Highlighting the
            <i>R</i>
            in CRT

Kass, David A.

doi:10.1161/circulationaha.107.728748

Cited by 9 publications

(3 citation statements)

References 29 publications

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“…Thus, in patients without a favorable clinical or echocardiographic response to CRT, the proportion in whom the therapy provided (BiV pacing) simply failed to improve the causative pathophysiology (LV dyssynchrony) remains unknown. 6 …”

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confidence: 99%

A Prospective Pilot Study to Evaluate the Relationship Between Acute Change in Left Ventricular Synchrony After Cardiac Resynchronization Therapy and Patient Outcome Using a Single-Injection Gated SPECT Protocol

Friehling

Chen

Saba

et al. 2011

Circ: Cardiovascular Imaging

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Background There are ongoing efforts to optimize patient selection criteria for cardiac resynchronization therapy (CRT). In this regard, the relationship between acute change in left ventricular synchrony (LV) after CRT and patient outcome remains undefined. Methods and Results A novel protocol was designed to evaluate acute change in left LV synchrony after CRT using phase analysis of standard gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging with a single injection of radiotracer and prospectively applied to 44 patients undergoing CRT. Immediately after CRT, 18 (41%), 11 (25%), and 15 (34%) patients had an improvement, no change, or a worsening in LV synchrony. An algorithm incorporating the presence of baseline dyssynchrony, myocardial scar burden, and lead concordance predicted acute improvement or no change in LV synchrony with 72% sensitivity, 93% specificity, 96% positive predictive value, and 64% negative predictive value and had 96% negative predictive value for acute deterioration in synchrony. Over a follow-up period of 9.6±6.8 months, patients who had an acute deterioration in synchrony after CRT had a higher composite event rate of death, heart failure hospitalizations, appropriate defibrillator discharges, and CRT device deactivation for worsening heart failure symptoms, compared with patients who had an improvement or no change [hazard ratio, 4.6 (1.3 to 16.0); log rank test; P=0.003]. Conclusions In this single-center pilot study, phase analysis of gated SPECT was successfully used to predict acute change in LV synchrony and patient outcome after CRT.

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confidence: 99%

A Prospective Pilot Study to Evaluate the Relationship Between Acute Change in Left Ventricular Synchrony After Cardiac Resynchronization Therapy and Patient Outcome Using a Single-Injection Gated SPECT Protocol

Friehling

Chen

Saba

et al. 2011

Circ: Cardiovascular Imaging

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“…However, we have shown that the optimization of pharmacological treatment during the first year of follow‐up was associated with a relative risk reduction of HF/death, which suggests a complementary effect of CRT and up‐titration of pharmacological therapy. The reason for this improvement might be that CRT provides acute hemodynamic improvement,19, 20, 21, 22 with an increase in cardiac output and a reduction in pulmonary capillary wedge and improvement in the mechanical activation sequence. Cardiac resynchronization therapy also supports systemic blood pressure and heart rate, enabling an increase in the doses of drugs without the associated risk of lethal bradycardia and hypotension.…”

Section: Discussionmentioning

confidence: 99%

Cardiac resynchronization therapy outcomes in patients under nonoptimal medical therapy

Álvarez‐Álvarez

García‐Seara

Martínez‐Sande

et al. 2018

Journal of Arrhythmia

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BackgroundCardiac resynchronization therapy (CRT) is indicated in symptomatic heart failure (HF) patients after achieving optimal medical therapy (OMT). However, many patients may not be under OMT when the CRT device is implanted. Here, we evaluate the long‐term benefits of CRT in symptomatic HF patients receiving or not OMT.MethodsWe investigated the effect of OMT on HF developing or death in 328 consecutive patients with a CRT device implanted between 2005 and 2015 in a single tertiary center. After the CRT implant, we categorized the patients into three groups: no OMT, OMT at baseline and after 1 year of follow‐up, and OMT only at the 1‐year follow‐up but not at baseline. We used multivariate Cox proportional hazards model to determine the effect of OMT on clinical outcomes.ResultsOne hundred and twenty‐two patients (37.2%) received OMT prior to CRT. OMT at baseline was not associated with a reduced risk of death or HF (HR 0.72; 95% CI 0.50‐1.02; P = 0.067) compared with no‐basal‐OMT patients. After CRT, patients without OMT had a higher risk of death or HF than patients who received OMT in follow‐up (HR 1.72, 95% CI 1.07‐2.78, P = 0.025), and the risk of the patients who received OMT at baseline and at the 1‐year follow‐up was similar to that of the patients who achieved OMT at the 1‐year follow‐up (HR 0.90, 95% CI 0.54‐1.50, P = 0.682).ConclusionBasal OMT prior to CRT is not associated with better outcomes in terms of HF/death compared with no basal OMT. The subgroup of patients who achieved OMT at the 1‐year follow‐up exhibited a reduced risk of HF and death compared with patients who did not.

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“…Others have suggested that non-responders do not display the same extent of improvement in some gene expression abnormalities as responders 24 , though this does not address whether a molecular signature may predict a future lack of response independent of apparent mechanical dysynchrony. It is worth repeating that while studies have claimed improvement in mechanical dysynchrony is mandatory for a clinical CRT response, the correlation between response (reverse remodeling based on reduction in end-systolic volume) and the extent of resynchronization (tissue Doppler) is poor to non-existent 19,32 . While this could reflect our metrics, differences in underlying myocardial pathobiology may indeed play an important role in explaining the variance.…”

Section: Mechanisms For Molecular/cellular Changes and Possible Role mentioning

confidence: 99%

Pathobiology of cardiac dyssynchrony and resynchronization

Kass

2009

Heart Rhythm

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Cardiac resynchronization therapy (CRT) represents the major new advance for the treatment of heart failure since the new millennium. With this therapy, failing hearts with discoordinate contraction due to conduction delay are subjected to bi-ventricular stimulation to “resynchronize” contraction and improve chamber function. Remarkably, CRT was mostly developed and tested in patients first, and the speed at which the concept became translated to an approved clinical therapy was unusually quick. To date, CRT is the only treatment for heart failure that can both acutely and chronically improve the systolic pump performance of the human failing heart, yet also enhances long term survival. This raises the importance of understanding how CRT works at the molecular and cellular level, as these insights might shed light on new approaches to treating heart failure more generally. Over the past 7 years, my laboratory and others at Johns Hopkins developed novel animal models to start to address this question, and new results are revealing intriguing insights into the mechanisms of CRT. This review, presented on the occasion of the 4th Annual Douglas Zipes Lecture at the 2009 Scientific Sessions of the Heart Rhythm Society, highlights these advances and new directions in CRT research.

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Highlighting the R in CRT

Cited by 9 publications

References 29 publications

A Prospective Pilot Study to Evaluate the Relationship Between Acute Change in Left Ventricular Synchrony After Cardiac Resynchronization Therapy and Patient Outcome Using a Single-Injection Gated SPECT Protocol

A Prospective Pilot Study to Evaluate the Relationship Between Acute Change in Left Ventricular Synchrony After Cardiac Resynchronization Therapy and Patient Outcome Using a Single-Injection Gated SPECT Protocol

Cardiac resynchronization therapy outcomes in patients under nonoptimal medical therapy

Pathobiology of cardiac dyssynchrony and resynchronization

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