Large variability in clinical judgement and definitions of left bundle branch block to identify candidates for cardiac resynchronisation therapy

Stipdonk, Antonius M.W. van; Vanbelle, Sophie; Horst, Iris A.; Luermans, Justin; Meine, M.; Maass, Alexander H.; Auricchio, Angelo; Prinzen, Frits W.; Vernooy, Kevin

doi:10.1016/j.ijcard.2019.01.051

Cited by 40 publications

(29 citation statements)

References 18 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…As a matter of fact, these patients may benefit from CRT instead . Third, as reported by van Stipdonk et al, different definitions (ESC, AHA/ACC/HRS, MADIT, and Strauss) have significant variation in the probability of classifying LBBB. As a result, it is better to compare all of these definitions for the impact of successful LBBAP.…”

Section: Discussionmentioning

confidence: 89%

Typical BBB morphology and implantation depth of 3830 electrode predict QRS correction by left bundle branch area pacing

Jiang

Qin

et al. 2019

Pacing Clinical Electrophis

View full text Add to dashboard Cite

Aim: Strict criteria of typical left bundle branch block (LBBB) can help with the prediction for cardiac resynchronization therapy response. The aim of this study is to determine whether the use of strict criteria for both LBBB and right bundle branch block (RBBB) predicts successful QRS correction (≤130 ms) by left bundle branch area pacing (LBBAP).Methods: Consecutive patients with pacemaker indications according to the present guideline who also underwent LBBAP implantation were retrospectively assessed. Inclusion criteria were patients with BBB and the baseline QRSd > 130 ms. Baseline characteristics and pacing parameters were compared between typical and atypical BBB groups. Multivariate logistic regression was used to adjust for covariates that were found in univariate analyses for successful QRS correction by LBBAP.Results: Seventy-three patients were enrolled. Among them, 10 (13.6%) had atypical BBB (5 LBBB and 5 RBBB) and 63 (86.4%) had typical BBB (30 LBBB and 33 RBBB). The rate of successful QRS correction was higher in typical-BBB patients (52/63; 82.5%) than that in atypical-BBB patients (3/10; 30%), P < .001. Paced QRSd was obviously narrower in patients with typical BBB than that in patients with atypical-BBB (118 ± 14 vs 133 ± 14 ms, P = .003). In multivariate logistic regression, only typical BBB morphology and the implantation depth of 3830 pacing electrode in the ventricular septum were independent predictors for successful QRS correction. Conclusion:This study demonstrates that patients with typical-BBB morphology benefit more from LBBAP for QRS correction. Typical BBB morphology together with deep penetration of 3830 ventricular electrode in the interventricular septum predicts the success of QRS correction by LBBAP. K E Y W O R D SLBBB, left bundle area pacing, morphology, QRS correction, RBBB, typical

show abstract

Section: Discussionmentioning

confidence: 89%

Typical BBB morphology and implantation depth of 3830 electrode predict QRS correction by left bundle branch area pacing

Jiang

Qin

et al. 2019

Pacing Clinical Electrophis

View full text Add to dashboard Cite

show abstract

“…The cut-off of 150 ms is based on subgroup analyses of large CRT trials which demonstrated that positive outcome of CRT was predominantly confined to patients with a QRS duration !150 ms [20]. While classifying LBBB may seem trivial for cardiologists, considerable intra-and inter-observer variability exists in whether a patient has LBBB or not [21]. There exist multiple criteria for diagnosis of LBBB and the strength of the association of LBBB to outcome in CRT depends on its classification [22].…”

