Reduction In Left Ventricular End-systolic Volume Research Articles

Dispersion of repolarization increases after cardiac resynchronization therapy in patients who do not undergo left ventricular reverse remodelling

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Wellcome/EPSRC Centre for Medical Engineering CardioInsight Inc. Background The effect of CRT on dispersion of repolarization and arrhythmic risk is unclear. LV epicardial pacing has been associated with increased dispersion of repolarization, which may be due to altered activation and repolarization sequence. However, while CRT-induced ventricular arrhythmias have been reported, evidence from large clinical trials suggest CRT has a favourable effect on arrhythmic risk, with a lower incidence of arrhythmia in patients who undergo LV reverse remodelling. Purpose To investigate the effect of CRT and LV reverse remodelling on dispersion of repolarization using electrocardiographic imaging (ECGi). Methods 11 patients with heart failure and electrical dyssynchrony underwent ECGi after CRT implant and again at 6 months. Reconstructed epicardial electrograms were used to create maps of activation recovery intervals (ARI), an accepted surrogate for action potential duration, which were corrected for heart rate. LV ARI dispersion was calculated as the standard deviation of ARI across the LV epicardium. The methodology is summarized in figure 1. Results Mean age at implant was 74±10 years and 82% of patients were male. 64% had ischaemic aetiology of heart failure, and mean LV ejection fraction was 29±10%. 64% of patients had underlying LBBB, 28% had an RV-paced rhythm and 9% had RBBB. 8 patients had a ≥15% reduction in LV end-systolic volume (LVESV) with CRT at 6 months (volumetric responders). Example ARI maps for 1 patient are shown in figure 2A. There was a significant increase in LV ARI dispersion at 6 months compared to baseline (36.4±7.2ms vs 28.2±7.7ms; P=0.03) [Fig 2B]. In a multiple linear regression analysis, volumetric response was an independent predictor of relative change in LV ARI dispersion from baseline to 6 months (P=0.04). In a sub-analysis, for volumetric responders there was no significant difference in LV ARI dispersion between baseline and CRT at 6 months (36.4 ±6.1 vs 30.1±7.8 ms; P=0.1). In comparison, in volumetric non-responders there was a significant increase in LV ARI dispersion (38.3±1.2 vs 22.6±2.6 ms; P=0.01). The relative change in LV ARI dispersion from baseline to CRT 6-months was greater for volumetric non-responders compared to volumetric responders (70.7 ±21.3% vs 27.0 ±35.4%; P=0.04) [Fig 2C]. There was a moderate negative correlation between relative change in LV ARI dispersion and relative reduction in LVESV (R=-0.5), however this did not meet statistical significance (P=0.12) [Fig 2D]. Conclusion CRT increases dispersion of repolarization at 6 months. However, this potentially arrhythmogenic effect of epicardial pacing was only observed in CRT non-responders, which is in keeping with previous evidence that LV reverse remodelling reduces risk of ventricular arrhythmia.

Real-time image-guided lead placement in cardiac resynchronisation therapy: feasibility and outcome in a multicentre setting

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Image-guidance to assist left ventricular (LV) lead placement may improve outcome after cardiac resynchronisation therapy (CRT). Because previous approaches and results varied greatly, the optimal strategy remains unknown. To date, only a few studies investigated ‘real-time’ guidance, and feasibility in a multicentre setting is lacking altogether. Methods In 30 patients from three hospitals, cardiac magnetic resonance imaging (MRI) was performed to identify myocardial scar and late mechanical activation (LMA). LMA was determined using radial strain, plotted over time. Segments without scar but clear LMA were classified as optimal, according to an accurate 36-segment model. LV-lead deployment was guided, in real-time, using live image-overlay with fluoroscopy. After 6 months, volumetric response was defined as ≥15% reduction in LV end-systolic volume (∆LVESV). Reduction in log-transformed N-terminal pro-brain natriuretic peptide (NT-proBNP) was assessed at 2 months. Results Real-time image-guidance was successful performed in all CRT patients (age 66±10 years; 59% male, 72% non-ischemic cardiomyopathy; 69% left bundle branch block). LV-leads were deployed as follows: within (24%), adjacent (52%), or remote (24%) from the pre-defined target. According to the traditional 18-segment model, a remote position occurred only once. On average, 86% of patients demonstrated a volumetric response (mean ∆LVESV 36±29%). In addition, lead placement was association with reduction in log-transformed NT-proBNP (Figure 1). Conclusion Real-time image-guidance towards a pre-defined target for LV-lead placement was feasible in a multicentre setting, and has promising clinical results. Efficacy will be further investigated in the randomised controlled ‘Advanced Image Supported Lead Placement in Cardiac Resynchronization Therapy’ trial.

