Strategies to improve cardiac resynchronization therapy

Vernooy, Kevin; Deursen, Caroline J.M. van; Strik, Marc; Prinzen, Frits W.

doi:10.1038/nrcardio.2014.67

Cited by 76 publications

(57 citation statements)

References 159 publications

(108 reference statements)

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“…However, the high rate of non-responders (around 30%) and the associated costs are still of primary concern [29], [30]. In order to optimize CRT some studies aimed at identifying the best configuration of the device, including lead positioning [31]–[35], which has also been investigated with in-silico experiments [36], [37].…”

Section: Introductionmentioning

confidence: 99%

Quantitative Analysis of Electro-Anatomical Maps: Application to an Experimental Model of Left Bundle Branch Block/Cardiac Resynchronization Therapy

Iglesias

Duchateau

Butakoff

et al. 2017

IEEE J. Transl. Eng. Health Med.

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Electro-anatomical maps (EAMs) are commonly acquired in clinical routine for guiding ablation therapies. They provide voltage and activation time information on a 3-D anatomical mesh representation, making them useful for analyzing the electrical activation patterns in specific pathologies. However, the variability between the different acquisitions and anatomies hampers the comparison between different maps. This paper presents two contributions for the analysis of electrical patterns in EAM data from biventricular surfaces of cardiac chambers. The first contribution is an integrated automatic 2-D disk representation (2-D bull’s eye plot) of the left ventricle (LV) and right ventricle (RV) obtained with a quasi-conformal mapping from the 3-D EAM meshes, that allows an analysis of cardiac resynchronization therapy (CRT) lead positioning, interpretation of global (total activation time), and local indices (local activation time (LAT), surrogates of conduction velocity, inter-ventricular, and transmural delays) that characterize changes in the electrical activation pattern. The second contribution is a set of indices derived from the electrical activation: speed maps, computed from LAT values, to study the electrical wave propagation, and histograms of isochrones to analyze regional electrical heterogeneities in the ventricles. We have applied the proposed methods to look for the underlying physiological mechanisms of left bundle branch block (LBBB) and CRT, with the goal of optimizing the therapy by improving CRT response. To better illustrate the benefits of the proposed tools, we created a set of synthetically generated and fully controlled activation patterns, where the proposed representation and indices were validated. Then, the proposed analysis tools are used to analyze EAM data from an experimental swine model of induced LBBB with an implanted CRT device. We have analyzed and compared the electrical activation patterns at baseline, LBBB, and CRT stages in four animals: two without any structural disease and two with an induced infarction. By relating the CRT lead location with electrical dyssynchrony, we evaluated current hypotheses about lead placement in CRT and showed that optimal pacing sites should target the RV lead close to the apex and the LV one distant from it.

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Section: Introductionmentioning

confidence: 99%

Quantitative Analysis of Electro-Anatomical Maps: Application to an Experimental Model of Left Bundle Branch Block/Cardiac Resynchronization Therapy

Iglesias

Duchateau

Butakoff

et al. 2017

IEEE J. Transl. Eng. Health Med.

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“…It is generally accepted that CRT has a beneficial effect in patients with large left ventricle dyssynchrony 7 as manifested by LBBB morphology in an ECG. Unfortunately, QRS morphology does not directly reflect the electrical dyssynchrony.…”

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confidence: 99%

Ventricular Electrical Delay Measured From Body Surface ECGs Is Associated With Cardiac Resynchronization Therapy Response in Left Bundle Branch Block Patients From the MADIT-CRT Trial (Multicenter Automatic Defibrillator Implantation-Cardiac Resynchronization Therapy)

