Left ventricular dyssynchrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation

doi:10.1016/j.amjcard.2003.06.016

The American Journal of Cardiology

Volume 92, Issue 10, 15 November 2003, Pages 1238-1240

https://doi.org/10.1016/j.amjcard.2003.06.016 Get rights and content

Abstract

We evaluated patients with end-stage heart failure who have a high likelihood of response to cardiac resynchronization therapy (biventricular pacing). It appears that 20% of patients do not respond to this expensive therapy despite the use of selection criteria (dilated cardiomyopathy, heart failure, New York Heart Association class II or IV, left ventricular ejection fraction <35%, left bundle branch block, and QRS >120 ms). The presence of left ventricular dyssynchrony is needed to result in improvement after cardiac resynchronization therapy.

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Cited by (410)

Multimodality Imaging for Selecting Candidates for CRT: Do We Have a Single Alley to Increase Responders?
2024, Current Problems in Cardiology
Cardiac resynchronization therapy has evolved in recent years to provide a reduction of morbidity and mortality for many patients with heart failure. Its application and optimization is an evolving field and its use requires a multidisciplinary approach for patient and device selection, technical preprocedural planning, and optimization. While echocardiography has always been considered the first line for the evaluation of patients, additional imaging techniques have gained increasing evidence in recent years. Today different details about heart anatomy, function, dissynchrony can be investigated by magnetic resonance, cardiac computed tomography, nuclear imaging, and more, with the aim of obtaining clues to reach a maximal response from the electrical therapy. The purpose of this review is to provide a practical analysis of the single and combined use of different imaging techniques in the preoperative and perioperative phases of cardiac resynchronization therapy, underlining their main advantages, limitations, and information provided.
A method using deep learning to discover new predictors from left-ventricular mechanical dyssynchrony for CRT response
2023, Journal of Nuclear Cardiology
Studies have shown that the conventional parameters characterizing left ventricular mechanical dyssynchrony (LVMD) measured on gated SPECT myocardial perfusion imaging (MPI) have their own statistical limitations in predicting cardiac resynchronization therapy (CRT) response. The purpose of this study is to discover new predictors from the polarmaps of LVMD by deep learning to help select heart failure patients with a high likelihood of response to CRT.
One hundred and fifty-seven patients who underwent rest gated SPECT MPI were enrolled in this study. CRT response was defined as an increase in left ventricular ejection fraction (LVEF) > 5% at 6 ± 1 month follow up. The autoencoder (AE) technique, an unsupervised deep learning method, was applied to the polarmaps of LVMD to extract new predictors characterizing LVMD. Pearson correlation analysis was used to explain the relationships between new predictors and existing clinical parameters. Patients from the IAEA VISION-CRT trial were used for an external validation. Heatmaps were used to interpret the AE-extracted feature.
Complete data were obtained in 130 patients, and 68.5% of them were classified as CRT responders. After variable selection by feature importance ranking and correlation analysis, one AE-extracted LVMD predictor was included in the statistical analysis. This new AE-extracted LVMD predictor showed statistical significance in the univariate (OR 2.00, P = .026) and multivariate (OR 1.11, P = .021) analyses, respectively. Moreover, the new AE-extracted LVMD predictor not only had incremental value over PBW and significant clinical variables, including QRS duration and left ventricular end-systolic volume (AUC 0.74 vs 0.72, LH 7.33, P = .007), but also showed encouraging predictive value in the 165 patients from the IAEA VISION-CRT trial (P < .1). The heatmaps for calculation of the AE-extracted predictor showed higher weights on the anterior, lateral, and inferior myocardial walls, which are recommended as LV pacing sites in clinical practice.
AE techniques have significant value in the discovery of new clinical predictors. The new AE-extracted LVMD predictor extracted from the baseline gated SPECT MPI has the potential to improve the prediction of CRT response.
Relationship of echocardiographic left ventricular dyssynchrony with QRS width on surface electrocardiogram in patients with systolic heart failure: An observational study
2021, Indian Heart Journal
This study aimed to evaluate left ventricular dyssynchrony with QRS width on ECG in patients with systolic heart failure. 100 study patients were classified into two groups. Narrow QRS group-N- QRS (80-119 msec) and Wide QRS group-W- QRS (120-160 msec). Out of each 50 patients in W- QRS group, 38(76%) had LV dyssynchrony and 18 (36%) in N- QRS group had ventricular dyssynchrony. Dyssynchrony in narrow QRS patients with heart failure also needs attention as a therapeutic target in future studies.
Cardiac resynchronization therapy and device-based cardiac contractility modulation
2020, Emerging Technologies for Heart Diseases: Volume 1: Treatments for Heart Failure and Valvular Disorders
Heart Failure (HF) is a global epidemic characterized by significant morbidity and mortality. Cardiac resynchronization therapy (CRT) and cardiac contractility modulation (CCM) are two device-based therapies currently available for HF patients. CRT enables favorable remodeling and improves quality of life (QOL) and mortality in HF patients with systolic dysfunction and ventricular dyssynchrony. A significant minority of patients does not benefit from CRT, and considerable research efforts are dedicated to improving CRT response. CCM is an emerging technology which improves left ventricular energy dynamics and remodeling by delivering non-excitatory electrical signals during the absolute refractory period. Initial studies of CCM have shown improvements in QOL and functional capacity in HF patients with systolic dysfunction and intact ventricular synchrony. Larger studies with longer follow-up are required before CCM is adopted into routine practice. This chapter will review current applications of CRT and CCM as well as describe future directions and challenges.