Explainable deep learning outperforms guideline criteria and QRSarea for prediction of outcome after cardiac resynchronization therapy

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Organisation for Health Research and Development (ZonMw) Background Electrocardiogram-based prediction models for cardiac resynchronization therapy (CRT) response mainly focus on the QRS complex, but other information in the electrocardiogram (ECG) is neglected. Purpose We sought to identify and visualize ECG features using an explainable deep learning-based algorithm (FactorECG) to predict CRT outcome and echocardiographic response, and compare this to state-of-the-art parameters, including QRSarea. Methods Patients who underwent CRT implantation in three academic hospitals were analyzed for clinical outcome (death, left ventricular assist device implantation, or heart transplantation), and echocardiographic response (≥ 15% left ventricular end-systolic volume reduction at 6 months). Pre-implantation ECGs were converted into their respective FactorECG. By using a deep learning algorithm trained on 1.1 million ECGs, a compressed version of the median beat ECG was obtained, where all ECG features are summarized in only 21 explainable factors of variation (interactive tool: https://decoder.ecgx.ai). The 21 FactorECG values per patient were used in a Cox and logistic regression model, for outcome and response, respectively. Models were trained on data from two hospitals (n = 936 for outcome and n = 591 for response) and externally validated in a third hospital (n = 339 for outcome and n = 230 for response). Furthermore, ESC CRT guideline indications and vectorcardiographic QRSarea were used as a comparison. Results The deep learning-based approach was able to predict clinical outcome (AUC = 0.74 [95% confidence interval (CI) 0.69 - 0.80]) and echocardiographic response (AUC = 0.70 [95% CI 0.63 - 0.77]). Moreover, it significantly outperformed a model based on the ESC CRT guidelines for outcome (AUC = 0.57 [95% CI 0.50-0.63]) and response (AUC = 0.57 [95% CI 0.51 - 0.64]). In comparison with QRSarea, the deep learning-based approach performed significantly better for outcome (AUC = 0.61 [95% CI 0.53-0.69], but similar for response (AUC = 0.70 [95% CI 0.64-0.77]. Based on QRSarea and predicted probabilities of the deep learning approach, for both outcome at three years and response, four groups of similar size were identified and compared to the ESC CRT guidelines (Figure 1). Important ECG factors for poor response and clinical outcome were identified as anterior T-wave inversion (F9), increased heart rate (F10), non-LBBB morphology (F26) and increased PR-interval (F8, Figure 2). Conclusion Without compromising interpretability, the deep learning-based algorithm objectively identified CRT recipients with good clinical outcome and echocardiographic response. This approach outperformed QRSarea for outcome, and QRS morphology and duration as used in the ESC CRT guidelines for both outcome and echocardiographic response. Hence, most predictive information for CRT response is found within the QRS complex, whereas the complete median beat ECG provides additional predictive information for clinical outcome.

Vascular conditioning prevents adverse left ventricular remodelling after acute myocardial infarction: a randomised remote conditioning study

Abstract Funding Acknowledgements Type of funding sources: Other. Main funding source(s): EU-CARDIOPROTECTION COST ACTION (European Cooperation in Science and Technology-Action) (CA16225) Background Remote ischemic conditioning (RIC) alleviates ischemia-reperfusion injury via several pathways, including micro-RNAs (miRs) expression and oxidative stress modulation. Purpose We investigated the effects of RIC on endothelial glycocalyx, arterial stiffness, LV remodelling, and the underlying mediators within the vasculature as a target for protection. Methods We block-randomised 270 patients within 48 h of STEMI post-PCI to either one or two cycles of bilateral brachial cuff inflation, and a control group without RIC. We measured: (a) the perfusion boundary region (PBR) of the sublingual arterial microvessels to assess glycocalyx integrity and (b) the carotid-femoral pulse wave velocity (PWV) at baseline (T0), following every RIC cycle (T1, T2), and 40 min after RIC onset (T3); (c) miR-144, -150, -21, -208, nitrate-nitrite (NOx) and malondialdehyde (MDA) plasma levels at baseline (T0) and 40 min after RIC onset (T3); and (d) LV volumes at baseline and after one year. Results Compared to baseline, there was a greater PBR and PWV decrease, miR-144 and NOx levels increase (p < 0.05) at T3 following single- than double-cycle inflation (PBR:ΔT0-T3 = 0.249 ± 0.033 vs 0.126 ± 0.034 μm, p = 0.03 and PWV:0.4 ± 0.21 vs -1.02 ± 0.24 m/s, p = 0.03). Increased miR-150,-21,-208 (p < 0.05) and reduced MDA was observed after both protocols. Increased miR-144 was related to PWV reduction (r = 0.763, p < 0.001) after the first-cycle inflation in both protocols. After one year, single-cycle RIC was associated with LV end-systolic volume reduction (LVESV) > 15% (odds-ratio of 3.75, p = 0.029). MiR-144 and PWV changes post-RIC were interrelated and associated with LVESV reduction at follow-up (r = 0.40 and 0.37, p < 0.05), in the single-cycle RIC. Conclusions RIC evokes "vascular conditioning" likely by upregulation of cardio-protective microRNAs, NOx production, and oxidative stress reduction, facilitating reverse LV remodelling.

