Resynchronization Therapy In Heart Failure Research Articles

Clinical characteristics and outcome of cardiac resynchronization therapy for heart failure in National Hospital of Sri Lanka from year 2005 to 2020 – a retrospective observational study

BackgroundCardiac resynchronization therapy (CRT) has been a well-established treatment modality for moderate to severe left ventricular systolic dysfunction with left ventricular desynchrony. This is the pioneering study that analyses the cohort who underwent CRT implantation at the National Hospital of Sri Lanka (NHSL) in Colombo from 2005 to 2020.ObjectivesThis study was carried out to describe socio-demographic factors, improvements in clinical outcome (symptoms, electrocardiographic, and echocardiographic features), and post-CRT complications in the study population, as well as to determine the efficacy of CRT in heart failure.MethodA retrospective observational study was conducted on all the living patients who had undergone CRT implantation from 2005 to 2020. The data was gathered from all the consented patients who visited the device programming clinic using a physician-administered questionnaire and clinical records. Data was analyzed using SPSS 25, and significant statistics were assessed with the McNemer test, the Student T test, and the Chi-Squared test.ResultsThe study included 50 patients with a mean age of 52.82+/− 11.66 years and female predominance (56%, n = 28). Idiopathic dilated cardiomyopathy (50%, n = 25) was the leading etiological factor, followed by ischemic cardiomyopathy (28%, n = 14). Clinical symptoms have improved significantly with CRT implantation (p < 0.001). A significant improvement was found in NYHA functional class (p < 0.001, 95% CI = 0.072 to 0.284), QRS width (p < 0.001, 95% CI = 0.229 to 0.534), ejection fraction (p < 0.001, 95% CI = − 16.437 to − 8.504), and LV EDD (p < 0.001, 95% CI = 2.89 to 9.24). Post-CRT complications included lead malfunction (6%, n = 3) and chronic (14%, n = 7), bleeding or hematoma (2%, n = 1), pocket erosion or infection (6%, n = 3), and infective endocarditis (2%, n = 1).ConclusionAccording to the study, CRT significantly improves both clinical and functional outcomes in patients with moderate to severe heart failure.

Conduction system pacing vs. biventricular pacing for cardiac resynchronization therapy in heart failure with reduced ejection fraction: An updated systematic review and meta-analysis

Conduction system pacing (CSP) is considered an effective and physiological form of pacing in patients requiring cardiac resynchronization therapy (CRT). To compare electrocardiographic (ECG), echocardiographic (ECHO) characteristics and clinical outcomes among patients with heart failure with reduced ejection fraction (HFrEF) undergoing CRT with CSP or biventricular pacing (BVP). This study protocol was registered in the PROSPERO registry (CRD42022375155) and the review was conducted per the PRISMA protocol. Four major databases were searched from inception till October 20, 2022, for relevant studies comparing CSP to BVP for CRT in patients with HFrEF. From a total of 10,072 references identified, 35 full-text were assessed and 18 studies (6 RCTs, 12 observational studies) were included in the review. Following left bundle branch area pacing (LBBAP), on average, paced QRS duration was 28 ms narrower in comparison to BVP (MD -27.69, CI -36.59 to -18.80), and a similar result was obtained with HBP vs. BVP as well. Left ventricular ejection fraction (LVEF) improvement was greater with CSP in comparison to BVP [LBBAP (MD 6.03, CI 4.16-7.91); HBP (MD 3.79, CI 0.46-7.11); HPSP (MD 6.60, CI 4.42-8.78). There were higher odds of being responders (OR 3.82, CI 1.88-7.75)/super responders (OR 2.08, CI 1.53-2.82) (per ECHO findings) in the CSP group, and overall mortality (OR 0.61, CI 0.40-0.93) and hospitalization for HF (HHF) (OR 0.37, CI 0.25-0.55) was lower in CSP group. Our analysis showed better ECG, ECHO, and clinical outcomes in terms of mortality and HHF with CSP compared to BVP.

Upgrade of right ventricular pacing to cardiac resynchronization therapy in heart failure: a randomized trial.

De novo implanted cardiac resynchronization therapy with defibrillator (CRT-D) reduces the risk of morbidity and mortality in patients with left bundle branch block, heart failure and reduced ejection fraction (HFrEF). However, among HFrEF patients with right ventricular pacing (RVP), the efficacy of CRT-D upgrade is uncertain. In this multicentre, randomized, controlled trial, 360 symptomatic (New York Heart Association Classes II-IVa) HFrEF patients with a pacemaker or implantable cardioverter defibrillator (ICD), high RVP burden ≥ 20%, and a wide paced QRS complex duration ≥ 150 ms were randomly assigned to receive CRT-D upgrade (n = 215) or ICD (n = 145) in a 3:2 ratio. The primary outcome was the composite of all-cause mortality, heart failure hospitalization, or <15% reduction of left ventricular end-systolic volume assessed at 12 months. Secondary outcomes included all-cause mortality or heart failure hospitalization. Over a median follow-up of 12.4 months, the primary outcome occurred in 58/179 (32.4%) in the CRT-D arm vs. 101/128 (78.9%) in the ICD arm (odds ratio 0.11; 95% confidence interval 0.06-0.19; P < .001). All-cause mortality or heart failure hospitalization occurred in 22/215 (10%) in the CRT-D arm vs. 46/145 (32%) in the ICD arm (hazard ratio 0.27; 95% confidence interval 0.16-0.47; P < .001). The incidence of procedure- or device-related complications was similar between the two arms [CRT-D group 25/211 (12.3%) vs. ICD group 11/142 (7.8%)]. In pacemaker or ICD patients with significant RVP burden and reduced ejection fraction, upgrade to CRT-D compared with ICD therapy reduced the combined risk of all-cause mortality, heart failure hospitalization, or absence of reverse remodelling.

