Browsing by Author "Daraban, Ana Maria (54887342600)"

Guidelines aim at translating inclusion criteria of high-quality clinical landmark trials into indications for treatment recommendations in order to guarantee a solid evidence base for the clinical practice. In the field of cardiac resynchronization therapy (CRT), the inclusion criteria of landmark trials that impacted the current recommendations for patient selection were left ventricular ejection fraction <-35%3,4, <-40%5), New York Heart Association (NYHA) Class (I-II,1,5 II,4 II-III,2 III,3 II-IV,6 III-IV7,8), and QRS width (>-120ms,2,5 >-130ms,4,7,9 >-150ms3,10). Recommendations have been further influenced by study results showing a better response of patients with left bundle branch block (LBBB) than non-LBBBmorphology. 11 The suggested possible harm of CRT implantation in patients with QRS duration less than 130 ms by some studies12 has led to increasing the threshold for CRT implantation from 120ms in 2013 guidelines13 to 130ms in the 2016 edition of the European guidelines.14 While this approach ensures a strong evidence base for a certain treatment, it does not necessarily guarantee the optimal strategy for patient selection, as relevant or potentially favourable selection criteria might not have been tested. In the case of CRT, which has become an established treatment option for patients with heart failure, left ventricular (LV) dysfunction and conduction delays, still approximately one-third of the patients remain non-responders to this costlyand invasive therapy.15 One such potential selection criterion, which is not considered in current guidelines is mechanical dyssynchrony. This is in particular due to the disappointing results of studies that tested the additional predictive value of parameters derived from the timing of longitudinal myocardial velocity peaks as surrogate of mechanical dyssynchrony, which failed to show any additional value over conventional guideline criteria despite promising results from single-centre studies.16 In the meantime, however, there is growing evidence that advanced concepts such as the detection of specific motion patterns could be a potential guide for CRT candidate selection.17,18 The PREDICT-CRT trial investigated the association between CRT outcome and a novel parameter of mechanical dyssynchrony, characterized by a short septal contraction pulling the apex septally ['septal flash' (SF)] followed by a delayed lateral wall contraction which causes a lateral motion of the apex ['apical rocking' (ApRock)]. This specific pattern of contraction in addition to similar parameters which rely on the same phenomena, have been shown to be strongly associated with better survival and CRT response.17,19-26 In this study, we relate current CRT guideline recommendations for patient selection with patient outcome and investigate the potential additive prognostic value of echocardiographic markers of mechanical dyssynchrony. © 2018. For permissions.

Objectives The aim of this study was to compare the volumetric response and the long-term survival after cardiac resynchronization therapy (CRT) in patients with intrinsic left bundle branch block (LBBB) versus chronic right ventricular pacing (RVP) with respect to the presence of mechanical dyssynchrony (MD). Background Chronic RVP induces an iatrogenic LBBB and asynchronous left ventricular contraction that is potentially reversible by upgrading to CRT. Methods A total of 914 patients eligible for CRT (117 with conventional pacemakers and 797 with intrinsic LBBB) were included in the study. MD was visually assessed before CRT and was defined as the presence of either apical rocking and/or septal flash on baseline echocardiograms. Patients with a left ventricular end-systolic volume decrease of ≥15% during the follow-up were considered responders. Patients were followed for all-cause mortality during the median follow-up of 48 months (interquartile range: 29 to 66 months). Results MD was observed in 51% of patients with RVP versus 77% in patients with intrinsic LBBB (p < 0.001). Patients with RVP and MD had a similar likelihood of volumetric response as did patients with intrinsic LBBB and MD (adjusted odds ratio: 0.71; 95% confidence interval: 0.33 to 1.53; p = 0.385). There was no significant difference in long-term survival between patients with RVP and intrinsic LBBB (adjusted hazard ratio: 1.101; 95% confidence interval: 0.658 to 1.842; p = 0.714). Patients with visual MD and either intrinsic LBBB or RVP had a more favorable survival than those without MD (p < 0.001). Conclusions The likelihood of volumetric response and a favorable long-term survival of patients with RVP was similar to those of patients with intrinsic LBBB and were mainly determined by the presence of MD and not by the nature of LBBB. © 2017 American College of Cardiology Foundation

Setting up a randomized trial to assess the association of mechanical dyssynchrony (MD) and the success of cardiac resynchronization therapy (CRT) in heart failure with a wide QRS complex is ethically challenging. We therefore investigated this association in a retrospective cohort study observing different treatment strategies which were chosen based on the availability of health care resources. The survival of 500 patients from six Western European centers treated with CRT was compared to their 137 Eastern European counterparts not treated with CRT, with regard to the presence of MD. MD was visually assessed and was defined as the presence of apical rocking and/or septal flash. Patients were followed for a mean of 26 ± 8 months for the occurrence of death of any cause. As compared with medical therapy alone, CRT was associated with a more favorable survival (hazard ratio (HR), 0.53; 95% confidence interval (CI) 0.35–0.79; P = 0.002). Patients with MD treated by CRT had better survival than patients belonging to all other groups—they showed 72%, 66% and 56% reduction in all-cause mortality, respectively, compared to patients with MD not treated by CRT (HR 0.28; 95% CI 0.17–0.44), patients without MD treated by CRT (HR 0.34; 95% CI 0.22–0.52) and patients without MD not treated by CRT (HR 0.44; 95% CI 0.25–0.76). Patients with wide QRS complex who are treated with CRT have a significantly better survival when MD is present. © 2020, Springer Nature B.V.

Aims: Clinical experience indicates that limited or no reverse left ventricular (LV) remodelling may not necessarily imply non-response to cardiac resynchronization therapy (CRT). We investigated the association of the extent of LV remodelling, mechanical dyssynchrony, and survival in patients undergoing CRT. Methods and results: In 356 CRT candidates, three blinded readers visually assessed the presence of mechanical dyssynchrony (either apical rocking and/or septal flash) before device implantation and also its correction by CRT 12 ± 3 months post-implantation. To assess LV reverse remodelling, end-systolic volumes (ESV) were measured at the same time points. Patients were divided into four subgroups: no LV remodelling (ESV change 0 ± 5%), mild LV reverse remodelling (ESV reduction 5-15%), significant LV reverse remodelling (ESV reduction ≥15%), and LV volume expansion (ESV increase ≥5%). Patients were followed for all-cause mortality during the median follow-up of 36 months. Patients with LV remodelling as in the above defined groups showed 58, 54, and 84% reduction in all-cause mortality compared to patients with volume expansion. In multivariable analysis, LVESV change remained independently associated with survival, with an 8% reduction in mortality for every 10% decrease in LVESV (P = 0.0039), but an optimal cut-off point could not be established. In comparison, patients with corrected mechanical dyssynchrony showed 71% reduction in all-cause mortality (P < 0.001). Conclusion: Volumetric response assessed at 1-year after CRT is strongly associated with long-term mortality. However, an optimal cut-off cannot be established. The association of the correction of mechanical dyssynchrony with survival was stronger than that of any volumetric cut-off. © The Author 2017.