Orthodromic and Antidromic Snare Techniques for Left Ventricular Lead Implantation in Cardiac Resynchronization Therapy

The snare technique can be used to overcome unsuitable cardiac venous anatomies for left ventricular (LV) lead implantation in cardiac resynchronization therapy (CRT) procedures. However, limited data exist regarding performance of the snare technique. We classified 262 patients undergoing CRT procedure into the snare (n = 20) or conventional group (n = 242) according to the LV lead implantation method. We compared the safety, efficacy, and composite outcome (all-cause death and heart failure readmission) at 3 years post-implant between the snare and conventional groups. In the snare group, all LV leads were implanted safely using orthodromic (n = 15) or antidromic (n = 5) techniques, and no immediate complications occurred including vessel perforation, tamponade, and lead dislodgement. During follow-up, LV lead threshold and impedance remained stable without requiring lead revision in the snare group. There were no significant between-group differences regarding LV ejection fraction increase (12 ± 13% vs. 12 ± 13%, p = 0.929) and LV end-systolic volume reduction (18 ± 48% vs. 28 ± 31%, p = 0.501). Both groups exhibited comparable CRT-response rates (62.5% vs. 60.6%, p = 1.000). The risk of primary outcome was not significantly different between the two groups (25.9% vs. 30.9%, p = 0.817). In patients who failed conventional LV lead implantation for CRT, the snare technique could be a safe and effective solution to overcome difficult coronary venous anatomy.

Combined assessment of septal scar and septal flash by cardiac magnetic resonance identifies responders to cardiac resynchronization therapy

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): South-Eastern Norway Regional Health Authority. Research grants of the University of Leuven. Background Left ventricular (LV) scar, particularly in the lateral wall and septum, reduces response rate to cardiac resynchronization therapy (CRT), whereas a dyssynchronous LV contraction pattern (septal flash) suggests good response. Lateral wall scar abolishes septal flash. Therefore, a combined approach of septal scar and septal flash may characterize the myocardial substrate responsive to CRT. Cardiac magnetic resonance (CMR) may assess both scar and contraction pattern. Purpose The present study aimed to determine if combined assessment of septal scar and septal flash by CMR as single image modality identifies responders to CRT. Methods We investigated all CRT recipients with available CMR from a prospective, multicenter study (n = 136), with both ischemic and non-ischemic heart failure. Septal scar was assessed by late gadolinium enhancement (LGE) from a stack of short axis slices (n = 128) and septal flash determined visually on ordinary cine sequences (n = 136). CRT response was defined as ≥15% reduction in LV end-systolic volume by echocardiography at 6 months follow-up. We also assessed heart transplantation or death of any cause 39 ± 13 months after device implantation. Results In multivariate analysis including percentage septal scar (LGE), septal flash, QRS-duration and QRS-morphology, septal LGE and septal flash were the only independent predictors of CRT response (both p < 0.001). A combined approach of septal LGE and septal flash predicted CRT response with area under the curve 0.86 (95% confidence interval (CI): 0.78-0.94) and long-term survival without heart transplantation with hazard ratio 0.18 (95% CI: 0.05-0.61). A practical approach to selection of CRT candidates by septal LGE and septal flash is illustrated in the present figure. As shown, absence of septal LGE indicated excellent response rate (93%) to CRT independent of other parameters. When septal LGE was present, however, overall response rate was substantially lower (58%), but presence or absence of septal flash separated responders from non-responders with high accuracy. This sequential approach correctly classified 86% of patients. Importantly, the approach was equally accurate in patients with intermediate QRS duration (130-150ms), where 93% of patients were correctly classified. Conclusions Combined assessment of septal LGE and septal flash by CMR as single image modality identifies CRT responders with high accuracy and predicts long-term survival. Abstract Figure.

Junctional AV ablation in patients with atrial fibrillation undergoing cardiac resynchronization therapy (JAVA-CRT): results of a multicenter randomized clinical trial pilot program.

IntroductionCardiac resynchronization therapy (CRT) improves outcomes in sinus rhythm, but the data in atrial fibrillation (AF) is limited. Atrio-ventricular junctional ablation (AVJA) has been proposed as a remedy. The objective was to test if AVJA results in LV end-systolic volume (ESV) reduction ≥ 15% from baseline to 6 months.MethodsThe trial was a prospective multicenter randomized trial in 26 patients with permanent AF who were randomized 1:1 to CRT-D with or without AVJA.ResultsLVESV improved similarly by at least 15% in 5/10 (50%) in the CRT-D-only arm and in 6/12 (50%) in the AVJA + CRT-D arm (OR = 1.00 [0.14, 7.21], p = 1.00). In the CRT-D-only arm, the median 6-month improvement in LVEF was 9.2%, not different from the AVJA + CRT-D arm, 8.2%. When both groups were combined, a significant increase in LVEF was observed (25.4% at baseline vs 36.2% at 6 months, p = 0.002). NYHA class from baseline to 6 months for all patients combined improved 1 class in 15 of 24 (62.5%), whereas 9 remained in the same class and 0 degraded to a worse class.ConclusionIn patients with permanent AF, reduced LVEF, and broad QRS who were eligible for CRT, there was insufficient evidence that AVJA improved echocardiographic or clinical outcomes; the results should be interpreted in light of a smaller than planned sample size. CRT, however, seemed to be effective in the combined study cohort overall, suggesting that CRT can be reasonably deployed in patients with AF.Trial registrationClinicalTrials.gov Identifier: NCT02946853.