Effectiveness of adding a defibrillator with cardiac resynchronization therapy in heart failure according to the modified Model for End-stage Liver Disease-Albumin score.

Current guidelines lack clear recommendations between the implantation of cardiac resynchronization therapy (CRT) with defibrillator (CRT-D) and CRT with pacemaker (CRT-P). We hypothesized that modified model for end-stage liver disease score including albumin (MELD-Albumin score), could be used to select patients who may not benefit from CRT-D. We consecutively included patients with CRT-P or CRT-D implantation between 2010 and 2022. The primary endpoint was the composite of all-cause mortality or worsening heart failure. We performed multivariable-adjusted Cox proportional hazard regression. We assessed the interaction between the MELD-Albumin score and the effect of adding a defibrillator with CRT.A total of 752 patients were included in this study, with 291 implanted CRT-P. During a median follow-up of 880 days, 205 patients reached the primary endpoint. MELD-Albumin score was significantly associated with the primary endpoint in the CRT-D group [HR 1.16 (1.09-1.24); P < 0.001] but not in the CRT-P group [HR 1.03 (0.95-1.12); P = 0.49]. There was a significant interaction between the MELD-Albumin score and the effect of CRTD (P = 0.013). The optimal cut-off value of the MELD-Albumin score was 12. For patients with MELD-Albumin ≥ 12, CRT-D was associated with a higher occurrence of the primary endpoint [HR 1.99 (1.10-3.58); P = 0.02], whereas not in patients with MELD-Albumin < 12 [HR 1.19 (0.83-1.70); P = 0.35). Our findings suggest that CRT-D is associated with an excess risk of composite clinical endpoints in HF patients with higher MELD-Albumin score.

Electroanatomic mapping system guided His bundle pacemaker implantation: experience of the His bundle registry graz

Abstract Funding Acknowledgements Type of funding sources: None. Background Electric conduction disturbances are very common, however, patients in need for ventricular pacing may suffer from pacing-induced heart failure due to unphysiological pacing by the right ventricular lead. Conducting system pacing allows to overcome this common issue with a more physiologic approach, but real-life procedural data using this technology is scarce. Methods We report a single centre experience of the first 63 consecutive patients being implanted with a His-bundle-based pacemaker 09/2020-11/2022 per 3D-mapping guided implantation due to bradyarrhythmia, or for cardiac resynchronisation therapy in heart failure combined with a left-ventricular lead (HOT-CRT) ± a right ventricular defibrillator lead. The identification of the His-bundle-location was done with a 3D electroanatomic mapping system via an introducing sheath that is provided with electrodes at its tip. Results Mean age was 71 [18;87] years, 18/63 (29%) patients were female, mean baseline LVEF was 46±15%. Baseline ECG was captured before implantation: QRS width was 127±34ms, with typical LBBB in 19/63 (30%), typical RBBB in 5/63 (8%), alternating BBB in two patient (3%) and either no BBB or ventricular escape rhythm in 37/63 (59%). Indications for implantation were AV-block grade II-III in 31/63 (49%), primary prophylactic ICD indication in HFrEF in 18/63 (29%), atrial fibrillation with bradycardic conduction in 8/63 patients (13%), sick-sinus-syndrome in 4/63 (7%) and secondary prophylactic ICD indication in one patient (2%). In 57/63 (90,5%) a primary device was implanted, in 6/63 (9,5%) a pre-existent device was upgraded with a HB lead. Therefore, 23 dual-chamber-pacemaker, 5 single-chamber-pacemaker, 10 single-chamber CRT-P, 17 dual-chamber CRT-P, 4 single-chamber CRT-D, 4 dual-chamber CRT-D were implanted. In 63 patients his bundle pacing was attempted, while in 6/63 (9%) patients outside of this analysis the attempt was not successful, these patients were consecutively implanted with a non-HBP-device and therefor excluded from the further analysis. In the 63 patients included in this analysis with a primary successful pacing at the his-position, 5/63 (8%) his-bundle-leads dislocated within the first 48 hours, leading to a secondary success rate of 92%. There were two post-procedural pneumothorax that needed drainage, no major procedure-related complications occurred. Median skin-to skin procedure time was 111±47 minutes in his-bundle-device-implantation. The paced QRS width at the post-implantation follow up was 113±27ms with a change in QRS width of -15±39ms (+72; -92ms). The mean his-bundle sensing was 5,38±5,6mV and the mean threshold 1,1±0,86V over 1,0±0,5ms (0,4;1,5ms). The proportion of ventricular pacing was 75±36%. Conclusion Electroanatomic-guided His bundle pacing as a new innovative technic for physiological pacing is viable including high implantation success rate as well as electric impact, both regarding QRS width and pacing threshold.

