Outcome Of Cardiac Resynchronization Therapy Research Articles

Differences in outcome of cardiac resynchronization therapy between iscehemic cardiomyopathy and non-ischemic cardiomyopathy

The aim of this review is to detect the difference in outcome of cardiac resynchronization therapy (CRT) between ischemic cardiomyopathy (ICM) and non-ischemic cardiomyopathy (NICM). By reviewing some clinical trials of large scale, we found that restore of heart structure and function in NICM was more significant than ICM. However, there were no significant differences in clinical outcome of improving cardiac function and quality of life, decreasing heart failure re-hospitalization and mortality. Key words: Myocardial ischemia/TH; Cardiomyopathies/TH; Cardiac pacing, artificial; Review

Short-term outcome of cardiac resynchronization therapy – a comparison between newly implanted and chronically right ventricle-paced patients

BackgroundCardiac resynchronization therapy (CRT) is considered as a standard adjunct therapy in symptomatic patients with congestive heart failure (CHF) who have a prolonged QRS. There is an increasing number of patients who do not receive de novo CRT devices but are upgraded from right ventricular (RV) pacing to biventricular stimulation. We wanted to evaluate the benefit of CRT in patients with chronic RV pacing in comparison to previously non-paced heart failure patients. MethodsOne hundred and sixty-five patients who had their device newly implanted (group I) and 116 who were upgraded from previously implanted RV pacing systems (group II) at Mayo Clinic Hospital were retrospectively analyzed. Clinical and echocardiographic response to CRT was evaluated. Mean follow-up time was 290±250days. ResultsBaseline characteristics did not differ between the two groups of patients. Clinical response rate was identical in Groups I and II (65 vs. 65%, respectively; P=0.98) and echocardiographic response rate was similar in both groups of patients (64 vs. 62%; P=0.80). Post-implant QRS increased in group I and was reduced in group II (5 (27.4) vs. −20.0 (33.9) ms; P<0.001). NYHA class improvement (−0.7 (0.6) vs. −0.7 (0.6), P=0.81), LV ejection fraction increase (9.2 (12.9) vs. 8.2 (9.9)%; P=0.55) and LV end-systolic volume reduction (−34.5 (50.7) vs. −25.7 (47.4)%; P=0.28) were comparable in both groups. ConclusionsChronically RV-paced patients who receive CRT have similar short-term benefits when compared with patients with new CRT implantations.

60. Mid-term outcome of cardiac resynchronization therapy in pediatrics: single institution experience

Cardiac resynchronization therapy (CRT) has become an increasingly important therapeutic option for patients (pts) to treat dyssynchrony associated moderate and severe heart failure. Few reports however, determined the beneficial effects of CRT in pediatrics and midterm outcome following this therapy. Our aim is to assess the mid-term outcomes of CRT in children with evidence of dyssynchrony associated heart failure. Cardiac resynchronization therapy is beneficial in treating congenital heart disease patients who have evidence of dyssynchrony associated heart failure. Retrospective review of 18 consecutive pediatric patients who underwent CRT at our institution between January 2002 and August 2011 Cardiac resynchronization pacemaker was implanted in 18 pts the majority of pts (14) with congenital heart disease. Fourteen pts had preexisting complete heart block and chronic right ventricular pacing. Epicardial left ventricular leads were implanted in all pts while the atrial and right ventricular leads approach varied according to the pt size and anatomy. Indication for CRT was symptomatic dilated cardiomyopathy with evidence of electrical and/or mechanical dyssynchrony demonstrated by M-mode, 3-D echo, or tissue Doppler. The median age of this cohort was 14 years (range 6 months–16 years), the median follow-up time was 7.2 years (range 1–10 years). Subjectively, 16 out of 18 pts reported symptomatic improvement with decreased hospitalizations. The left ventricular ejection fraction improved from mean of 27% (SD 13%) to mean of 50% (SD 13%) ( P value P value P value = 0.1) suggesting that electrical resynchronization is not a prerequisite for clinical improvement in this cohort. Children including those with congenital heart disease patients who have evidence of dyssynchrony associated heart failure appear to benefit from cardiac resynchronization therapy on the mid-term. Selection criteria should include the use of new technologies to demonstrate mechanical dyssynchrony beside other conventional indications of CRT. Further studies looking at long-term benefits of CRT in pediatric and CHD patients are needed.