Impact of adaptive cardiac resynchronization therapy in patients with systolic heart failure: Beyond QRS duration and morphology

BackgroundMechanical and electrical restoration by cardiac resynchronization therapy (CRT) with adaptive pacing algorithm (aCRT) in heart failure patients with a moderately wide (120–149 ms) QRS has not been fully evaluated. The purpose of this study was to investigate the therapeutic effect of aCRT compared with conventional biventricular CRT (BiV-CRT) regardless of QRS morphology. MethodsSeventeen consecutive patients with a QRS ≥120 ms, regardless of morphology, underwent CRT device implantation with an aCRT pacing algorithm. Propensity score matched analysis was performed to evaluate the impact of aCRT on the improvement in mechanical and electrical parameters after CRT device implantation using historical controls (HC) from the clinical registry of BiV-CRT (START trial). ResultsLeft ventricular (LV) volume significantly decreased after CRT in all patients in both the aCRT and HC groups. The difference in relative reduction of LV end-systolic volume (LVESV) was not significantly different between the 2 arms. QRS shortening after CRT was significantly greater in the aCRT group than in the BiV-CRT group, and the difference was prominent in patients with a moderately wide QRS (120–149 ms). In patients with a moderately wide QRS, the relative reduction in LVESV [39 (29–47)% vs. 2 (−6–20)%, p = 0.04] and proportion of LV volume responders (90% vs. 38%, p = 0.04) were significantly greater in the aCRT group than in the HC group. The proportion of volume responders was not significantly different in patients with a wide QRS (≥150 ms). ConclusionsThe aCRT algorithm improved electrical and mechanical parameters in patients with a moderately wide QRS, regardless of QRS morphology.

Add-on Therapy With Sacubitril/Valsartan and Clinical Outcomes in CRT-D Nonresponder Patients.

:No data on the add-on sacubitril/valsartan (S/V) therapy among cardiac resynchronization therapy with a defibrillator (CRT-D) nonresponder patients are currently available in literature. We conducted a prospective observational study including 190 CRT-D nonresponder patients with symptomatic heart failure with reduced ejection fraction despite the optimal medical therapy from at least 1 year. The primary endpoint was the rate of additional responders (left ventricular end-systolic volume reduction >15%) at 12 months from the introduction of S/V therapy. At the end of the 12 months follow-up, 37 patients (19.5%) were deemed as “additional responders” to the combination use of CRT + S/V therapy. The only clinical predictor of additional response was a lower left ventricular ejection fraction [OR 0.881 (0.815–0.953), P = 0.002] at baseline. At 12 months follow-up, there were significant improvements in heart failure (HF) symptoms and functional status [New York Heart Association 2 (2–3) vs. 1 (1–2), P < 0.001; physical activity duration/day: 10 (8–12) vs. 13 (10–18) hours, P < 0.001]. Compared with the 12 months preceding S/V introduction, there were significant reductions in the rate of HF rehospitalization (35.5% vs. 19.5%, P < 0.001), in atrial tachycardia/atrial fibrillation burden [6.0 (5.0–8.0) % vs. 0 (0–2.0) %, P < 0.001] and in the proportions of patients experiencing ventricular arrhythmias (21.6% vs. 6.3%; P < 0.001). Our results indicate that S/V add-on therapy in CRT-D nonresponder patients is associated with 19.5% of additional responders, a reduction in HF symptoms and rehospitalizations, AF burden, and ventricular arrhythmias.

266 Deformation imaging by strain in chronic heart failure over sacubitril–valsartan: a multicentre echocardiographic registry (discover)—ARNI

Abstract Aims Sacubitril/valsartan have changed the treatment of heart failure with reduced ejection fraction (HFrEF), due to the positive effects morbidity and mortality partly mediated by left ventricular reverse remodelling (LVRR). The aim of this multicentre study was to identify echocardiographic predictors of LVRR after sacubitril/valsartan administration. Methods and results Patients with HFrEF requiring therapy with sacubitril/valsartan from 13 Italian centres were included. Echocardiographic indexes including speckle tracking echocardiography (STE) indexes were used to predict LVRR [defined as LV end-systolic volume reduction and ejection fraction (LVEF) improvement &amp;gt; 10% at follow-up] at 6 months follow-up as the primary endpoint. Changes in symptoms (NYHA class) and neurohormonal activations [N-terminal-pro-brain natriuretic peptide (NTproBNP)] were also evaluated as secondary endpoints. The final population (excluding patients with poor acoustic windows and missing data) consists of 341 patients [mean age: 65 ± 10 years; 18% female, median LVEF 30% (interquartile range: 25–34)]. At 6 months follow-up, 82 (24%) patients showed early complete response (LVRR and LVEF ≥35%), 55 (16%) early incomplete response (LVRR and LVEF &amp;lt;35%), 204 (60%) no response (no LVRR and LVEF &amp;lt;35%). Non-ischaemic etiology, a lower left atrial volume index and a higher global longitudinal strain were all independent predictors of LVRR at multivariable logistic analysis (all P &amp;lt; 0.01). LA strain was the best predictor of positive changes in NYHA class and NT-proBNP (all P &amp;lt; 0.05) (Figure 1). Conclusions STE parameters at baseline could be useful to predict LVRR and clinical response to sacubitril-valsartan, and thus could be used as a guide for treatment in patients with HFrEF.