Association between left ventricular lead position and intrinsic QRS morphology with regard to clinical outcome in cardiac resynchronization therapy for heart failure.

Left ventricular (LV) lead position may be an important factor for delivering effective cardiac resynchronization therapy (CRT). We therefore aimed to evaluate the effects of LV lead position, stratified by native QRS morphology, regarding the clinical outcome. A total of 1295 CRT-implanted patients were retrospectively evaluated. LV lead position was classified as lateral, anterior, inferior, or apical, and was determined using the left and right anterior oblique X-ray views. Kaplan Meier and Cox regression were performed to evaluate the effects on all-cause mortality and heart failure hospitalization, and the potential interaction between LV lead position and native ECG morphologies. A total of 1295 patients were included. Patients were aged 69 ± 7 years, 20% were female, 46% received a CRT-Pacemaker (vs. CRT-Defibrillator), mean LVEF was 25% ± 7%, and median follow-up was 3.3 years [IQR 1.6-5-7 years]. Eight hundred and eighty-two patients (68%) had a lateral LV lead location, 207 (16%) anterior, 155 (12%) apical, and 51 (4%) inferior. Patients with lateral LV lead position had larger QRS reduction (-13 ± 27 ms vs. -3 ± 24 ms, p < .001). Non-lateral lead location was associated with a higher risk for all-cause mortality (HR 1.34 [1.09-1.67], p = .007) and heart failure hospitalization (HR 1.25 [1.03-1.52], p = .03). This association was strongest for patients with native left or right bundle branch block, and not significant for patients with prior paced QRS or nonspecific intraventricular conduction delay. In patients treated with CRT, non-lateral LV lead positions (including apical, anterior, and inferior positions) were associated with worse clinical outcome and less reduction of QRS duration. This association was strongest for patients with native LBBB or RBBB.

Cardiac Resynchronization Therapy in Heart Failure in Sub-Saharan Africa Environment: Experience of the Principal Hospital of Dakar (Senegal)

Cardiac Resynchronization Therapy in Heart Failure in Sub-Saharan Africa Environment: Experience of the Principal Hospital of Dakar (Senegal)

Sex and Gender Bias as a Mechanistic Determinant of Cardiovascular Disease Outcomes.

Defined as a prejudice either for or against something, biases at the provider, patient, and societal level all contribute to differences in cardiovascular disease recognition and treatment, resulting in outcome disparities between sexes and genders. Provider bias in the under-recognition of female-predominant cardiovascular disease and risks might result in underscreened and undertreated patients. Furthermore, therapies for female-predominant phenotypes including nonobstructive coronary artery disease and heart failure with preserved ejection fraction are less well researched, contributing to undertreated female patients. Conversely, women are less likely toseek urgent medical attention, potentially related to societal bias to put others first, which contributes to diagnostic delays. Furthermore, women are less likely to have discussions around risk factors for coronary artery disease compared with men, partially because they are less likely to consider themselves at risk for heart disease. Provider bias in interpreting a greater number of presenting symptoms, some of which have been labelled as "atypical," can lead to mislabelling presentations as noncardiovascular. Furthermore, providers might avoid discussions around certain therapies including thrombolysis for stroke, and cardiac resynchronization therapy in heart failure, because it is incorrectly assumed that women are not interested in pursuing options deemed more invasive. To mitigate bias, organizations should aim to increase the visibility and involvement of women in research, health promotion, and clinical and leadership endeavours. More research needs to be done to identify effective interventions to mitigate sex and gender bias and the resultant cardiovascular outcome discrepancies.

Electroanatomic mapping system guided his bundle pacemaker implantation: experience of the his bundle registry graz

