Impaired Recovery of Left Ventricular Function in Patients With Cardiomyopathy and Left Bundle Branch Block

Sze, Edward; Samad, Zainab; Dunning, Allison; Campbell, Kevin R; Loring, Zak; Atwater, Brett D.; Chiswell, Karen; Kisslo, Joseph; Velázquez, Eric J.; Daubert, James P.

doi:10.1016/j.jacc.2017.11.020

Cited by 83 publications

(64 citation statements)

References 43 publications

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“…Some patients who exhibit left bundle branch block (LBBB) improve less on optimal medical therapy alone and often present mid-range EF. [ 47 ] This association of LBBB and HFmrEF raises the question as to whether this cohort of patients may benefit significantly from expanding the indications for implantation of a CRT device to LVEF >35%, particularly in the absence of reasons other than LBBB itself as the cause of LV dysfunction. [ 48 ]…”

Section: Predictors Of Lvef Transitionmentioning

confidence: 99%

Heart Failure With Mid-range or Recovered Ejection Fraction: Differential Determinants of Transition

et al. 2020

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The recent definition of an intermediate clinical phenotype of heart failure (HF) based on an ejection fraction (EF) of between 40% and 49%, namely HF with mid-range EF (HFmrEF), has fuelled investigations into the clinical profile and prognosis of this patient group. HFmrEF shares common clinical features with other HF phenotypes, such as a high prevalence of ischaemic aetiology, as in HF with reduced EF (HFrEF), or hypertension and diabetes, as in HF with preserved EF (HFpEF), and benefits from the cornerstone drugs indicated for HFrEF. Among the HF phenotypes, HFmrEF is characterised by the highest rate of transition to either recovery or worsening of the severe systolic dysfunction profile that is the target of disease-modifying therapies, with opposite prognostic implications. This article focuses on the epidemiology, clinical characteristics and therapeutic approaches for HFmrEF, and discusses the major determinants of transition to HFpEF or HFrEF.

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Section: Predictors Of Lvef Transitionmentioning

confidence: 99%

Heart Failure With Mid-range or Recovered Ejection Fraction: Differential Determinants of Transition

et al. 2020

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“…[9][10][11] More recent work now suggests that LBBB in itself may represent a previously unrecognized cause of LV dysfunction and may impair left ventricular recovery. 12 In the present analysis the authors set out to investigate the LBBB and its relationship with mechanical dyssynchrony using myocardial perfusion imaging (MPI) and vector electrocardiography (VECG, another surrogate of mechanical myocyte activation, derived form an ECG analysis). In a retrospective analysis the authors selected 45 patients with LBBB and 24 controls out of a cohort of 994 patients.…”

Section: See Related Article Pp 1227-1239mentioning

confidence: 99%

A troubled marriage: When electrical and mechanical dyssynchrony don’t go along

Fudim

Borges‐Neto²

2019

Journal of Nuclear Cardiology

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The following editorial refers to the article published by Sillanmäki et al. titled ''Relationships between electrical and mechanical dyssynchrony in patients with left bundle branch block and healthy controls'' in the XX edition of the Journal of Nuclear Cardiology.Mechanical contraction of the heart muscle is initiated by electrical activation of myocytes. Left ventricular mechanical dyssynchrony (LVMD) refers to a difference in the timing of mechanical contraction or relaxation between different segments of the left ventricle (LV). It is important to acknowledge that mechanical dyssynchrony does not equal electrical dyssynchrony which is defined by an asynchronous electrical activation of the LV leading to a prolonged QRS duration ([ 120 ms) on the ECG, and is usually the result of a left bundle branch block (LBBB). Although electrical and mechanical dyssynchrony often coincide, electrical and mechanical dyssynchrony are commonly not present at the same time in a given patient. 1,2 Cardiac resynchronization therapy (CRT) was developed with the goal to treat mechanical dyssynchrony with the hope it will improve cardiac performance and improve outcomes. [3][4][5] Right at the getgo the simple assumption was made that electrical dyssynchrony and mechanical dyssynchrony track well with each other, and since it is so much easier to mea-sure and quantify electrical dyssynchrony (presence of absence of a LBBB and QRS width), the electrical dyssynchrony on ECG became the designated target of CRT. Currently, presence of electrical dyssynchrony is among the inclusion criteria for CRT in heart failure (HF) patients. Other criteria include left ventricular ejection fraction (LVEF) B 35% and New York Heart Association class II-IV despite optimal medical therapy. Under those criteria, biventricular pacing has been shown to reduce all-cause mortality. 6 Nonetheless, among patients who meet the criteria, around 30% to 40% fail to show an improvement in clinical symptoms and cardiac function, 7 suggesting the need for a more efficient selection of CRT candidates to improve patient outcomes and decrease costs. Today we know that diseased hearts with electrical dyssynchrony do not equally respond to CRT. The two key determinants of treatment response that emerged are QRS width and presence of LBBB. Meta-analysis of three randomized trials suggests that a wide QRS duration [ 150 ms, regardless of QRS morphology, is most important for CRT response. 8 Further, the majority of clinical trials that studied CRT have found that it is mostly efficacious in patients with LBBB. 9-11 More recent work now suggests that LBBB in itself may represent a previously unrecognized cause of LV dysfunction and may impair left ventricular recovery. 12 In the present analysis the authors set out to investigate the LBBB and its relationship with mechanical dyssynchrony using myocardial perfusion imaging (MPI) and vector electrocardiography (VECG, another surrogate of mechanical myocyte activation, derived form an ECG analysis). In a retrospective analys...