Radial strain imaging-guided lead placement for improving response to cardiac resynchronization therapy in patients with ischaemic cardiomyopathy: the Raise CRT trial.

To evaluate the benefit of speckle tracking radial strain imaging (STRSI)-guided left ventricular (LV) lead (LVL) positioning in cardiac resynchronization therapy (CRT) in patients (pts) with ischaemic cardiomyopathy with CRT indication. We conducted a prospective randomized controlled trial. Patients were enrolled in nine centres with 2:1 randomization into two groups (guided vs. control). Patients underwent STRSI to identify the optimal LV position from six LV segments at midventricular level. Implantation via STRSI was attempted for recommended segment in the guided group only. Follow-up included echocardiography (6 months) and clinical evaluation (6 and 12 months). The primary endpoint was comparison % reduction in LV end-systolic volume at 6 months with baseline. Secondary endpoints included hospitalizations for heart failure and death, and improvement in additional echocardiographic measurements and quality of life score. A total of 172 patients (115 guided vs. 57 control) were enrolled. In the guided group, 60% of the implanted LV leads were adjudicated to be successfully located at the recommended segment, whereas in the control group 44% reached the best STRSI determined segment. There was no difference between the groups in any of the primary or secondary endpoints at 6 and 12 months. Our findings suggest that echo-guided implantation of an LV lead using STRSI does not improve the clinical or echocardiographic response compared with conventional implantation.

Evaluation of the relationship between anti-inflammatory cytokines and adverse cardiac remodeling after myocardial infarction.

Aim To clarify the role of interleukin (IL) - 10 and members of its subfamily (IL-19 and IL-26) in cardiac remodeling during the post-myocardial infarction (MI) period.Material and methods A total of 45 patients with ST-segment elevation MI were enrolled. Serum cytokine concentrations were measured at the first day and 14 days post-MI. Left ventricular (LV) reverse remodeling (RR) was defined as the reduction of LV end-diastolic volume or LV end-systolic volume by ≥ 12 % in cardiac magnetic resonance images at 6‑mo follow-up. A 12 % increase was defined as adverse remodeling (AR).Results The post-MI first-day median IL-10 (9.7 pg / ml vs. 17.6 pg / ml, p&lt;0.001), median IL-19 (28.7 pg / ml vs. 36.9 pg / ml, p&lt;0.001), and median IL-26 (47.8 pg / ml vs. 90.7 pg / ml, p&lt;0.001) were lower in the RR group compared to the AR group. There was a significant decrease in the concentration of anti-inflammatory cytokines in the AR group from the first to the 14 days post-MI. However, no significant change was observed in the RR group. Regression analysis revealed that a low IL-10 concentration on the post-MI first day was related to RR (OR=0.76, p=0.035). A 1 % increase in change of IL-10 concentration increased the probability of RR by 1.07 times.Conclusion The concentrations of cytokines were higher in the AR group, but this elevation was not sustained and significantly decreased for the 14 days post-MI. In the RR group, the concentrations of cytokines did not change and stable for the 14 days post-MI. As a reflection of this findings, stable IL-10 concentration may play a role the improvement of cardiac functions.

Deformation imaging by strain in chronic heart failure over sacubitril/valsartan: a multicenter echocardiographic registry (DISCOVER) ARNI