16-73: Long term outcomes of cardiac resynchronization therapy with a defibrillator according to QRS duration in patients with left bundle branch block

16-73: Long term outcomes of cardiac resynchronization therapy with a defibrillator according to QRS duration in patients with left bundle branch block

139-06: Impact of mechanical activation and right-to-left ventricular interlead electrical delay on response to cardiac resynchronization therapy

Purpose: Prior studies suggest that a LV lead position in the latest mechanically activated segment (mechanically concordant) and a long right-to-left interlead sensed electrical delay (RL-IED) improves cardiac resynchronization therapy (CRT) outcome. We compared the effect of a mechanically concordant LV lead and a long RL-IED on clinical and echocardiographic outcome in patients receiving a CRT device. Methods: We prospectively included 161 patients in NYHA class II-IV and an ECG with a left bundle branch block (age 70 ± 9 years, 39 (24%) female, QRS width 173 ± 21 ms, LV EF 25 ± 6 %, end-systolic (ESV) volume 197 ± 71 ml). The LV lead position was verified by postimplant cardiac CT. The segment with the latest mechanical activation segment was determined by preimplant speckle tracking radial strain echocardiography. The RL-IED was measured during CRT implant and expressed as a percentage of preimplant QRS width. Follow-up was performed after six months. Results: The LV lead was positioned mechanically concordant in 75 (47%) patients, while 82 (51%) and 4 (2%) had the lead in an adjacent or remote segment, respectively. The median RL_IED was 63 (range 1–84) %. The proportion of patients improving in NYHA class, the increase in LV EF, and reduction in ESV was similar in patients with or without a mechanically concordant LV lead (51 vs. 68 %, P = 0.12; 13 ± 9 vs. 11 ± 9 %, P = 0.11; 74 ± 56 vs. 66 ± 53 ml, P = 0.39, respectively). Separated by the median RL-IED, 69 % with a long RL-IED improved in NYHA class compared to 46 % with a short RL-IED (P < 0.01). Patients with a long RL-EID had a larger increase in LVEF and reduction in ESV (13 ± 10 vs. 11 ± 7 %, P = 0.04; 86 ± 54 vs. 54 ± 50 ml, P < 0.001, respectively). Conclusion: A long RL-IED, but not a mechanically concordant LV lead position, is associated with improved clinical and echocardiographic CRT outcome in patients with a high degree of mechanically optimal LV lead positions concordant or adjacent to the segment with latest mechanical activation.

56-59: Response to cardiac resynchronization therapy and outcomes in hemodialysis patients

Purpose: To identify the impact of hemodialysis on response to cardiac resynchronization therapy (CRT) and outcomes. Method: This study included 993 consecutive patients who had undergone CRT. Response to CRT was defined as a 15% reduction in left ventricular end-systolic volume after 6 months. We compared response to CRT and outcomes between 59 hemodialysis patients and 934 non-hemodialysis patients. Results: A mean follow-up period was 37.5 months. All-cause mortality in hemodialysis patients was statistically higher than non-hemodialysis patients (log-rank p = 0.042). Multivariate analysis revealed that hemodialysis was an independent predictor of all-cause mortality (OR = 1.669, p = 0.026). The proportion of the response to CRT in hemodialysis patients was statistically lower than non-hemodialysis patients (45.2% vs. 60.2%; p = 0.043). The proportion of 20% elevation in left ventricular ejection fraction after 6 months in hemodialysis patients was also lower than non-hemodialysis patients (34.1% vs. 53.3%; p = 0.017). Conclusion: Hemodialysis is associated with a poor response to CRT and adverse outcomes.

19-06: Clinical Outcomes at One Year Follow UP in cardiac resynchronization therapy with Acute Optimization of Left Ventricular Pacing Site and Multipoint Pacing

Introduction: The clinical response to cardiac resynchronization therapy (CRT) is variable. The optimization of the left ventricle (LV) pacing site increases the number of responder to CRT. The Multipoint (MPP) pacing could further increase hemodynamic response to and clinical outcome of CRT. The purpose of our study was to test the hypothesis that pts optimized at implant and treated with MPP experience superior long-term clinical outcomes than conventional CRT pts. Methods: 110 HF pts treated for 1 year with either conventional CRT(STD, N = 54), CRT with hemodynamic and electrical optimized LV pacing site (OPT, N = 36), and with optimized LV pacing site + MPP (OPT-MPP, N = 20) were evaluated to determine CRT response relative to baseline. Responders were classified in terms of 1-year reduction in end-systolic volume index≥ 15%, reduction in NYHA class ≥ 1, and PACKER score variation (NYHA response with no HF-related hospitalization or death). Results: In terms of ESVi, 55.6% of STD, 72.2% of OPT, and 90.0% of OPT-MPP pts were responders. In terms of NYHA, 66.7% of STD, 77.8% of OPT, and 95.0% of OPT-MPP pts responded, with more MPP pts experiencing a NYHA downgrade of 2 classes or beyond. Likewise, 59.3.0% of STD, 66.7% of OPT, and 90.0% of OPT-MPP pts exhibited a 1-year PACKER response.