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients with bradyarrhythmia in need for ventricular pacing may suffer from pacing-induced heart failure due to unphysiological right ventricular pacing. His bundle pacing (HBP) allows to overcome this common issue with a more physiologic approach but real-life procedural data using this technology is scarce. Methods We report a single centre experience of the first 44 consecutive patients being implanted with a His-bundle-based pacemaker 09/2020-11/2021 per 3D-mapping guided implantation due to different types of bradyarrhythmia, or for cardiac resynchronisation therapy in heart failure combined with a left-ventricular lead (HOT-CRT) ± a right ventricular defibrillator lead. The positioning of the His-bundle-lead was done by identifying the His-bundle-location with a 3D electroanatomic mapping system via an introducing sheath that is provided with electrodes at its tip. Results Mean age was 70 [16;86] years, 12/44 (27%) patients were female, mean baseline LVEF was 44±18%. Baseline ECG was captured: QRS width was 123±33ms, with typical LBBB in 14/44 (32%), typical RBBB in 4/44 (9%), alternating BBB in one patient (2%) and either no BBB or ventricular escape rhythm in 25/44 (57%). Indications for implantation were AV-block grade II-III in 19/44 (43%), primary prophylactic ICD indication in HFrEF in 13/44 (30%), atrial fibrillation with bradycardic conduction in 7/44 patients (16%), sick-sinus-syndrome in 4/44 (9%) and secondary prophylactic ICD indication in one patient (2%). In 41/44 (93%) a primary device was implanted, in 3/44 (7%) a pre-existent device was upgraded with a HB lead. Therefore, 14 dual-chamber-pacemaker, 5 single-chamber-pacemaker, 8 single-chamber CRT-P, 11 dual-chamber CRT-P, 4 single-chamber CRT-D, 2 dual-chamber CRT-D were implanted. In 50 patients HBP was attempted, while in 6/50 (12%) patients outside of this analysis the attempt was not successful, these patients were consecutively implanted with a non-HBP-device and therefor excluded from the further analysis. In the 44 patients included in this analysis with primary successful HBP, 4/44 (9%) his-bundle-leads dislocated within the first 48 hours, leading to a secondary success rate of 91%. There were two post-procedural pneumothorax that needed drainage, no major procedure-related complications occurred. Median skin-to skin procedure time was 109±50 minutes. The paced QRS width at the post-implantation follow up was 115±32ms with a change in QRS width of -10ms (+72;-92ms). When excluding the secondary lead dislocations and including only the successful HB paced QRS complexes, the paced QRS width was 105±30ms and the change in QRS width was -12±42ms. The mean his-bundle threshold was 1,2±1V over 0,5ms (0,5;1,5ms). The proportion of ventricular pacing was 69±38%. Conclusion Electroanatomic-guided His bundle pacing is feasible, with high implantation success rate and electric impact, both regarding QRS width and pacing threshold.

Multi-lead pacing for cardiac resynchronization therapy in heart failure: a meta-analysis of randomized controlled trials.

AimsMulti-lead pacing is a potential therapy to improve response to cardiac resynchronization therapy (CRT) by providing rapid activation of the myocardium from multiple sites. Here, we perform a meta-analysis of randomized controlled trials to assess the efficacy of multi-lead pacing.Methods and resultsA literature search was performed which identified 251 unique records. After screening, 6 studies were found to meet inclusion criteria, with 415 patients included in the meta-analysis. Four studies performed multi-lead pacing with two left ventricular (LV) leads and one right ventricular (RV) lead. One study used two RV leads and one LV lead, and one study used both configurations. There was no difference between multi-lead pacing and conventional CRT in LV end-systolic volume [mean difference (MD) −0.54 mL, P = 0.93] or LV ejection fraction (MD 1.42%, P = 0.40). There was a borderline significant improvement in Minnesota Living With Heart Failure Questionnaire score for multi-lead pacing vs. conventional CRT (MD −4.46, P = 0.05), but the difference was not significant when only patients receiving LV-only multi-lead pacing were included (MD −3.59, P = 0.25). There was also no difference between groups for 6-min walk test (MD 15.06 m, P = 0.38) or New York Heart Association class at follow-up [odds ratio (OR) 1.49, P = 0.24]. There was no difference in mortality between groups (OR 1.11, P = 0.77).ConclusionThis meta-analysis does not support the use of multi-lead pacing for CRT delivery. However, significant variation between studies was noted, and therefore a benefit for multi-lead pacing in select patients cannot be excluded, and further investigation may be warranted.

Arrhythmic and Mortality Outcomes Among Ischemic Versus Nonischemic Cardiomyopathy Patients Receiving Primary ICD Therapy.

This study sought to determine the association of cardiomyopathy etiology with the likelihood of ventricular arrhythmias, appropriate implantable cardioverter-defibrillator (ICD) therapy, and mortality. There are conflicting data on the benefit of primary prevention ICD therapy in patients with ischemic versus nonischemic cardiomyopathy (ICM/NICM). The study population comprised 4803 patients with ICM (n=3,106) or NICM (n=1,697) with a primary prevention ICD enrolled in 5 randomized trials conducted between 1997 and 2017. The primary end point was sustained ventricular tachycardia (VT)≥200 beats/min or ventricular fibrillation (VF). Secondary end points included appropriate ICD therapy and all-cause mortality. Differences in cause-specific mortality, including noncardiac, sudden cardiac, and non-sudden cardiac death, were also examined. Patients with ICM were significantly older and had more comorbid conditions, whereas those with NICM had a more advanced heart failure class at enrollment and were more often prescribed medical or cardiac resynchronization therapy for heart failure. Multivariate analysis showed that ICM versus NICM had a similar risk of VT/VF events (HR: 0.98 [95%CI: 0.79-1.20]) and appropriate ICD therapy (HR: 1.03 [95%CI: 0.87-1.22]), whereas the risk of all-cause mortality was 1.8-fold higher among ICM versus NICM patients (HR: 1.84 [95%CI: 1.42-2.38]), dominated by non-sudden cardiac mortality. Combined data from 5 landmark ICD clinical trials show that ICM patients experience a similar risk of life-threatening ventricular arrhythmic events but have an increased risk of all-cause mortality, dominated by non-sudden cardiac death, compared with NICM patients.