Abstract Background Sacubitril/valsartan changed the treatment of heart failure with reduced ejection fraction (HFrEF), due to the positive effects morbidity and mortality partly mediated by left ventricular reverse remodeling (LVRR). The aim of this multicenter study was to identify echocardiographic predictors of LVRR after sacubitril/valsartan administration. Methods Patients with HFrEF requiring therapy with sacubitril/valsartan from 13 Italian centers were included. Echocardiographic indexes including speckle tracking echocardiography (STE) were used to predict LVRR (defined as LV end-systolic volume reduction and ejection fraction [LVEF] improvement &amp;gt;10% at follow-up) at 6 months follow-up as the primary endpoint. Changes in symptoms (NYHA class) and neurohormonal activations (N-terminal-pro-brain natriuretic peptide [NTproBNP]) were also evaluated as secondary endpoints. Patients with poor acoustic windows and missing data were excluded. Results The final population consisted of 341 patients (mean age: 65±10 years; 18% female, median LVEF 30% [interquartile range:25; 34]. At 6 months follow-up, cardiac dimensions and function, including left heart STE parameters, improved (Table 1). Moreover, 82 (24%) patients showed early complete response (LVRR and LVEF ≥35%), 55 (16%) early incomplete response (LVRR and LVEF &amp;lt;35%), 204 (60%) no response (no LVRR and LVEF &amp;lt;35%) after 6 months of sacubitril/valsartan. Among patients with ischemic etiology, 68% (108) did not develop LV RR. Age, sex, general characteristics, baseline NYHA class and NT-pro BNP did not significantly differ between the groups.Conversely, baseline LV dimensions and LVEF showed significant differences between the groups (p&amp;lt;0.0001). Also, STE parameters were considerably better in group 1 compared to group 2 and 3 both at baseline and follow-up. Non-ischemic etiology, a lower left atrial volume index and a higher global longitudinal strain were all independent predictors of LVRR at multivariable logistic analysis (all p&amp;lt;0.01). With ROC and spline curves, LV GLS &amp;gt;−9.3% showed a good accuracy in predicting LV RR (Figure 1). LA strain was the best predictor of positive changes in NYHA class and NT-proBNP (all p&amp;lt;0.05). Conclusions STE parameters at baseline could be useful to predict LVRR and early clinical response to sacubitril-valsartan, and thus could be used as a guide for treatment in patients with HFrEF. Funding Acknowledgement Type of funding sources: None. Table 1Figure 1

Left atrial strain is a predictor of left ventricular systolic and diastolic reverse remodelling in CRT candidates

The left atrium (LA) has a pivotal role in cardiac performance and LA deformation is a well-known prognostic predictor in several clinical conditions including heart failure with reduced ejection fraction. The aim of this study is to investigate the effect of cardiac resynchronization therapy (CRT) on both LA morphology and function and to assess the impact of LA reservoir strain (LARS) on left ventricular (LV) systolic and diastolic remodelling after CRT. Two hundred and twenty-one CRT-candidates were prospectively included in the study in four tertiary centres and underwent echocardiography before CRT-implantation and at 6-month follow-up (FU). CRT-response was defined by a 15% reduction in LV end-systolic volume. LV systolic and diastolic remodelling were defined as the percent reduction in LV end-systolic and end-diastolic volume at FU. Indexed LA volume (LAVI) and LV-global longitudinal (GLS) strain were the main parameters correlated with LARS, with LV-GLS being the strongest determinant of LARS (r = -0.59, P < 0.0001). CRT induced a significant improvement in LAVI and LARS in responders (both P < 0.0001). LARS was an independent predictor of both LV systolic and diastolic remodelling at follow-up (r = -0.14, P = 0.049 and r = -0.17, P = 0.002, respectively). CRT induces a significant improvement in LAVI and LARS in responders. In CRT candidates, the evaluation of LARS before CRT delivery is an independent predictor of LV systolic and diastolic remodelling at FU.

B-PO04-181 AN EVALUATION OF LEFT VENTRICULAR REVERSE REMODELING IN PATIENTS WITH LEFT BUNDLE BRANCH BLOCK AND QRS DURATION LESS THAN 150MS

The benefit of cardiac resynchronization therapy (CRT) for patients with left bundle branch block (LBBB) and QRS duration (QRSd) between 120 and 150 milliseconds (ms) remains contested. Left ventricular (LV) reverse remodeling may help identify the benefit of CRT in these patients. We hypothesized that patients with LBBB QRSd between 120 and 150ms would have significant LV reverse remodeling on echocardiography after initiation of CRT comparable to patients with LBBB QRSd > 150ms. We aimed to study the effects of CRT on LV reverse remodeling in patients with LBBB QRSd < 150ms compared to patients with QRSd > 150ms. From a cohort of 258 patients who initiated CRT between 2016 and 2019, we performed a retrospective case-control study comparing the reduction in LV end-systolic volume (LVESV) of 19 patients with New York Heart Association Class II-III symptoms on goal-directed medical therapy (GDMT) with LBBB and QRSd < 150ms who received CRT and 19 controls with QRSd > 150ms. LVESV was measured on echocardiography within 6 months prior to CRT implantation and at least 1 year after implantation. There was a significant reduction in LVESV (mL) in patients with QRSd < 150ms from 121.25 to 84.91 (p = 0.0399) and in patients with QRSd > 150ms from 162.2 to 140.1 (p = 0.019). There was no significant difference in the absolute or relative magnitude of the reduction in LVESV between the two groups (absolute: 25.74 vs 44.98 mL, p = 0.48, relative: 27.67% and 28.91%, p = 0.91). Spacing of the echocardiograms before and after CRT introduction did not significantly differ between cases and controls (432.4 vs 460.9 days, p = 0.579). LV reverse remodeling occurred significantly and comparably in both patients with LBBB and QRSd < 150ms and patients with LBBB and QRSd > 150ms. As reduction in LVESV is an important predictor of survival with biventricular pacing, CRT may provide benefit to patients with systolic dysfunction on GDMT with LBBB and QRSd < 150ms.