Interventricular Electrical Delay IsPredictive of Response to CardiacResynchronizationTherapy.

This study was conceived to evaluate the relationship between interventricular electrical delay, as measured by the right ventricle-left ventricle (RV-LV) interval, and outcomes in a prospectively designed substudy of the SMART-AV (SMARTDELAY determined AV Optimization) trial. Despite the well-documented benefit of cardiac resynchronization therapy (CRT), the nonresponder rate remains an important clinical problem. Implanting LV leads by traditional anatomic criteria has limited impact on outcomes. However, pacing at sites with late electrical activation improves CRT response rates. Thus, we hypothesized that interventricular electrical delay is associated with improved CRT outcomes. This was a multicenter study of patients with advanced heart failure undergoing CRT implantation. In 419 subjects, the unpaced RV-LV interval was measured in sinus rhythm. LV volumes and ejection fraction were measured by echocardiography at baseline and after 6 months of CRT by a blinded core laboratory. Quality of life (QOL) was assessed by a standardized questionnaire. When separated by quartiles based on interventricular delay, the magnitudes of LV volumes, ejection fraction and the QOL measure increased significantly with prolongation of RV-LV delay (p< 0.05). The LV end-systolic volume response rate increased progressively from 30% to 75% (p< 0.001), and the QOL response rate increased from 50% to 65% (p= 0.08). Patients in the highest quartile of RV-LV had a 5.98-fold increase (p< 0.001) in their odds of a reverse remodeling response, with female sex, ischemic etiology, and baseline LV end-systolic volume being the other independent predictors of response. Baseline interventricular delay is a potent independent predictor of remodeling and QOL responses with CRT.

Cardiac Resynchronization Therapy: US Trends and Disparities in Utilization and Outcomes.

The use of cardiac resynchronization therapy (CRT) has increased significantly since its initial approval in 2001 for use in patients with advanced heart failure. However, trends in utilization of CRT have not been systematically characterized. We used the Nationwide Inpatient Sample database to identify all patients with CRT implantation during 2002 to 2010. The overall trends in CRT device implantation, patient characteristics, and outcomes were examined in detail and compared among demographic subgroups. During 2002 to 2010, a total of 374,202 CRT procedures were recorded. Significant and persistent gender and racial disparities favoring men (71.4%) and white (79.6%), respectively, were noted in all years. The highest number of CRT devices were implanted in the 65- to 84-year age group (64.6%), with significant increase in number of CRT implants in older patients ≥ 85 years over the years (P = 0.02). The CRT-associated in-hospital mortality improved from 1.08% in 2003 to 0.70% in 2010 (P = 0.03). The correlates of higher mortality included males (0.93% versus 0.71% in females; P = 0.04) and older age (age ≥ 85 years had 1.5% mortality versus 0.8% for age < 85 year; P < 0.001). The mean hospital length of stay for CRT decreased, while mean CRT-associated hospital charges increased progressively over the years. Factors associated with higher charges were gender (males > females), older age, and greater comorbidities. CRT implantation is a relatively safe procedure that has become safer in higher risk patients. However, significant disparities in CRT utilization exist in certain demographic subgroups, and these disparities have persisted across the years.

The role of electrocardiography in the elaboration of a new paradigm in cardiac resynchronization therapy for patients with nonspecific intraventricular conduction disturbance.