Right ventricular function and its coupling to pulmonary circulation predicts exercise tolerance in systolic heart failure.

AimsRight ventricular (RV) dysfunction, pulmonary hypertension, and exercise intolerance have prognostic values, but their interrelation is not fully understood. We investigated how RV function alone and its coupling with pulmonary circulation (RV‐PA) predict cardio‐respiratory fitness in patients with heart failure and reduced ejection fraction (HFrEF).Methods and resultsThe Evaluation of Resynchronization Therapy for Heart Failure (EARTH) study included 205 HFrEF patients with narrow (n = 85) and prolonged (n = 120) QRS duration undergoing implantable cardioverter defibrillator implantation. All patients underwent a comprehensive evaluation with exercise tolerance tests and echocardiography. We investigated the correlations at baseline between RV parameters {size, function [tricuspid annular plane systolic excursion (TAPSE), RV fractional area change (RV‐FAC), and RV myocardial performance index (RV‐MPI)], pulmonary artery systolic pressure (PASP), and tricuspid regurgitation}; left ventricular ejection fraction (LVEF), left ventricular end‐diastolic volume index (LVEDVi), and left atrial volume index (LAVi); and cardiopulmonary exercise test (CPET) [peak VO2, minute ventilation/carbon dioxide production (VE/VCO2), 6 min walk distance (6MWD), and submaximal exercise duration (SED)]. We also studied the relationship between RV‐PA coupling (TAPSE/PASP ratio) and echocardiographic parameters in patients with both data available. Univariate and multivariate linear regression models were used. Patients enrolled in EARTH (overall population) were mostly male (73.2%), mean age 61.0 ± 9.8 years, New York Heart Association class II–III (87.8%), mean LVEF of 26.6 ± 7.7%, and reduced peak VO2 (15.1 ± 4.6 mL/kg/min). Of these, 100 had both TAPSE and PASP available (TAPSE/PASP population): they exhibited higher BNP, wider QRS duration, larger LVEDVi, with more having tricuspid regurgitation compared with the 105 patients for whom these values were not available (all P < 0.05). RV‐FAC (β = 7.5), LAVi (β = −0.1), and sex (female, β = −1.9) predicted peak VO2 in the overall population (all P = 0.01). When available, TAPSE/PASP ratio was the only echocardiographic parameter associated with peak VO2 (β = 6.8; P < 0.01), a threshold ≤0.45 predicting a peak VO2 ≤ 14 mL/kg/min (0.39 for VO2 ≤ 12). RV‐MPI was the only echocardiographic parameter associated with ventilatory inefficiency (VE/VCO2) and 6MWD (β = 21.9 and β = −69.3, respectively, both P ≤ 0.01) in the overall population. In presence of TAPSE/PASP, it became an important predictor for those two CPET (β = −18.0 and β = 72.4, respectively, both P < 0.01), together with RV‐MPI (β = 18.5, P < 0.01) for VE/VCO2. Tricuspid regurgitation predicted SED (β = −3.2, P = 0.03).ConclusionsRight ventricular function assessed by echocardiography (RV‐MPI and RV‐FAC) is closely associated with exercise tolerance in patients with HFrEF. When the TAPSE/PASP ratio is available, this marker of RV‐PA coupling becomes the stronger echocardiographic predictor of exercise capacity in this population, highlighting its potential role as a screening tool to identify patients with reduced exercise capacity and potentially triage them to formal peak VO2 and/or evaluation for advanced HF therapies.

Novel active fixation lead guided by electrical delay can improve response to cardiac resynchronization therapy in heart failure.