B-IN01-06 PERSONALIZED APPROACH FOR CARDIAC RESYNCHRONIZATION THERAPY (CRT) IMPLANTATION GUIDED BY REAL-TIME NON-INVASIVE 3D ELECTROCARDIOGRAPHIC MAPPING

The optimal approach for CRT implantation is not established. To evaluate the feasibility of CRT implantation under electrocardiographic mapping guidance. Thirty consecutive patients with left ventricular ejection fraction (LVEF) ≤35% and conduction delay (9 LBBB and 21 non-LBBB) were recruited. A 252-electrode vest (CardioInsight, Medtronic) was worn by the patient during the procedure to measure the total activation time (TAT) when different pacing combinations of biventricular pacing (BVP), His-bundle pacing (HBP) and/or left bundle branch pacing (LBBP) were tested. The combination that resulted in the shortest TAT would be chosen. Clinical response was defined by ≥1 NYHA class improvement and echocardiographic response by LV end-systolic volume reduction ≥15% and/or LVEF improvement ≥10% at 6-months follow-up. Final pacing configurations involved LBBP in 40%, HBP in 33%, BVP in 13% and RV or LV pacing alone in 13% of patients. Mean QRS duration shortened from 164±18ms to 128±18ms and LVEF improved from 26±6% to 39±14% (both p <0.01). Clinical and echocardiographic response rates were 80% and 73%, respectively. Super echocardiographic responder rate (final LVEF >45%) was 33%. Mean TAT (57ms vs. 87ms) was significantly lower and TAT reduction (42% vs. 12%) was significantly greater with final pacing-configuration compared to BVP, respectively (both p<0.01). Personalized approach for CRT implantation using real-time non-invasive electrocardiographic mapping was feasible and associated with better resynchronization results compared to BVP.

B-PO01-100 PERSONALIZED APPROACH FOR CARDIAC RESYNCHRONIZATION THERAPY (CRT) IMPLANTATION GUIDED BY REAL-TIME NON-INVASIVE 3D ELECTROCARDIOGRAPHIC MAPPING

The optimal approach for CRT implantation is not established. To evaluate the feasibility of CRT implantation under electrocardiographic mapping guidance. Thirty consecutive patients with left ventricular ejection fraction (LVEF) ≤35% and conduction delay (9 LBBB and 21 non-LBBB) were recruited. A 252-electrode vest (CardioInsight, Medtronic) was worn by the patient during the procedure to measure the total activation time (TAT) when different pacing combinations of biventricular pacing (BVP), His-bundle pacing (HBP) and/or left bundle branch pacing (LBBP) were tested. The combination that resulted in the shortest TAT would be chosen. Clinical response was defined by ≥1 NYHA class improvement and echocardiographic response by LV end-systolic volume reduction ≥15% and/or LVEF improvement ≥10% at 6-months follow-up. Final pacing configurations involved LBBP in 40%, HBP in 33%, BVP in 13% and RV or LV pacing alone in 13% of patients. Mean QRS duration shortened from 164±18ms to 128±18ms and LVEF improved from 26±6% to 39±14% (both p <0.01). Clinical and echocardiographic response rates were 80% and 73%, respectively. Super echocardiographic responder rate (final LVEF >45%) was 33%. Mean TAT (57ms vs. 87ms) was significantly lower and TAT reduction (42% vs. 12%) was significantly greater with final pacing-configuration compared to BVP, respectively (both p<0.01). Personalized approach for CRT implantation using real-time non-invasive electrocardiographic mapping was feasible and associated with better resynchronization results compared to BVP.

B-PO03-081 CLINICAL SIGNIFICANCE OF POST-PROCEDURAL FUNCTIONAL MITRAL REGURGITATION AFTER ATRIAL FIBRILLATION ABLATION IN PATIENTS WITH LEFT VENTRICULAR SYSTOLIC DYSFUNCTION