Plešinger

Jurák

Halámek

et al. 2018

Circ: Arrhythmia and Electrophysiology

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BACKGROUND:Although cardiac resynchronization therapy (CRT) is beneficial in heart failure patients with left bundle branch block, 30% of these patients do not respond to the therapy. Identifying these patients before implantation of the device is one of the current challenges in clinical cardiology. METHODS:We verified the diagnostic contribution and an optimized computerized approach to measuring ventricular electrical activation delay (VED) from body surface 12-lead ECGs. We applied the method to ECGs acquired before implantation (baseline) in the MADIT-CRT trial (Multicenter Automatic Defibrillator Implantation-Cardiac Resynchronization Therapy). VED values were dichotomized using its quartiles, and we tested the association of VED values with the MADIT-CRT primary end point of heart failure or death. Multivariate Cox proportional models were used to estimate the risk of study end points. In addition, the association between VED values and hemodynamic changes after CRT-D implantation was examined using 1-year follow-up echocardiograms. RESULTS:Our results showed that left bundle branch block patients with baseline VED <31.2 ms had a 35% risk of MADIT-CRT end points, whereas patients with VED ≥31.2 ms had a 14% risk (P<0.001). The hazard ratio for predicting primary end points in patients with low VED was 2.34 (95% confidence interval, 1.53-3.57; P<0.001). Higher VED values were also associated with beneficial hemodynamic changes. These strong VED associations were not found in the right bundle branch block and intraventricular conduction delay cohorts of the MADIT-CRT trial. CONCLUSIONS:Left bundle branch block patients with a high baseline VED value benefited most from CRT, whereas left bundle branch block patients with low VED did not show CRT benefits.

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“…It has been pointed out that of 26 articles with the most cited CRT responses, a total of 17 criteria were used to predict CRT response, and approximately 75% of these criteria were weakly consistent with only % being strongly consistent [5]. The non-response rates were the lowest when the results of the 6-min walk test or quality of life scores were used, and the highest when hard outcomes such as hospitalization and mortality were used [6].…”

Section: The Definition Of Nonresponsementioning

confidence: 99%

“…Studies on left ventricular double electrode pacing have discovered that myocardial remodeling can be improved. In patients who are non-responsive to biventricular pacing, left ventricular pacing alone may be considered [6]. Additionally, more pacing configurations such as quadrupole electrodes have been used in clinical practice.…”

Section: Left Ventricular Electrode Implantationmentioning

confidence: 99%

Prevention of non-response to cardiac resynchronization therapy: points to remember

et al. 2019

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Cardiac resynchronization therapy (CRT) is an important and effective therapy for end-stage heart failure. Non-response to CRT is one of the main obstacles to its application in clinical practice. There is no uniform consensus or definition of CRT "response." Clinical symptoms, ventricular remodeling indices, and cardiovascular events have been reported to be associated with nonresponders. To prevent non-response to CRT, three aspects should be thoroughly considered: preoperative patient selection, electrode implantation, and postoperative management. Preoperative selection of appropriate patients for CRT treatment is an important step in preventing non-response. Currently, the CRT inclusion criteria are mainly based on the morphology of QRS waves in deciding ventricular dyssynchrony. Echocardiography and cardiac magnetic resonance are being explored to predict nonresponse to CRT. The location of left ventricular electrode implantation is a current hot spot of research; it is important to identify the location of the latest exciting ventricular segment and avoid scars. Cardiac magnetic resonance and ultrasonic spot tracking are being progressively developed in this field. Some new techniques such as His Bundle pacing, endocardial electrodes, and novel sensors are also being investigated. Postoperative management of patients is another essential step towards preventing non-response; it mainly focuses on the treatment of the disease itself and CRT program control optimization. CRT treatment is just one part of the overall treatment of heart failure, and multidisciplinary efforts are needed to improve the overall outcome.

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Strategies to improve cardiac resynchronization therapy

Cited by 76 publications

References 159 publications

Quantitative Analysis of Electro-Anatomical Maps: Application to an Experimental Model of Left Bundle Branch Block/Cardiac Resynchronization Therapy

Quantitative Analysis of Electro-Anatomical Maps: Application to an Experimental Model of Left Bundle Branch Block/Cardiac Resynchronization Therapy

Ventricular Electrical Delay Measured From Body Surface ECGs Is Associated With Cardiac Resynchronization Therapy Response in Left Bundle Branch Block Patients From the MADIT-CRT Trial (Multicenter Automatic Defibrillator Implantation-Cardiac Resynchronization Therapy)

Prevention of non-response to cardiac resynchronization therapy: points to remember

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