AimsCardiac resynchronization therapy (CRT) for heart failure (HF) recently has shown optimal results by targeting electrically delayed sites in coronary sinus (CS) branches. However this purpose often cannot be reached because of unstable left ventricular (LV) lead position. In current study were assessed the long‐term effects of the novel active fixation LV lead in CS, guided by electrical delay (QLV), in patients with HF due to coronary artery disease.MethodsOne hundred eighty‐five consecutive patients underwent CRT with intraoperative evaluation of QLV in the target position of the LV lead. When the novel active fixation LV lead was available, 98 consecutive patients received it, composing the Fix group. They were compared with 87 patients with a conventional passive fixation lead (No Fix group). The final LV lead position was assessed by fluoroscopy. Clinical response to CRT was assessed within a period of about 3 years: patients experiencing HF rehospitalization and death due to HF were defined as non‐responders.ResultsThere were no significant differences between groups in the final position of LV lead in left anterior oblique view (Pearson χ 2 = 0.12; P = 0.73). In right anterior oblique view, a basal position was reached more in the Fix group (38%) than in the No Fix group (6.5%) (Pearson χ 2 = 23.095; P < 0.001). QLV was significantly greater in the Fix group (122.6 ± 33.2 ms; SE = 3.6) than in the No Fix group (97.5 ± 37.8 ms; SE = 4.9) (t = 4.17; P < 0.001). Rehospitalizations for HF were 37 in the No Fix group and 14 in the Fix group. Deaths due to HF were 49 in the No Fix group and 18 in the Fix group. Survival analysis, assessed by Cox regression, showed that the Fix group had a better outcome both for HF rehospitalizations [hazard ratio (HR) = 0.48; 95% confidence interval (CI) = 0.25–0.9; P = 0.023] and death due to HF (HR = 0.55; 95% CI = 0.31–0.97; P = 0.04) in comparison with the No Fix group. Adjustment for baseline characteristics by multivariate analysis showed that an active fixation lead in CS, as a covariate, was still significant both for HF rehospitalizations (HR 0.46; 95% CI = 0.24–0.88; P = 0.019) and for death due to HF (HR 0.5; 95% CI = 0.28–0.9; P = 0.021).ConclusionsThe novel active fixation LV lead allowed to target sites with greater QLV. Often maximum QLV was documented in basal segments, were stability of conventional passive fixation leads is not enough. Patients receiving it experienced less HF rehospitalizations and less death due to HF. Active fixation lead in CS guided by QLV can improve long‐term prognosis in patients with HF due to coronary artery disease undergoing to CRT.

Evaluation of potential underuse of cardiac resynchronization therapy for heart failure with reduced ejection fraction.

BackgroundThe number of patients with chronic heart failure is increasing in Japan. However, the annual number of patients with heart failure who receive cardiac resynchronization therapy (CRT) has been constant in the last few years. In this study, we evaluated patients who did not receive CRT despite being eligible for this treatment to elucidate the clinical impact of CRT administration.MethodsWe assessed 214 patients with a left ventricular ejection fraction (LVEF) ≤ 50% (excluding patients treated with CRT) who underwent transthoracic echocardiography between January and May 2020 at our institution. The patients were stratified into two groups: Group A (n = 26; patients eligible for CRT) and Group B (n = 188; patients ineligible for CRT); however, all patients only received pharmacological therapy. We retrospectively analyzed the prognosis of these patients with respect to the cumulative number of hospitalizations for heart failure and cardiogenic deaths.ResultsWe observed no significant between‐group differences in age, sex, and severity/diagnosis of organic heart disease. Group A had a significantly higher number of hospitalizations for heart failure and cardiogenic deaths than Group B (log‐rank test, P < .01; hazard ratio, 3.05; 95% confidence interval, 1.31‐7.09; average follow‐up period, 675 days).ConclusionsThis study shows that 12% of patients were eligible for CRT. However, the implantation rate was low and no one was implanted. CRT is underutilized in patients who have heart failure with reduced LVEF. Therefore, we strongly recommend CRT for patients with indications for CRT.

Clinical Significance of Global Wasted Work in patients receiving Cardiac Resynchronization Therapy for Heart Failure

Risk stratification remains key in the management of patients with heart failure (HF). Besides enduring standards such as left ventricular (LV) ejection fraction, the amount of LV myocardial global wasted work (GWW) might better predict outcome in HF patients who are eligible for cardiac resynchronization therapy (CRT). The aim of this study is to evaluate the relation between preoperative GWW and outcome in a large prospective cohort of patients with heart failure and reduced ejection fraction (HFrEF) receiving CRT. The study included 249 HF patients. GWW was calculated by speckle tracking strain two-dimensional echocardiography using pressure-strain loops. The primary outcome of the study was all-cause death. A combined response to CRT defined as LV reverse remodeling and/or absence of hospitalization for HF was also studied. Median follow-up was 48 months (interquartile range 43-54). Median preoperative GWW was 281 (184-388) mmHg%. Preoperative GWW correlated with mortality during follow-up (hazard ratio (HR) 1.5 (1.1-2.0) per SD decrement, P = 0.006). After adjustment on established predictors of outcome in HFrEF patients receiving CRT, patients with GWW < 200 mmHg% remained at increased risk for all-cause death compared with those with GWW ≥ 200 mmHg% (adjusted HR, 2.0; 95%CI, 1.1–3.9; P = 0.0245). GWW had significant additional prognostic value for mortality prediction over the baseline model (Chi 2 to improve 4.85, P = 0.028). Preoperative GWW < 200 mmHg% also independently predicted absence of CRT response ( Fig. 1 ). A low preoperative GWW (< 200 mmHg%) increases the risk of all-cause death by two-fold and predicts the absence of CRT response in CRT recipients.

Regional protein expression changes within the left ventricle in a mouse model of dyssynchronous and resynchronized heart failure.