Functional mitral regurgitation (FMR) is a common finding in patients with atrial fibrillation (AF) and reduced left ventricular (LV) ejection fraction (LVEF). Although association between FMR severity and prognosis is reported in heart failure patients, structural reverse remodeling after AF ablation can reduce the FMR severity, and the clinical significance of this change is still unclear. The purpose of the present study was as follows: (1) to examine the change of FMR severity before and after AF ablation in patients with reduced LVEF, (2) to evaluate the contribution of left atrial (LA) and LV reverse remodeling to the FMR improvement, and (3) to investigate the impact of pre- and post-procedural FMR on long-term clinical outcomes. A total of 407 patients with baseline LVEF of <50% who underwent first-time AF ablation were retrospectively evaluated. Patients were divided into 4 groups according to the pre- and post-procedural FMR severity: no or mild FMR at baseline which remained unchanged at 6 months after AF ablation (group 1), moderate to severe FMR which improved to no or mild (group 2), no or mild FMR which worsened to moderate to severe (group 3), and moderate to severe FMR which remained unchanged (group 4). The endpoint was composite of heart failure hospitalization and cardiovascular death. The number of patients with group 1, 2, 3, and 4 were 283 (69%), 74 (18%), 11 (3%), and 39 (10%), respectively. Reduction in LA volume (47±25ml vs. 30±23 ml, p <0.001) and LV end-systolic volume (37±30 ml vs. 23±21 ml, p <0.001) was significantly larger in patients with group 2 compared to the other patients. Over a median follow-up of 3 months, 28 patients experienced the endpoint. The event rate was 2.8%, 8.1%, 27.3%, and 25.6% in patients with group 1, 2, 3, and 4, respectively (log-rank p <0.001). Age-adjusted multivariate cox regression analysis including pre- and post-procedural FMR severity revealed that moderate to severe FMR at 6 months (hazard ratio, 3.28; 95% confidence interval 1.26-8.54) was significantly associated with the unfavorable events. AF ablation modified the FMR severity. Moderate to severe FMR at 6 months after AF ablation was strongly associated with unfavorable events in patients with reduced LVEF.

Impact of physiological pacing on functional mitral regurgitation in systolic dysfunction: Initial echocardiographic remodeling findings after His bundle pacing.

BackgroundAlthough His bundle pacing (HBP) has been shown to improve left ventricular ejection fraction (LVEF), its impact on mitral regurgitation (MR) remains uncertain.ObjectivesThe aim of this study was to evaluate change in functional MR after HBP in patients with left ventricular (LV) systolic dysfunction.MethodsPaired echocardiograms were retrospectively assessed in patients with reduced LVEF (<50%) undergoing HBP for pacing or resynchronization. The primary outcomes assessed were change in MR, LVEF, LV volumes, and valve geometry pre- and post-HBP. MR reduction was characterized as a decline in ≥1 MR grade post-HBP in patients with ≥grade 3 MR at baseline.ResultsThirty patients were analyzed: age 68 ± 15 years, 73% male, LVEF 32% ± 10%, 38% coronary artery disease, 33% history of atrial fibrillation. Baseline QRS was 162 ± 31 ms: 33% left bundle branch block, 37% right bundle branch block, 17% paced, and 13% narrow QRS. Significant reductions in LV end-systolic volume (122 mL [73–152 mL] to 89 mL [71–122 mL], P = .006) and increase in LV ejection fraction (31% [25%–37%] to 39% [30%–49%], P < .001) were observed after HBP. Ten patients had grade 3 or 4 MR at baseline, with reduction in MR observed in 7. In patients with at least grade 3 MR at baseline, reduction in LV volumes, improved mitral valve geometry, and greater LV contractility were associated with MR reduction. Greater reduction in paced QRS width was present in MR responders compared to non-MR responders (-40% vs -25%, P = .04).ConclusionsIn this initial detailed echocardiographic analysis in patients with LV systolic dysfunction, HBP reduced functional MR through favorable ventricular remodeling.

Long-term reverse remodeling and clinical improvement by MultiPoint Pacing in a randomized, international, Middle Eastern heart failure study

PurposeCardiac resynchronization therapy (CRT) with multipoint left ventricular (LV) pacing (MultiPoint™ Pacing, MPP) has been shown to improve CRT response, although MPP response using automated pacing vector programming has not been demonstrated in the Middle East. The purpose of this study was to compare the impact of MPP to conventional biventricular pacing (BiV) using echocardiographic and clinical changes at 6-month post-implant.MethodsThis prospective, randomized study was conducted at 13 Middle Eastern centers. After de novo CRT-D implant (Abbott Unify Quadra MP™ or Quadra Assura MP™) with quadripolar LV lead (Abbott Quartet™), patients were randomized to either BiV or MPP therapy. In BiV patients, the LV pacing vector was selected per standard practice; in MPP patients, the two LV pacing vectors were selected automatically using VectSelect. CRT response was defined at 6-month post-implant by a reduction in LV end-systolic volume (ESV) ≥ 15%.ResultsOne hundred and forty-two patients (61 years old, 68% male, NYHA class II/III/IV 19%/75%/6%, 33% ischemic, 57% hypertension, 52% diabetes, 158 ms QRS, 25.8% ejection fraction [EF]) were randomized to either BiV (N = 69) or MPP (N = 73). After 6 months, MPP vs. BiV patients experienced greater ESV reduction (25.0% vs. 15.3%, P = 0.08), greater EF improvement (11.9% vs. 8.6%, P = 0.36), significantly greater ESV response rate (68.5% vs. 50.7%, P = 0.04), and significantly greater NYHA class improvement rate (80.8% vs. 60.3%, P = 0.01).ConclusionsWith MPP and automatic LV vector selection, more CRT patients in the Middle East experienced reverse remodeling and clinical improvement relative to conventional BiV pacing.