Cardiac resynchronization therapy (CRT) is associated with a favorable outcome only in patients with left bundle branch block (LBBB) pattern and in patients with a QRS duration > 150 ms, in patients with non-LBBB pattern with a QRS duration of 120–150 ms usually is not beneficial. After adjusting for QRS duration, QRS morphology was no longer a determinant of the clinical response to CRT. In contrast to the mainstream view, we hypothesized that the unfavorable CRT outcome in patients with non-LBBB and a QRS duration of 120–150 ms is not due to the QRS morphology itself, but to less dyssynchrony and unfavorable patient characteristics in this subgroup, such as more ischemic etiology and greater prevalence of male patients compared with patients with LBBB pattern. Further, the current CRT technique is devised to eliminate the dyssynchrony present in patients with LBBB pattern and inappropriate to eliminate the dyssynchrony in patients with non-LBBB pattern. We also hypothesized that electrocardiography may also provide information about the presence of interventricular and left intraventricular dyssynchrony and the approximate location of the latest activated left ventricular (LV) region. To this end, we devised new ECG criteria to estimate interventricular and LV intraventricular dyssynchrony and the approximate location of the latest activated LV region. Our preliminary data demonstrated that the latest activated LV region in patients with nonspecific intraventricular conduction disturbance (NICD) pattern might be at a remote site from that present in patients with LBBB pattern, which might necessitate the invention of a novel CRT technique for patients with NICD pattern. The application of the new interventricular and LV intraventricular dyssynchrony ECG criteria and a potential novel CRT technique might decrease the currently high nonresponder rate in patients with NICD pattern.

The clinical outcome of cardiac resynchronization therapy in post-surgical valvular cardiomyopathy.

Trials have shown that cardiac resynchronization therapy (CRT) is effective in patients with 'non-ischaemic cardiomyopathy'. Patients with post-surgical valvular cardiomyopathy (PSVCM) have been excluded from such trials. We sought to compare the clinical outcome of CRT in patients with PSVCM, idiopathic dilated cardiomyopathy (IDCM), or ischaemic cardiomyopathy (ICM). Clinical events and response to CRT were quantified in 556 patients (PSVCM = 38; IDCM = 165; ICM = 353) over 4.52 years [median, inter-quartile range (IQR): 4.42]. Response to CRT was defined as survival for ≥1 year free of hospitalizations plus improvement by ≥1 NYHA class or ≥25% in 6-min walking distance. Cardiac resynchronization therapy was initiated at 5.86 years (median, IQR: 9.86) after aortic valve replacement (73.7%) or mitral valve replacement/repair (44.7%). Compared with PSVCM, IDCM was associated with a lower total mortality [hazards ratio, HR: 0.54 (95% confidence interval, CI 0.34-0.84)], cardiac mortality [HR: 0.43 (95% CI 0.26-0.70)], and total mortality or major adverse cardiovascular events [HR: 0.57 (95% CI 0.37-0.87)], independent of known confounders. Compared with PSVCM, ICM was associated with a similar risk of death from pump failure [HR: 0.83 (95% CI 0.50-1.37)] and IDCM was associated with a lower risk [HR: 0.46 (95% CI 0.26-0.82)]. Response to CRT was similar across the groups. Compared with IDCM, PSVCM was associated with a worse outcome after CRT. Outcomes from PSVCM were similar to ICM. These findings indicate that PSVCM behaves very differently to IDCM after CRT.

Prognostic value of collagen turnover biomarkers in cardiac resynchronization therapy: A subanalysis of the TRUST CRT randomized trial population

A substantial proportion of patients do not respond to cardiac resynchronization therapy (CRT). Various echocardiographic and biochemical markers including collagen turnover biomarkers were suggested to predict CRT results. However, pathological significance of collagen turnover biomarkers in CRT remains controversial. The aim of the present study was to evaluate the relationship between levels of collagen turnover biomarkers (amino-terminal propeptide of procollagen type I and amino-terminal propeptide of procollagen type III [PIIINP]), N-terminal of the prohormone brain natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein, and matrix metalloproteinases (metalloproteinase-2 and metalloproteinase-9) and echocardiographic response to CRT and clinical outcomes. The study population consisted of patients enrolled in the Triple Site Versus Standard Cardiac Resynchronization Therapy trial. Blood samples were obtained before implantation of a CRT with defibrillator. The levels of PIIINP, amino-terminal propeptide of procollagen type I, metalloproteinase-2, and metalloproteinase-9 were determined using commercially available ELISA kits. High-sensitivity C-reactive protein and NT-proBNP levels were determined in a standard way. Samples were collected from 74 of 100 enrolled patients. The multivariate logistic regression analysis demonstrated that low PIIINP levels (odds ratio [OR] 3.56; 95% confidence interval [CI] 1.23-10.24; P = .017) and baseline ejection fraction (OR 2.14; 95% CI 1.11-4.11; P = .02) were favorably associated with echocardiographic response. PIIINP and NT-proBNP levels appeared to be independent predictors of all-cause mortality (PIIINP: OR 3.11; 95% CI 1.21-7.89; P = .033; NT-proBNP: OR 2.05; 95% CI 1.11-4.96; P = .039) and risk of major cardiac adverse event (PIIINP: OR 3.56; 95% CI 1.53-9.15; P = .007; NT-proBNP: OR 4.51; 95% CI 1.75-11.6; P = .001). PIIINP levels showed significant additive value in predicting mortality as compared with NT-proBNP levels, but they were not superior to ejection fraction in predicting response. Survival analysis with cutoff values identified by receiver operating characteristic analysis confirmed a significant benefit associated with low baseline PIIINP levels. Low PIIINP levels are associated with favorable echocardiographic response and long-term survival in CRT recipients.

