Longer right to left ventricular activation delay at cardiac resynchronization therapy implantation is associated with improved clinical outcome in left bundle branch block patients

Kosztin, Annamária; Kutyifa, Valentina; Nagy, Vivien Klaudia; Gellér, László; Zima, Endre; Molnár, Levente; Szilágyi, Szabolcs; Özcan, Emin Evren; Merkely, Béla

doi:10.1093/europace/euv117

Cited by 20 publications

(27 citation statements)

References 23 publications

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“…1A). This difference translated into a 77% reduction in the risk of HF or death (HR = 0.23; 95% CI 0.11-0.49; p < 0.001), after adjustment for relevant clinical covariates [25]. Similar findings were observed for all-cause mortality (Fig.…”

Section: Procedure-related Parameterssupporting

confidence: 72%

“…In a few small studies the RV-LV AD or QRS to LV sensed (Q-LV) delay [23,24] were able to predict the clinical and echocardiographic response to CRT. In a pro-spective study of our group, during a median follow-up of 2.2 years, 44 (35%) patients experienced HF events or death, and 36 (29%) patients died [25]. Patients with a longer activation delay (RV-LV AD ≥ 86 ms) had a lower rate of HF and death analysed cumulatively as compared to those with RV-LV AD < 86 ms. All-cause mortality occurred less frequently in the former group compared to the latter group.…”

Section: Procedure-related Parametersmentioning

confidence: 85%

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Cardiac resynchronisation therapy: current benefits and pitfalls

et al. 2018

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Cardiac resynchronisation therapy (CRT) has been shown to reduce all-cause mortality, heart failure events, and symptoms while improving exercise capacity and quality of life. Nevertheless, despite a large number of multicentre randomised trials and clear evidence confirming the above, there is still a higher number of patients who fail to develop reverse remodelling. In order to select the optimal patient population, the current European Society of Cardiology guidelines recommend a simultaneous evaluation of QRS morphology and width. However, based on recent data, QRS width itself is a less accurate parameter in the prediction of the outcome, as compared to QRS morphology. Furthermore, the baseline left ventricular (LV) ejection fraction (LVEF), which is also an known criterion for selecting CRT candidates (partly applied due to cost-benefit reasons), can be misleading. Data showed that patients with LVEF > 35% might also benefit from this type of treatment. Thus, LVEF should be evaluated less rigorously when screening patients for resynchronisation therapy. While the subsequent beneficial response to CRT is multifactorial, procedure-related parameters, such as LV lead position, are also crucial. The first data released recently confirmed the previous empiric clinical experience indicating that the LV lead should be implanted into the lateral or posterior coronary sinus side branch. This location was associated with a better long-term clinical outcome in terms of death and heart failure events. Some issues related to CRT are awaiting further clarification, such as the choice of the type of the implanted device (pacemaker or defibrillator) or the decision about CRT device upgrade. This review discusses the current evidence regarding the above, focusing on the questions that should be handled with caution or require clarification.

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Section: Procedure-related Parameterssupporting

confidence: 72%

Section: Procedure-related Parametersmentioning

confidence: 85%

Cardiac resynchronisation therapy: current benefits and pitfalls

et al. 2018

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“…Third, recent work has highlighted the potential survival benefit associated with electric-based LV lead implantation strategies in CRT. 27 Given the association between persistent MR and decreased survival in CRT, 3,4 our findings suggest a potential role for an electric-based optimization strategy post implant (eg, RV-LV electric distance and paced QRS width) particularly in those with nonresponse (clinical and echocardiographic) or persistent MR after CRT. Final, the impact of CRT on MR remains a point of active investigation with an emerging recognition of novel applications of LV pacing for the treatment of MR in heart failure.…”

Section: Discussionmentioning

confidence: 68%

“…First, conflicting findings about the benefits of anatomic-based lead targeting strategies 11,12 have refocused interest in electric-targeting strategies, such as LV electric delay (ie, QLV) or RV-LV electric delay. 27 Longer QLV has been associated with acute hemodynamic benefits, 10 6-month reverse remodeling, 9 and clinical outcomes 12-month postimplant. 8 With the expanding use of multisite LV Table III in the Data Supplement. †MR response was assessed in patients with >mild MR (N=225).…”

Section: Discussionmentioning

confidence: 99%

Longer Left Ventricular Electric Delay Reduces Mitral Regurgitation After Cardiac Resynchronization Therapy

