined as the non-qV7–9 group. Multivariate analysis was performed to compare all-cause mortality and incidence of hospitalization for heart failure between the two groups. ResultsWe included 108 eligible patients. Twenty-nine patients were classified into the qV7–9 group and 79 patients were classified into the non-qV7–9 group. There were 22 patients (20 %) with ischemic etiology, 67 (62 %) with New York Heart Association functional class II or III heart failure, and 91 (84 %) with a defibrillator. The presence of Q waves in the synthesized V7–9 lead was significantly associated with worse outcomes, even with optimal medical treatment (adjusted hazard ratio, 2.1; 95 % confidence interval, 1.16–3.72; p = 0.03). ConclusionIn patients with heart failure and an LV ejection fraction of <35 %, the presence of Q waves in the synthetic V7–9 lead was associated with increased all-cause mortality and incidence of hospitalization after CRT device implantation.

Trends in the Use and Complications of Cardiac Resynchronization Therapy Device Implantation in Chronic Kidney Disease Patients.

Large-scale multi-hospital data on cardiac resynchronization therapy (CRT) device implantation in patients with chronic kidney disease (CKD) are currently lacking. The purpose of this study was to examine the incidence of CRT device implantation in patients hospitalized with CKD and the impact of CRT device implantation on hospital complications and outcomes. We analyzed the Nationwide Inpatient Sample from 2008-2014 to identify yearly trends in CRT device implantation during CKD hospitalizations. We compared CRT biventricular pacemakers (CRT-Ps) and CRT defibrillators (CRT-Ds). We also obtained rates of comorbidities and complications associated with CRT device implantations. From 2008-2014, the proportion of hospitalized patients with a concurrent diagnosis of CKD receiving CRT-P devices consistently went up from 2008 to 2014 (from 12.3% to 23.8%, P < .0001) compared to the number of hospitalized patients with a concurrent diagnosis of CKD receiving CRT-D devices, which showed a consistent downward trend (from 87.7% to 76.2%, P < .0001). During CKD hospitalizations, most CRT device implantations were performed in patients aged 65-84 years (68.6%) and in men (74.3%). The most common complication of CRT device implantation during hospitalizations involving CKD was hemorrhage or hematoma (2.7%). Patients hospitalized with CKD who developed any complication associated with CRT device implantation had 3.35-fold increased odds of mortality compared to those without complications (odds ratio, 3.35; 95% confidence interval, 2.18-5.16; P < .0001). In summary, this study shows that CRT-P implantations became more common in CKD patients, while the rate of CRT-D implantations decreased over time. Hemorrhage or hematoma was the most common complication (2.7%), and the mortality risk was increased by 3.35 times in patients who developed periprocedural complications.

Proarrhythmic effect of bipolar epicardial left ventricular stimulation in CRT resolved maintaining biventricular pacing with unipolar-cathodical configuration: A peculiar case report.

The effect of cardiac resynchronization therapy (CRT) on the risk of ventricular arrhythmias is controversial. Several studies reported a decreased risk, but some studies reported a potential proarrhythmic effect of epicardial left ventricular pacing resolved upon discontinuation of biventricular pacing (BiVp). A 67-year-old woman with a history of heart failure due to nonischemic cardiomyopathy and left bundle branch block was hospitalized for CRT device implantation. Unpredictably, as soon as the leads have been connected to the generator, an electrical storm (ES) occurred with relapsing self-resolving polymorphic ventricular tachycardia (PVT) triggered by ventricular extra beats with short-long-short sequences. The ES was resolved without interrupting BiVp switching to unipolar left ventricular (LV) pacing. This allowed to keep CRT active with extreme clinical benefit for the patient and to demonstrate that the cause of the PVT was the anodic capture of bipolar LV stimulation. Reverse electrical remodeling was also demonstrated after 3 months of effective BiVp. Proarrhythmic effect of CRT is a rare but significant complication of CRT, and it may compel to discontinuation of the BiVp. The reversal of the physiological transmural activation sequence of epicardial LV pacing and subsequent prolonging of corrected QT interval have been speculated as the most probable explanation, but our case highlights the possibility that the anodic capture may play a relevant role in PVT genesis.

Right ventricular cardiac resynchronization therapy in patients with right ventricular conduction delay and heart failure

Right ventricular cardiac resynchronization therapy in patients with right ventricular conduction delay and heart failure

Long-term results of patients implanted with CRT: Single centre experience

Cardiac resynchronization therapy (CRT) is an established therapeutic option in selected heart failure patients. Data on its pronounced long-term outcome are scarce. To assess clinical outcomes of CRT and cardiac events over the long term. We conducted a retrospective study of all CRT device implantations from March 2009 to March 2021 at university heart center Algiers. Baseline characteristics, improvement in NYHA class, changes in left ventricular ejection fraction (LVEF), CRT procedural complications and post CRT device implantations cardiac events were assessed. A total of 198 patients with a median age of 60 years were included, sixty four percent were male, 84.85% had non ischemic cardiomyopathy whose 18.18% had post-surgical valvular cardiomyopathy, and 71.72% were in sinus rhythm whereas 26.77% were in atrial fibrillation. 89.39% had a bundle branch block, 12.63% had an atrio-ventricular block and 5.55% had a pacemaker. The mean LVEF was 28.2% ± 5.886. Mostly of the patients (60.61%) had received a CRTP. Procedural complications occurred in 32 pts (16%) (8 coronary sinus dissections, 14 lead dislodgements, 3 phrenic stimulation and 7 infections). During a mean follow up of 4 years, 45 pts died (22.73%), 31 pts were hospitalized for acute decompensated heart failure (15.66%). An improvement in dyspnea was reported in 81.31%. An improvement of LVEF was reported in 76.26% and 21.72% had normalized their LVEF. The ischemic cardiomyopathy was independent predictor of non-response to CRT (OR, 5.95; 95% CI, 2.16–16.37; P = 0.0005). Selected patients who survive for at least 4 years experience sustained improvement in LVEF and NYHA-class.