Cardiac resynchronization therapy pacemaker: critical appraisal of the adaptive CRT-P device.

Cardiac resynchronization therapy (CRT) is an effective and well-established therapy for patients suffering with heart failure, left ventricular (LV) systolic dysfunction (ejection fraction ≤35%), and electrical dyssynchrony, demonstrated by a surface QRS duration of ≥120 ms. Patients undergoing treatment with CRT have shown significant improvement in functional class, quality of life, LV ejection fraction, exercise capacity, hemodynamics, and reverse remodeling of LV, and ultimately, morbidity and mortality. However, 30%–40% of patients who receive a CRT device may not show improvement, and they are termed as non responders. The nonresponders have a poor prognosis; several methods have been developed to try to enhance response to CRT. Echocardiography-guided optimization of CRT has not resulted in significant clinical benefit, since it is done at rest with the patient in supine position. An ideal optimization strategy would provide continuous monitoring and adjustment of device pacing to provide maximal cardiac resynchronization, under a multitude of physiologic states. Intrinsic activation of the right ventricle (RV) with paced activation of the RV, even in the setting of biventricular (BiV) pacing, may result in an adverse effect on cardiac performance. With this physiology, the use of LV-only pacing may be preferred and may enhance CRT. Adaptive CRT is a novel device-based algorithm that was designed to achieve patient-specific adjustment in CRT so as to provide appropriate BiV pacing or LV-only pacing. This article will review the goals of CRT optimization, and implementation and outcomes associated with adaptive CRT.

Atrial reverse remodelling is associated with outcome of cardiac resynchronization therapy.

To study the prognostic effect of atrial reverse remodelling on outcome of cardiac resynchronization therapy (CRT). Patients receiving a CRT device in the University Medical Centre Groningen were included. Atrial reverse remodelling was defined as a ≥10% reduction in left atrial volume index at 6-month follow-up. Success of CRT was defined as ventricular reverse remodelling with a reduction in left ventricular end-systolic volume of ≥15% at 6-month follow-up. Primary endpoint was all-cause mortality or heart failure hospitalizations. A total of 365 patients (mean age 65.1 ± 11.0 years, 73% men) were included; among them, 221 (61%) were in sinus rhythm and had no prior atrial fibrillation (AF), and 144 patients (39%) had a history of AF. During a mean follow up of 2.0 ± 1.0 years, 49 patients died. Cox regression analysis revealed that patients with no atrial and no ventricular reverse remodelling had the worst outcome (hazard ratio 3.1, 95% confidence interval 1.4-7.1, P = 0.006). Outcome in patients with only atrial reverse remodelling was comparable with outcome in patients with both atrial and ventricular reverse remodelling (hazard ratio 2.0, 95% confidence interval 0.7-5.6, P = 0.21). Patients without atrial and ventricular reverse remodelling have the worst outcome. Patients with only atrial reverse remodelling have improved left ventricular diastolic filling during follow-up and demonstrate a comparable outcome with patients with both atrial and ventricular reverse remodelling. Assessment of atrial reverse remodelling may provide additional prognostic information in determining CRT outcome.

Haemodynamic effects of cardiac resynchronization therapy using single-vein, three-pole, multipoint left ventricular pacing in patients with ischaemic cardiomyopathy and a left ventricular free wall scar: the MAESTRO study.