Section: Traditional Determinants Of Crt Responsementioning

confidence: 99%

Non-invasive cardiac mapping for non-response in cardiac resynchronization therapy

et al. 2019

View full text Add to dashboard Cite

Cardiac resynchronization therapy (CRT) is an effective intervention in selected patients with moderate-to-severe heart failure with reduced ejection fraction and abnormal left ventricular activation time. The non-response rate of approximately 30% has remained nearly unchanged since this therapy was introduced 25 years ago. While intracardiac mapping is widely used for diagnosis and guidance of therapy in patients with tachyarrhythmia, its application in characterization of the electrical substrate to elucidate the mechanisms involved in CRT response remain anecdotal. In the present review, we describe the traditional determinants of CRT response before presenting novel non-invasive techniques used for CRT optimization. We discuss efforts to identify the target electrical substrate to guide the deployment of pacing electrodes during the operative procedure. Non-invasive body surface mapping technologies such as ECG imaging or ECG belt enables prediction of acute and chronic CRT response. While electrical dyssynchrony parameters provide high predictive accuracy for CRT response when obtained during intrinsic conduction, their predictive value is less when acquired during CRT or LV-pacing. KEY MESSAGES Classic predictors of CRT response are female gender, NYHA class III, left ventricular ejection fraction !25%, QRS duration !150 ms and estimated glomerular filtration rate !60 mL/min. ECG-imaging is a comprehensive non-invasive mapping system which allows to express the amount of electrical asynchrony of a CRT candidate. Non-invasive body surface mapping technologies enables excellent prediction of acute and chronic CRT response before implantation. When performed during CRT or LV-pacing, the added value of these mapping systems remains unclear.

show abstract

“…Their HFQRS maps express a rather RBBB pattern, and special attention should be paid to the biventricular stimulator settings if ever implanted. The proper setting of cut-off values (QRSd, definitions of notches and slurs), as well as the debate about the best definition of SLBBB based on QRS shape, remains wide open [17, 18, 19, 20]. SLBBB classification is a binary parameter defined from multiple binary sub-parameters such as QRSd and the occurrence of notches and slurs.…”

Section: Discussionmentioning

confidence: 99%

The relationship between ECG predictors of cardiac resynchronization therapy benefit

et al. 2019

View full text Add to dashboard Cite

Introduction Cardiac resynchronization therapy (CRT) is an effective treatment that reduces mortality and improves cardiac function in patients with left bundle branch block (LBBB). However, about 30% of patients passing the current criteria do not benefit or benefit only a little from CRT. Three predictors of benefit based on different ECG properties were compared: 1) “strict” left bundle branch block classification (SLBBB); 2) QRS area; 3) ventricular electrical delay (VED) which defines the septal-lateral conduction delay. These predictors have never been analyzed concurrently. We analyzed the relationship between them on a subset of 602 records from the MADIT-CRT trial. Methods & results SLBBB classification was performed by two experts; QRS area and VED were computed fully automatically. High-frequency QRS (HFQRS) maps were used to inspect conduction abnormalities. The correlation between SLBBB and other predictors was R = 0.613, 0.523 and 0.390 for VED, QRS area in Z lead, and QRS duration, respectively. Scatter plots were used to pick up disagreement between the predictors. The majority of SLBBB subjects– 295 of 330 (89%)–are supposed to respond positively to CRT according to the VED and QRS area, though 93 of 272 (34%) non-SLBBB should also benefit from CRT according to the VED and QRS area. Conclusion SLBBB classification is limited by the proper setting of cut-off values. In addition, it is too “strict” and excludes patients that may benefit from CRT therapy. QRS area and VED are clearly defined parameters. They may be used to optimize biventricular stimulation. Detailed analysis of conduction irregularities with CRT optimization should be based on HFQRS maps.

show abstract

Large variability in clinical judgement and definitions of left bundle branch block to identify candidates for cardiac resynchronisation therapy

Cited by 40 publications

References 18 publications

Typical BBB morphology and implantation depth of 3830 electrode predict QRS correction by left bundle branch area pacing

Typical BBB morphology and implantation depth of 3830 electrode predict QRS correction by left bundle branch area pacing

Non-invasive cardiac mapping for non-response in cardiac resynchronization therapy

The relationship between ECG predictors of cardiac resynchronization therapy benefit

Contact Info

Product

Resources

About