Effect of Li's catheter in the cardiac resynchronization therapy implantation

Objective: To evaluate the effect of Li's catheter in cardiac resynchronization therapy (CRT) implantation. Methods: This study was a retrospective cohort study. Patients with indications for CRT implantation who visited the Department of Cardiology, Peking University People's Hospital from January 1, 2016 to January 1, 2022 were enrolled. Patients were divided into Li's catheter group (CRT implantation with Li's catheter) and control group (CRT implantation with the traditional method). The general clinical data of the patients were obtained through the electronic medical record system. Li's catheter is a new type of coronary sinus angiography balloon catheter independently developed by Dr. Li Xuebin (patent number: 201320413174.1). The primary outcome was the success rate of CRT device implantation, and the secondary outcomes included efficacy and safety parameters. Efficacy indicators included operation time, coronary sinus angiography time, left ventricular lead implantation time, X-ray exposure time, left ventricular lead threshold, and diaphragm stimulation. Safety outcomes included incidence of coronary sinus dissection, cardiac tamponade, and pericardial effusion. Results: A total of 170 patients were enrolled in this study, including 90 in Li's catheter group and 80 in control group. Age, male proportion of patients, proportion of patients with ischemic cardiomyopathy, hypertension, diabetes mellitus, chronic renal insufficiency, New York Heart Association (NYHA) functional classification, left ventricular ejection fraction, left ventricular end-diastolic diameter, proportion of left bundle branch block, and preoperative QRS wave width were similar between the two groups (all P>0.05). In Li's catheter group, 34 cases (37.8%) implanted with CRT defibrillators, and 28 cases (35.0%) implanted with CRT defibrillators in control group, the difference was not statistically significant (P=0.710). The success rate of CRT device implantation in Li's catheter group was 100% (90/90), which was significantly higher than that in control group (93.8%, 75/80, P=0.023).The operation time was 57.0 (52.0, 62.3) minutes, the time to complete coronary sinus angiography was 8.0 (6.0, 9.0) minutes, and the time of left ventricular electrode implantation was 8.0 (7.0, 9.0) minutes in Li's catheter group, and was 91.3 (86.3, 97.0), 18.0 (16.0, 20.0), 25.0 (22.0, 27.7) minutes respectively in control group, all significantly shorter in Li's catheter group (all P<0.05). The exposure time of X-ray was 15.0 (14.0, 17.0) minutes in Li's catheter group, which was also significantly shorter than that in control group (32.5 (29.0, 36.0) minutes, P<0.001). There was no coronary sinus dissection and cardiac tamponade in Li's catheter group, and 1 patient (1.1%) had diaphragmatic stimulation in Li's catheter group. In control group, 6 patients (6.7%) had coronary sinus dissection, and 1 patient (1.1%) developed pericardial effusion, and 3 patients (3.3%) had diaphragmatic stimulation. The incidence of coronary sinus dissection in Li's catheter group was significantly lower than that in control group (P=0.011). The postoperative left ventricular thresholds in Li's catheter group and control group were similar (1.80 (1.60, 2.38) V/0.5 ms vs. 1.80 (1.60, 2.40) V/0.5 ms, P=0.120). Conclusions: Use of Li's catheter is associated with higher success rate of CRT implantation, short time of coronary sinus angiography and left ventricular electrode implantation, reduction of intraoperative X-ray exposure, and lower incidence of coronary vein dissection in this patient cohort.

Usefulness of Decapolar catheter via femoral approach on CS cannulation during CRT device implantation.

IntroductionCardiac resynchronization therapy (CRT) device insertion comprises of a transvenous pacing lead implanted in posterolateral branch of the coronary sinus (CS) for left ventricular (LV) pacing, in addition to leads in the right ventricle and right atrium. In patients undergoing CRT device implantation, failure of CS cannulation was earlier reported to be around 10% but has come down to about 4% in recent years. Although the use of electrophysiology (EP) catheter has been reported during CRT procedures but femoral approach to place decapolar catheter as fluoroscopic guide for CS ostium cannulation during LV lead implantation has not been evaluated.Materials and methodsThe aim of the study was to compare fluoroscopy time during CRT procedure between conventional technique and using decapolar EP catheter via femoral approach as fluoroscopic marker to cannulate CS.ResultsThis study included 21 patients. Group 1 (using decapolar catheter) had 12 patients and group 2 (using the conventional technique) had 9 patients. CS cannulation was successful in all 21 cases. The mean fluoroscopy time for the CS cannulation and LV lead placement in group 1 was 10.7 (±1.03) min and in group 2 was 19.1 (±1.51) min. This difference in mean fluoroscopy time for the CS cannulation and LV lead placement was statistically significant with p < .05.ConclusionThis study highlights the usefulness of decapolar catheter via femoral approach as a fluoroscopic guide for CS cannulation during CRT device implantation. The decreased fluoroscopic time results in decreased radiation exposure to not only the patient but also to the operator.