AimsThe biological mechanisms conveying the salutary effects of cardiac resynchronization therapy in heart failure remain elusive. We have recently developed a mouse model of heart failure with dyssynchrony/resynchronization. The aim of this study was to characterize regional left ventricular heterogeneity in protein expression comparing early (septum) and late (lateral) activated left ventricular wall segments in synchronous (SHF), dyssynchronous (DHF), and resynchronized heart failure (RHF).Methods and resultsMice subjected to ischaemia/reperfusion were divided into three groups: sinus rhythm for 4 weeks (SHF), right ventricular pacing for 4 weeks (DHF), and right ventricular pacing for 2 weeks and 2 weeks of sinus rhythm (RHF). Relative concentrations of 92 proteins from septal and lateral left ventricular wall segments (n = 10 per group) were compared within each group. We also analysed the effect of DHF vs. SHF and RHF vs. DHF on protein expression pattern comparing the same left ventricular segments between the groups. Proteins with significantly differential expression between left ventricular segments were analysed for protein–protein correlations, protein–protein interactions, and biological and signalling pathways. Eight proteins were significantly down‐regulated in the late activated (compared with early activated) lateral wall uniquely in RHF (P < 0.05 adjusted for a 5% false discovery rate): Erbb4, Ntf3, Pdgfb, Tnf, Notch3, Qdpr, Tpp1, and Itgb6. Protein correlation matrix showed that six of these were strongly and positively correlated and five had known protein–protein interactions. Biological pathways mainly down‐regulated in late activated myocardium in RHF were MAPK signalling and hypertrophic cardiomyopathy. There were no significantly differentially expressed proteins comparing the same left ventricular segments between the DHF and SHF (range of P‐values: 0.05–1.00) and RHF and DHF (range of P‐values: 0.32–1.00).ConclusionsIn a mouse model of heart failure with dyssynchrony and resynchronization, we observed down‐regulation of several proteins in the late activated lateral wall, compared with the septum, in resynchronized mice. These proteins display significant protein–protein correlation and share biological signalling pathways, including MAPK activation and hypertrophy signalling.

Right Ventricular Function Coupling to the Pulmonary Circulation Predicts Exercise Tolerance in Patients with Heart Failure and Reduced Ejection Fraction. Insight from the Evaluation of Resynchronization Therapy for Heart Failure (EARTH) Trial

Exercise tolerance has important prognostic value in patients with heart failure and reduced ejection fraction (HFrEF). The relationship between right ventricular function and its coupling to pulmonary circulation (RV-PA) and cardiopulmonary exercise tests (CPET) is not fully understood. We aimed to evaluate the value of RV echocardiographic parameters, including RV-PA, to predict exercise tolerance in HFrEF patients. We performed a sub-analysis of EARTH, which enrolled HFrEF patients undergoing defibrillator implantation. At baseline, an echocardiogram and various CPET [peak VO2; minute ventilation/carbon dioxide production slope (VE/VCO2); 6-minute walk distance (6MWD) and submaximal exercise duration (SED)] were performed. The primary outcome was the correlation of RV-PA (using TAPSE/sPAP, tricuspid annular plane systolic excursion on pulmonary artery systolic pressure ratio (T/P)) with peak VO2. Secondary outcomes include correlation between various RV parameters such as size [diameter at inlet and end-diastolic area in apical 4-chamber], RV function [TAPSE; right ventricular fractional area change (RV-FAC); RV myocardial performance index (RV-MPI)], sPAP and tricuspid regurgitation grade (TRG); and CPET variables. Univariate and multivariate linear regression models were used on patients for which both TAPSE and sPAP were available. 205 patients were enrolled in EARTH, with 100 having data on both TAPSE and sPAP (Men: 70.0%; NYHA class II: 55.0%; mean LVEF 26.5±7.8%). T/P was the only parameter found to be predictive of peak VO2 (β=6.8, p<0.01), together with BMI for 6MWD (β=72.4, p=0.04). ROC analysis for T/P value predictive of peak VO2 ≤14mL/kg/min showed sensitivity and specificity of 0.63 and 0.62 respectively, and area under the curve (AUC) of 0.66 (p<0.01) for an optimal threshold ≤0.45. T/P and RV-MPI were both predictors (β=-18.0, p<0.01; β=18.5, p<0.01 respectively) of VE/VCO2 slope, while only TRG and BMI predicted SED (β=-3.2, p=0.03). In HFrEF patients, RV-PA coupling (using TAPSE/sPAP) is a powerful predictor of maximal and submaximal exercise capacity and has a greater predictive value than the usual parameters including age, sex and LVEF.

Real-life data on heart failure and implantation of resynchronization devices in Tunisia

The aim of this study was to document clinical practice in Tunisia regarding the use of electronic cardiac devices in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). This is an ancillary analysis of the prospective NATURE HF registry (National TUnisian REgistry of Heart Failure). Between October 2017 and January 2019, we prospectively registered information of patients with heart failure and they were followed for one year. We analyzed data of patients with a diagnosis of HF, LVEF < 35% and indication for cardiac resynchronization therapy (CRT) devices with or without cardioverter-defibrillator, at the beginning of the study. Patients were followed for one year according to the practice of each center. A total of 2040 patients were included in the registry. Fifty-six of them received a CRT pacemaker (CRT-P; 40 patients) or CRT defibrillator (CRT-D; 16 patients). Mean age was 62 years and the most frequent causes of HF were ischemic. Overall mortality at one year was 16.1%. The hospitalization rate was 19.6%, significantly higher in patients with CRT-D than with CRT- P (12.5% vs. 37,5%, P = 0.03). The mortality rate was 16.1%, without any statistically significant difference in patients with CRT-P or CRT-D (12.5% vs. 25%, P = 0.25) ( Fig. 1 ). The NATURE HF registry shows that the use of cardiac resynchronization therapy in HF with reduced LVEF in Tunisia is in accordance with international recommendations but with lower rates which could be explained by the low income of the population.