The clinical response to cardiac resynchronization therapy (CRT) is variable. Multipoint left ventricular (LV) pacing could achieve more effective haemodynamic response than single-point LV pacing. Deployment of an LV lead over myocardial scar is associated with a poor haemodynamic response to and clinical outcome of CRT. We sought to determine whether the acute haemodynamic response to CRT using three-pole LV multipoint pacing (CRT3P-MPP) is superior to that to conventional CRT using single-site LV pacing (CRTSP) in patients with ischaemic cardiomyopathy and an LV free wall scar. Sixteen patients with ischaemic cardiomyopathy [aged 72.6 ± 7.7 years (mean ± SD), 81.3% male, QRS: 146.0 ± 14.2 ms, LBBB in 14 (87.5%)] in whom the LV lead was intentionally deployed straddling an LV free wall scar (assessed using cardiac magnetic resonance), underwent assessment of LV + dP/dtmax during CRT3P-MPP and CRTSP. Interindividually, the ΔLV + dP/dtmax in relation to AAI pacing with CRT3P-MPP (6.2 ± 13.3%) was higher than with basal and mid CRTSP (both P < 0.001), but similar to apical CRTSP. Intraindividually, significant differences in the ΔLV + dP/dtmax to optimal and worst pacing configurations were observed in 10 (62.5%) patients. Of the 8 patients who responded to at least one configuration, CRT3P-MPP was optimal in 5 (62.5%) and apical CRTSP was optimal in 3 (37.5%) (P = 0.0047). In terms of acute haemodynamic response, CRT3P-MPP was comparable an apical CRTSP and superior to basal and distal CRTSP. In the absence of within-device haemodynamic optimization, CRT3P-MPP may offer a haemodynamic advantage over a fixed CRTSP configuration.

Incremental value of cystatin C over conventional renal metrics for predicting clinical response and outcomes in cardiac resynchronization therapy: The BIOCRT study

BackgroundDespite the benefit of CRT in select patients with heart failure (HF), there remains significant need for predicting those at risk for adverse outcomes for this effective but costly therapy. CysC, an emerging marker of renal function, is predictive of worsening symptoms and mortality in patients with HF. This study assessed the utility of baseline and serial measures of cystatin C (CysC), compared to conventional creatinine-based measures of renal function (estimated glomerular filtration rate, eGFR), in predicting clinical outcomes following cardiac resynchronization therapy (CRT). MethodsIn 133 patients, we measured peripheral venous (PV) and coronary sinus (CS) CysC concentrations and peripheral creatinine levels at the time of CRT implant. Study endpoints included clinical response to CRT at 6months and major adverse cardiac events (MACE) at 2years. ResultsWhile all 3 renal metrics were predictive of MACE (all adjusted p≤0.02), only CysC was associated with CRT non-response at 6months (adjusted odds ratio 3.6, p=0.02). CysC improved prediction of CRT non-response (p≤0.003) in net reclassification index analysis compared to models utilizing standard renal metrics. Serial CysC >1mg/L was associated with 6-month CRT non-response and reduced 6-minute walk distance as well as 2-year MACE (all p≤0.04). ConclusionIn patients undergoing CRT, CysC demonstrated incremental benefit in the prediction of CRT non-response when compared to standard metrics of renal function. Baseline and serial measures of elevated CysC were predictive of CRT non-response and functional status at 6months as well as long-term clinical outcomes.

Abstract 15501: True Bipolar Left Ventricular Pacing is Associated With Better Survival in Cardiac Resynchronization Therapy Patients

Introduction: Prior studies suggested better outcomes in cardiac resynchronization therapy (CRT) patients with true bipolar left ventricular (LV) pacing compared to unipolar or extended bipolar LV pacing. However, we lack confirmatory data from larger patient cohorts. Methods: We reviewed de-identified device data from 65,620 HF patients with an RF-enabled CRT-D device followed on the LATITUDE system (LATITUDE® system, Boston Scientific, St. Paul, MN). Long-term survival was assessed by LV lead pacing polarity. Patients with LV bipolar leads paced between the LV tip and ring were identified as LV true bipolar pacing, while those with LV bipolar leads paced between the LV tip or LV ring to the RV coil were identified as LV extended bipolar pacing. Unipolar LV pacing was assessed as a separate sub-group. Kaplan-Meier survival analysis and multivariable Cox hazards regressions models were utilized to assess all-cause mortality by LV lead pacing polarity. Results: There were 24,033 patients (37%) with LV true bipolar pacing, 38,327 patients (58%) with extended bipolar LV pacing, and 3260 patients (5%) with LV unipolar pacing. LV true bipolar pacing was associated with a significantly higher likelihood of survival during follow-up compared to patients with LV unipolar pacing (log-rank p&lt;0.001), that translated into a significant 28% reduction in all-cause mortality (HR 0.72, 95% CI: 0.65-0.80, p&lt;0.001) after adjustment for age and gender (Figure). The survival benefit between LV true bipolar pacing and LV extended bipolar pacing was smaller, but nevertheless statistically significant (HR=0.91, 95% CI: 0.65-0.80; p&lt;0.001). Conclusion: In this large patient cohort, true bipolar LV pacing was associated with better long-term survival in cardiac resynchronization therapy patients compared to LV unipolar or LV extended bipolar pacing. When feasible, programming true bipolar LV lead pacing polarity should be considered in cardiac resynchronization therapy patients.

