Who Are the Super-Responders to Cardiac Resynchronization Therapy?

Rocha, Eduardo Arrais; Pereira, Francisco; Quidute, Ana Rosa Pinto; Abreu, Janessa Sampaio de; Lima, José Wellington Oliveira; Sobrinho, Carlos Roberto Martins Rodrigues; Scanavacca, Maurício

doi:10.5935/2359-4802.20170020

Cited by 4 publications

(2 citation statements)

References 17 publications

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“…Jin reported that biventricular pacing percentage greater than 98% was a good predictor of a super-response [ 22 ]. Some data suggest that patients with non-ischemic cardiomyopathy and an absence of myocardial infarction receive the greatest benefit from CRT, while patients with ischaemic heart disease tend to respond to CRT to a less extent than patients with non-ischaemic cardiomyopathy [ 14 , 16 , 23 ]. According to PROSPECT sub-analysis, patients with ischaemic HF showed less improvement in LVESV after CRT, although it is noteworthy that 31.8% of them were classified as SRs [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

“…Thus, in real clinical practice, the significance of QRS morphology for patient selection to CRT is still not clear. The presence of left hemiblock in right bundle branch block patients improved outcomes and, according to Rocha et al, these patients also became SRs (46% of the total SRs) [ 23 , 25 ]. The success of CRT in patients with non-LBBB morphology of QRS can be associated with the presence of mechanical dyssynchrony [ 26 , 27 ].…”

Section: Discussionmentioning

confidence: 99%

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Echocardiographic markers of dyssynchrony as predictors of super-response to cardiac resynchronisation therapy – a pilot study

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Kasprzak

et al. 2018

Cardiovasc Ultrasound

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BackgroundSome patients with congestive heart failure have greater improvement of cardiac remodelling after cardiac resynchronisation therapy (CRT) and they are identified as super-responders (SRs). It remains unclear if echocardiographic markers of dyssynchrony could accuratelly predict super-response to CRT. The aim of this study is to evaluate potential echocardiographic predictors associated with super-response to CRT.MethodsFifthy nine CRT patients (mean age 52.9 ± 9.0 years, 88% men) with congestive heart failure (54% ischaemic and 46% non-ischaemic aetiology) II-IV NYHA functional class were enrolled. To assess mechanical dyssynchrony we evaluated interventricular mechanical delay, the maximum delay between peak systolic velocities of the septal and posterior walls of left ventricle, duration of left ventricular pre-ejection period (LVPEP), left ventricular and interventricular dyssynchrony by tissue Doppler imaging and systolic dyssynchrony index by 3D echocardiography. After six months the patients were assessed for response and classified as SRs (reduction in left ventricular end-systolic volume (LVESV) ≥30%, n = 20) and non-SRs (reduction in LVESV < 30%, n = 39) and baseline data were analyzed to identify the predictors.ResultsBoth groups demonstrated significant improvement in NYHA functional class, increase in left ventricular ejection fraction and reduction in LVESV. All parameters of mechanical dyssynchrony at baseline were significantly higher in SR group. Multiple logistic regression analysis showed that LVPEP (HR 1.031; 95% CI 1.007–1.055; p = 0.011) was an independent predictor for CRT super-response. In ROC curve analysis LVPEP with a cut-off value of 147 ms demonstrated 73.7% sensitivity and 75% specificity (AUC = 0.753; p = 0.002) for the prediction of super-response to CRT.ConclusionGreater mechanical dyssynchrony is associated with super-response to CRT in patients with congestive heart failure. It is probable that an LVPEP > 147 ms can be used as independent predictor of super-response.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Echocardiographic markers of dyssynchrony as predictors of super-response to cardiac resynchronisation therapy – a pilot study

Кузнецов

Солдатова

Kasprzak

et al. 2018

Cardiovasc Ultrasound

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Cardiac Resynchronization Therapy: the Structural Response Is not Always Necessary