P1584 Characteristics of a new subgroup in chronic heart failure: heart failure with mid-range ejection fraction (HFmrEF)

Abstract Introduction Classification of patients with heart failure is based on left ventricular ejection fraction (LVEF). Until recently, two types of patients had been distinguished based on LVEF: those with reduced ejection fraction (HFrEF) and those with HF with preserved ejection fraction (HFpEF). The ESC guidelines of 2016 introduced a third separate subgroup for patients with a LVEF in the range of 40-50%: Heart failure with mid-range ejection fraction (HFmrEF). Purpose The goal of this study is to characterize and compare this subgroup (HFmrEF) to the other two subgroups (HFpEF and HFrEF). Secondly, mortality rates were studied and compared, depending on LVEF classification and global longitudinal strain (GLS). Methods All patients with Chronic Heart Failure (CHF) seen at the heart failure clinic, during a 1-year period were enrolled in this retrospective study. As an inclusion criterion in our study population, we only allowed patients with chronic heart failure, who were treated at least once with diuretics or a cardiac resynchronization therapy for heart failure. After gathering data of the HF population, the 3 subgroups (HFrEF, HFpEF and HFmrEF) were compared on the basis of different parameters like comorbidities, lab results, medication, ECG and echocardiography. Results HFmrEF significantly differed from HFpEF concerning the following parameters: higher prevalence of male gender and ischemic aetiology, lower prevalence of valvular and hypertensive aetiology, more dilated left ventricles and higher usage of ACE inhibitors and betablockers. HFmrEF was similar to HFpEF concerning older age, high prevalence of tachyarrhythmia, low use of device therapy and aldosterone antagonists. The survival rate after 853 days was 81,6% in HFrEF, 76,3% in HFmrEF and 81,1% in HFpEF (p = 0,634). When looking at the whole patient population, the Kaplan Meier estimation was significant (p &amp;lt; 0,001) with a survival rate after 853 days of 33,3% for the group with lower absolute values than 6,3% for GLS and 85% for group with higher absolute strain values. Conclusion Patients with HFmrEF didn’t really differentiate as one class apart from HFrEF or HFpEF, but some characteristics were similar to HFrEF, and some others to HFpEF. Finally some characteristics of HFmrEF were more in a grey zone with none of the characteristics of both HFrEF nor HFpEF. The all cause survival rate in 853 days among the 3 LVEF based groups, were quite similar. While the Kaplan Meier estimation indicated a lot higher mortality when GLS&amp;gt;-6,3% compared to GLS &amp;lt;-6,3%. Classifying chronic HF patients is probably more complex than simply stratifying patients by LVEF cut-off values. One must not forget to take comorbidities and aetiology in mind while managing heart failure. Abstract P1584 Figure. Aetiology in LVEF based groups

MP02: Diagnostic, medical, and surgical interventions that reduce emergency hospital admissions: a systematic review of systematic reviews of 215 randomized controlled trials

Introduction: Emergency hospital admissions are a growing concern for patients and health systems, globally. The objective of this study was to systematically review the evidence for diagnostic, medical, and surgical interventions that reduce emergency hospital admissions. Methods: We conducted a systematic review of systematic reviews by searching MEDLINE, PubMED, the Cochrane Database of Systematic Reviews, Google Scholar, and grey literature. Systematic reviews of any diagnostic, surgical, or medical interventions examining the effect on emergency hospital admissions among adults were included. The quality of reviews was assessed using AMSTAR and the quality of evidence was assessed using GRADE. The subsequent analysis was restricted to interventions with moderate or high-quality evidence only. Results: 13 051 titles and abstracts and 1 791 full-text articles were screened from which 42 systematic reviews were included. The reviews included an underlying evidence base of 215 randomized controlled trials with 135 282 patients. Of 20 unique diagnostic, medical, and surgical interventions identified, four had moderate (n = 4) or high (n = 0) quality evidence for significant reductions in hospital admissions in five patient populations. These were: cardiac resynchronization therapy for heart failure and atrial fibrillation, percutaneous aspiration for pneumothorax, early/routine coronary angiography for acute coronary syndrome (alone or comorbid with chronic kidney disease), and natriuretic peptide guided therapy for heart failure. Conclusion: We identified four interventions across five populations that when optimized, may lead to reductions in emergency hospital admissions. These finding can therefore help guide the development of quality indicators, standards, or practice guidelines.