Cardiac Resynchronization Therapy Outcomes in Type 2 Diabetic Patients: Role of MicroRNA Changes.

Heart failure (HF) and type 2 diabetes mellitus (T2DM) are two growing and related diseases in general population and particularly in elderly people. In selected patients affected by HF and severe dysfunction of left ventricle ejection fraction (LVEF), with left bundle brunch block, the cardiac resynchronization therapy with a defibrillator (CRT) is the treatment of choice to improve symptoms, NYHA class, and quality of life. CRT effects are related to alterations in genes and microRNAs (miRs) expression, which regulate cardiac processes involved in cardiac apoptosis, cardiac fibrosis, cardiac hypertrophy and angiogenesis, and membrane channel ionic currents. Different studies have shown a different prognosis in T2DM patients and T2DM elderly patients treated by CRT-D. We reviewed the literature data on CRT-D effect on adult and elderly patients with T2DM as compared with nondiabetic patients.

Young Investigators Competition1Left ventricular lead position, mechanical activation and myocardial scar in relation to the clinical outcome of cardiac resynchronisation therapy: the role of feature-tracking and contrast-enhanced cardiovascular magnetic resonance2Does the haemodynamic improvement of biventricular pacing truly arise from cardiac resynchronisation? quantifying the contribution of av and vv adjustment3Differential relationship of electrical delay with endocardial and epicardial left ventricular leads

Young Investigators Competition1Left ventricular lead position, mechanical activation and myocardial scar in relation to the clinical outcome of cardiac resynchronisation therapy: the role of feature-tracking and contrast-enhanced cardiovascular magnetic resonance2Does the haemodynamic improvement of biventricular pacing truly arise from cardiac resynchronisation? quantifying the contribution of av and vv adjustment3Differential relationship of electrical delay with endocardial and epicardial left ventricular leads

Endothelial Function Predicts New Hospitalization due to Heart Failure Following Cardiac Resynchronization Therapy.

Cardiac resynchronization therapy (CRT) has been established as a treatment for patients with chronic heart failure (HF). We tested the hypothesis that assessment of peripheral endothelial function is associated with the long-term outcome of CRT and its linkage to coronary flow reserve (CFR) was also investigated. From 2010, a total of 34 consecutive patients implanted with CRT for the treatment of advanced HF were evaluated at baseline (immediately before CRT) and 6-8 months after CRT. Endothelial function was evaluated by measurement of reactive hyperemia peripheral arterial tonometry (RH-PAT). In 24 of 34 patients, CFR was determined by transthoracic echocardiography. Based on the receiver-operating characteristic curves, depressed RH-PAT index (RHI) was defined as ≤1.5. Accurate follow-up information during the mean of 343 ± 120 days was obtained in 20 preserved RHI group (mean age 66 ± 1.8 years) and 14 depressed RHI group (71 ± 2.2 years). Kaplan-Meier survival analysis demonstrated that depressed RHI group had higher prevalence of new hospitalization due to HF progression (log-rank 5.40). Cox proportional hazards regression analysis revealed that the baseline log brain natriuretic peptide (hazard ratio 5.95) and the baseline RHI value (hazard ratio 0.066) were independently associated with the incidence of new hospitalization due to HF progression. The baseline RHI values were positively correlated with the 6-8 months change of CFR (R = 0.434, P = 0.0343). Our results suggest that the baseline peripheral endothelial function could predict the long-term outcome of CRT. The results also suggest that improvement of coronary microcirculation might be associated with the better baseline endothelial function.