Chatterjee¹,

Gold²,

Picard³

et al. 2016

Circ: Arrhythmia and Electrophysiology

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Background-Mitral regurgitation (MR) is associated with worse survival in those undergoing cardiac resynchronization therapy (CRT). Left ventricular (LV) lead position in CRT may ameliorate mechanisms of MR. We examine the association between a longer LV electric delay (QLV) at the LV stimulation site and MR reduction after CRT. Methods and Results-QLV was assessed retrospectively in 426 patients enrolled in the SMART-AV study (SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in CRT). QLV was defined as the time from QRS onset to the first large peak of the LV electrogram. Linear regression and logistic regression were used to assess the association between baseline QLV and MR reduction at 6 months (absolute change in vena contracta width and odds of ≥1 grade reduction in MR). At baseline, there was no difference in MR grade, LV dyssynchrony, or LV volumes in those with QLV above versus below the median (95 ms). After multivariable adjustment, increasing QLV was an independent predictor of MR reduction at 6 months as reflected by an increased odds of MR response (odds ratio: 1.13 [1.03-1.25]/10 ms increase QLV; P=0.02) and a decrease in vena contracta width (P<0.001). At 3 months, longer QLV (≥median) was associated with significant decrease in LV end-systolic volume (∆LV end-systolic volume −28.2±38.9 versus −4.9±33.8 mL, P<0.001). Adjustment for 3-month ΔLV end-systolic volume attenuated the association between QLV and 6-month MR reduction. Conclusions-In patients undergoing CRT, longer QLV was an independent predictor of MR reduction at 6 months and associated with interval 3-month LV reverse remodeling. These findings provide a mechanistic basis for using an electrictargeting LV lead strategy at the time of CRT implant. (Circ Arrhythm Electrophysiol. 2016;9:e004346.

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“…While the presented risk score is useful in predicting the long-term clinical outcome, it has some weaknesses, such as the lack of procedure-related parameters, e.g. the targeted coronary sinus side branch or the activation delays between the right and left ventricular leads, which might also influence the outcome of patients after CRT implantation [5].…”

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confidence: 99%

Application of “AL-FINE CRT” risk score before cardiac resynchronisation therapy implantation

Kosztin¹,

Boros²,

Geller³

et al. 2018

Kardiol Pol

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Article Kisiel et al., see p. 1441 The study by Kisiel et al. [1] retrospectively investigated the prognostic value of various parameters in 552 chronic heart failure patients undergoing cardiac resynchronisation therapy (CRT). The goal of the study was to set up a risk score system able to predict long-term mortality following CRT implantation and easily applicable in clinical practice.The main strength of the created score system, termed "AL-FINE CRT score" (Age [> 75 years], non-LBBB morphology [according to Strauss criteria], Furosemide dose [> 80 mg], Ischaemic aetiology, NYHA class (> III) and left ventricular EF [< 20%]), lies in the fact that its components can be easily obtained during the routine preimplantation check-up (medical history, physical examination, electrocardiography, and echocardiography) to assess the long-term mortality risk. The presence of any of the above variables equates to one point, so a maximum of six points could be achieved. Depending on the AL-FINE CRT score, the patients can be divided into three risk categories: low risk (0-1 points, five-year survival of approx. 80%), medium risk (2 points, five-year survival of approx. 60%), and high risk (3-6 points, five-year survival of approx. 40%). A high-risk score, according to the authors, should alert both the physician and the patient to evaluate the long-term benefit of the procedure more realistically and should identify those patients, in whom the implantation procedure might require more attention and maybe more experienced implanters in order to maximise the benefit [1]. The identified high-risk patients might also need "special care" following the implantation: more frequent follow-ups, strict device optimisation, multidisciplinary patient care, aggressive up-titration of medication, participation in rehabilitation programs, etc. Nevertheless, because the results are derived from a retrospective analysis, further prospective studies should validate the usefulness of the AL-FINE CRT model.Altogether there is a clear need to create applicable risk scores for patients who have undergone CRT implantation, to predict their long-term outcome. However, the validation and further assessment of the utility of such a score system are always challenging. A risk score system should not only be useful in risk prediction, but ideally it should also allow the clinicians to guide therapy or make therapeutic decisions, for instance regarding the choice of the device (implantable defibrillator [CRT-D] vs. pacemaker [CRT-P]), or the selection of pacemaker patients requiring CRT upgrade. To date, no such risk score systems exist, and the current guidelines do not clearly define the decision algorithm for the above processes [2,3]. On the other hand, one should be cautious about relying on risk score systems alone, as an automated procedure, because the therapeutic decisions, circumstances of the implantation, and further device programming also have an impact on the long-term clinical outcome of patients; therefore, risk score systems are ...

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Longer right to left ventricular activation delay at cardiac resynchronization therapy implantation is associated with improved clinical outcome in left bundle branch block patients

Cited by 20 publications

References 23 publications

Cardiac resynchronisation therapy: current benefits and pitfalls

Cardiac resynchronisation therapy: current benefits and pitfalls

Longer Left Ventricular Electric Delay Reduces Mitral Regurgitation After Cardiac Resynchronization Therapy

Application of “AL-FINE CRT” risk score before cardiac resynchronisation therapy implantation

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