Chiarini

Duarte

Silva

et al. 2019

J Cardiac Arrhtythmias

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Up to 30-40% of patients undergoing cardiac resynchronization therapy (CRT) are described as nonresponders since the initial studies. This paradigm has inspired several modifi cations of the devices, electrodes and surgical technique in the implant. The defi nition of CRT response should be rethought, standardized, and ratings based on structural and/or clinical response should be proposed. The authors discuss a series of cases in which sustained clinical improvement was achieved despite structural worsening. Objective: To assess the profi le of clinical responders to CRT who have worsened structurally. Method: It is a retrospective cohort of patients in outpatient follow-up from January 2012 to March 2017. We included 13 patients (2.7%) out of a total of 476 submitted to CRT. Inclusion criteria were to present an improvement in functional class according to the New York Heart Association criteria (FC-NYHA) ≥ 1 sustained for at least one year and absence of improvement or worsening of the structural parameters evaluated by transthoracic echocardiogram [ejection fraction (EF), diastolic diameter (LVDD) and systolic diameter (LVSD)]. The variables analyzed were age, gender, FC-NYHA, cardiopathy, echocardiographic and electrocardiographic parameters, medications in use, location of implanted electrodes, device programming, cardiary defi brillator therapies, and mortality. Statistical analysis was performed using non-parametric Wilcoxon and McNemar tests. Results: There were 13 patients, 92% male, mean age 60.9 ± 9.2 years and mean follow-up of 3.3 ± 1.1 years, 76% of CRT associated with implantable cardioverter defi brillator (CRT-D). In pre-implantation, 84.6% were in FC-NYHA III and then 61.5% were in FC-NYHA I (p = 0.001). The mean pre-implantation EF was 31.3 ± 7.6% and 26.6 ± 7.3 (p = 0.002) in the last evaluation. The predominant heart disease was non-ischemic in 92.5%, most of which were chagasic cardiomyopathy (CCM) (66%). In the TRC-D group, no shock therapy was recorded in the period; there was one death in a patient with ischemic cardiomyopathy (IC) for the septic shock of pulmonary focus after 2.2 years of follow-up. The mean QRS was 189.9 ± 23.1 ms to 157.9 ± 35.2 after CRT (p = 0.032). There was no signifi cant change in pre-and postimplant medications during follow-up. Conclusion: The absence of structural improvement should not be considered therapeutic failure, since CRT seeks to modify the electrical activation, and may be related to better performance and decrease of symptoms, even in evolutionary heart diseases.

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Terapia de Ressincronização Cardíaca: a Resposta Estrutural não se Faz Sempre Necessária

Chiarini

Duarte

Silva

et al. 2019

J Cardiac Arrhtythmias

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Até 30-40% dos pacientes submetidos à terapia de ressincronização cardíaca (TRC) são descritos como não respondedores desde os trabalhos iniciais. Esse paradigma tem inspirado diversas modificações dos dispositivos, eletrodos e técnica cirúrgica no implante. A definição de resposta à TRC deverá ser repensada, padronizada, e classificações pautadas na resposta estrutural e/ou clínica devem ser propostas. Os autores discutem uma série de casos em que se obteve melhora clínica sustentada a despeito da piora estrutural. Objetivo: Avaliar o perfi l dos pacientes respondedores clínicos à TRC que pioraram estruturalmente. Método: Trata-se de coorte retrospectiva de pacientes em seguimento ambulatorial de janeiro de 2012 a março de 2017. Foram incluídos 13 pacientes (2,7%) de um total de 476 submetidos à TRC. Os critérios de inclusão foram apresentar melhora da classe funcional pelos critérios da New York Heart Association (CF-NYHA) ≥ 1 sustentada por pelo menos um ano e ausência de melhora ou com piora dos parâmetros estruturais avaliados pelo ecocardiograma transtorácico [fração de ejeção (FE), diâmetro diastólico (DDVE) e diâmetro sistólico (DSVE)]. As variáveis analisadas foram idade, gênero, CF-NYHA, cardiopatia, parâmetros ecocardiográficos e eletrocardiográficos, medicações em uso, localização do implante dos eletrodos, programação do dispositivo, terapias do cardiodesfibrilador e mortalidade. A análise estatística foi realizada por meio dos testes não paramétricos de Wilcoxon e McNemar. Resultado: Foram 13 pacientes, sendo 92% do sexo masculino, idade média de 60,9 ± 9,2 anos e seguimento médio de 3,3 ± 1,1 anos, 76% de TRC associada a cardiodesfibrilador implantável (TRC-D). No pré-implante, 84,6% encontravam-se em CF-NYHA III e, em seguida, 61,5% estavam em CF-NYHA I (p = 0,001). A FE média pré-implante foi de 31,3 ± 7,6% e 26,6 ± 7,3 (p = 0,002) na última avaliação. A cardiopatia predominante foi a não isquêmica em 92,5%, sendo a maioria cardiomiopatia chagásica (CMC) (66%). No grupo TRC-D, não foi registrada terapia de choque no período; houve um óbito em um paciente com cardiomiopatia isquêmica (CMI) por choque séptico de foco pulmonar após 2,2 anos de seguimento. O QRS médio foi de 189,9 ± 23,1 ms para 157,9 ± 35,2 após TRC (p = 0,032). Não houve mudança significativa nas medicações administradas pré- e pós-implante durante o seguimento. Conclusão: A ausência de melhora estrutural não deve ser considerada falha terapêutica, pois a TRC procura modificar a ativação elétrica, podendo estar relacionada a melhor desempenho e diminuição dos sintomas, mesmo em cardiopatias evolutivas.

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Who Are the Super-Responders to Cardiac Resynchronization Therapy?

Abstract: Background: Patients submitted to cardiac resynchronization may develop response patterns that are higher than expected, with normalization of clinical and echocardiographic parameters.

Cited by 4 publications

References 17 publications

Echocardiographic markers of dyssynchrony as predictors of super-response to cardiac resynchronisation therapy – a pilot study

Echocardiographic markers of dyssynchrony as predictors of super-response to cardiac resynchronisation therapy – a pilot study

Cardiac Resynchronization Therapy: the Structural Response Is not Always Necessary

Terapia de Ressincronização Cardíaca: a Resposta Estrutural não se Faz Sempre Necessária

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