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“…Prior studies have shown an increased risk of overt cardiovascular disease and mortality with LBBB, with a relative risk ratio of 3.78 between isolated LBBB and development of LVSD 4,5 . In addition, multiple studies have illustrated the impaired response of patients with LBBB and both ischemic and nonischemic cardiomyopathies to guideline‐directed medical therapy (GDMT) 6,7 . Furthermore, the presence of LBBB is associated with worse mortality in patients with preexisting LVSD 8 .…”

Section: Introductionmentioning

confidence: 99%

His‐bundle pacing: A novel treatment for left bundle branch block‐mediated cardiomyopathy

Singh

Devabhaktuni²,

Ezzeddine

et al. 2020

Cardiovasc electrophysiol

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Background: Chronic left bundle branch block (LBBB) can lead to LBBB-mediated cardiomyopathy from left ventricular dysynchrony. His-bundle pacing (HBP) results in direct electrical synchrony using the native His-Purkinje system, providing a novel treatment for this cardiomyopathy. Objective: To assess the feasibility of HBP for cardiac resynchronization therapy (CRT) in LBBB-mediated cardiomyopathy patients. Methods: Retrospective database review was conducted on patients who underwent CRT by the HBP capable provider at Indiana University Health and Eskenazi Hospital from August 2015 to August 2017. A subset of patients who met the predefined syndrome criteria of LBBB-mediated cardiomyopathy who underwent HBP were identified. Clinical, echocardiographic, and electrocardiographic variables were extracted at baseline and follow-up. Results: Nine patients had cardiomyopathy and LBBB. Among those two were lost to follow-up. Seven patients were included in the analysis. The average time from device implantation to the last follow-up was 14.5 months. Left ventricular ejection fraction improved on average from 25% to 50% (p = .0001). The left ventricular endsystolic dimension decreased from 47 to 37 mm (p = .003) and the left ventricular end-diastolic dimension decreased from 55 to 48 mm (p = .03). QRS duration with HBP-CRT decreased from 152 to 115 ms. New York Heart Association classification improved from an average of 2.7-2. Conclusion: HBP is a viable technique for pursuing CRT in patients with LBBBmediated cardiomyopathy.

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Impaired Recovery of Left Ventricular Function in Patients With Cardiomyopathy and Left Bundle Branch Block

Abstract: LBBB is associated with a smaller degree of LVEF improvement compared with other QRS morphologies, even with GDMT. Some patients with LBBB may benefit from CRT earlier than guidelines currently recommend.

Cited by 83 publications

References 43 publications

Heart Failure With Mid-range or Recovered Ejection Fraction: Differential Determinants of Transition

Heart Failure With Mid-range or Recovered Ejection Fraction: Differential Determinants of Transition

A troubled marriage: When electrical and mechanical dyssynchrony don’t go along

His‐bundle pacing: A novel treatment for left bundle branch block‐mediated cardiomyopathy

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