Correlation between myocardial velocity measured using tissue doppler imaging in the left ventricular lead-implanted segment and response to cardiac resynchronization therapy
2019, Clinics
This study investigated whether tissue Doppler imaging parameters, especially the peak systolic velocity of the left ventricular lead-implanted segment (Ss), affect cardiac resynchronization therapy response.
In this case-control study, 110 enrolled patients were divided into cases (responder group, n=65) and controls (nonresponder group, n=45) based on whether their left ventricular end-systolic volume was reduced by ≥15% at 6 months after surgery. Preoperative clinical and echocardiographic data were collected. Multivariate logistic regression models were used to analyze the factors affecting the response to cardiac resynchronization therapy, and receiver operating characteristic curves were plotted to evaluate their diagnostic values.
The proportion of patients with left bundle branch block in the case group was higher than that in the control group. The control group showed a higher left atrial volume index, E/A ratio and E/Em ratio but lower Ss than that of the case group. A multivariate regression analysis showed that left bundle branch block, Ss, and an E/Em ratio>14 were independent risk factors affecting the response to cardiac resynchronization therapy. Ss=4.1 cm/s was the best diagnostic threshold according to the receiver operating characteristic curve.
Ss is an important factor affecting the response to cardiac resynchronization therapy. Patients with heart failure associated with Ss<4.1 cm/s have a higher risk of nonresponse.
Impact on long-term cardiovascular outcomes of different cardiac resynchronization therapy response criteria
2018, Revista Portuguesa de Cardiologia
There is a lack of consensus on the definition of response to cardiac resynchronization therapy (CRT), and it is not clear which response criteria have most influence on cardiac event-free survival.
To assess the predictive value of various response criteria in patients undergoing CRT and the agreement between them.
We performed a secondary analysis of the BETTER-HF trial. Patient response was classified at six months after CRT according to eleven criteria used in previous trials. The predictive value of response criteria for survival free from mortality, cardiac transplantation and heart failure hospitalization was assessed by Cox regression analysis. Agreement between the different response criteria was assessed using Cohen's kappa (κ).
A total of 115 patients were followed for a mean of 25 months. During follow-up, 15 deaths occurred (13%) and 29 patients had at least one adverse cardiac event (25%). Only five of the eleven response criteria were predictors of event-free survival. The most powerful isolated clinical and echocardiographic predictors were a reduction of ≥1 NYHA functional class (HR 0.39 for responders; 95% CI 0.18-0.83, p=0.014) and an increase of at least 15% in left ventricular ejection fraction (HR 0.43, 95% CI 0.20-0.90, p=0.024), respectively. Agreement between the different response criteria was poor.
Most currently used response criteria do not predict clinical outcomes and have poor agreement. It is essential to establish a consensus on the definition of CRT response in order to standardize studies.
Não existe consenso na definição de respondedor à ressincronização cardíaca (TRC), e desconhece-se qual o critério de resposta que poderá ter maior influência na sobrevida livre de eventos cardíacos.
Avaliar o valor preditivo de vários critérios de resposta em doentes submetidos à TRC, e analisar a concordância entre eles.
Subanálise do ensaio BETTER-HF. Os doentes foram classificados aos seis meses após TRC em respondedores, de acordo com onze critérios utilizados na literatura. O valor preditivo dos diferentes critérios de resposta para uma sobrevida livre de morte, transplante cardíaco e hospitalização por insuficiência cardíaca foi avaliado usando a regressão de Cox. A concordância entre os diferentes critérios foi avaliada usando o coeficiente k de Cohen.
115 doentes foram seguidos durante um período médio de 25 meses. Durante o follow-up ocorreram 15 mortes (13%) e 29 doentes tiveram, pelo menos, um evento cardíaco adverso (25%). Apenas cinco dos onze critérios de resposta foram preditores de sobrevida livre de eventos. Os preditores clínicos e ecocardiográficos isolados mais poderosos foram a redução de, pelo menos, uma classe funcional de NYHA (HR 0,39; IC 95% 0,18-0,83, p=0,014) e um aumento de, pelo menos, 15% na fração de ejeção ventricular esquerda (FEVE) (HR 0,43; IC 95% 0,20-0,90, p=0,024), respetivamente. A concordância entre os diferentes critérios de resposta foi fraca.
A maioria dos critérios de resposta utilizados não prevê outcomes clínicos e têm fraca concordância. É essencial criar um consenso na definição de resposta à TRC de forma a uniformizar os estudos.

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^☆: Dr. Molhoek is supported by grant 2001D015 and Dr. Bleeker is supported by grants 2002B109 and ICIN from the Dutch Heart Foundation, Utrecht, The Netherlands.

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Brief reportLeft ventricular dyssynchrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation☆

Abstract

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am Heart J

J Am Coll Cardiol

Am J Cardiol

Brief report
Left ventricular dyssynchrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation☆