Why QRS Duration Should Be Replaced by Better Measures of Electrical Activation to Improve Patient Selection for Cardiac Resynchronization Therapy

Engels, Elien B.; Mafi-Rad, Masih; Stipdonk, Antonius M.W. van; Vernooy, Kevin; Prinzen, Frits W.

doi:10.1007/s12265-016-9693-1

Cited by 25 publications

(22 citation statements)

References 59 publications

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“…Current guidelines recommend implantating a CRT device only when QRS is at least 120 ms with LBBB morphology or at least 150 ms without LBBB morphology. The cut-off of 150 ms is based on subgroup analyses of large CRT trials which demonstrated that positive outcome of CRT was predominantly confined to patients with a QRS duration !150 ms [20]. While classifying LBBB may seem trivial for cardiologists, considerable intra-and inter-observer variability exists in whether a patient has LBBB or not [21].…”

Section: Traditional Determinants Of Crt Responsementioning

confidence: 99%

Non-invasive cardiac mapping for non-response in cardiac resynchronization therapy

et al. 2019

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Cardiac resynchronization therapy (CRT) is an effective intervention in selected patients with moderate-to-severe heart failure with reduced ejection fraction and abnormal left ventricular activation time. The non-response rate of approximately 30% has remained nearly unchanged since this therapy was introduced 25 years ago. While intracardiac mapping is widely used for diagnosis and guidance of therapy in patients with tachyarrhythmia, its application in characterization of the electrical substrate to elucidate the mechanisms involved in CRT response remain anecdotal. In the present review, we describe the traditional determinants of CRT response before presenting novel non-invasive techniques used for CRT optimization. We discuss efforts to identify the target electrical substrate to guide the deployment of pacing electrodes during the operative procedure. Non-invasive body surface mapping technologies such as ECG imaging or ECG belt enables prediction of acute and chronic CRT response. While electrical dyssynchrony parameters provide high predictive accuracy for CRT response when obtained during intrinsic conduction, their predictive value is less when acquired during CRT or LV-pacing. KEY MESSAGES Classic predictors of CRT response are female gender, NYHA class III, left ventricular ejection fraction !25%, QRS duration !150 ms and estimated glomerular filtration rate !60 mL/min. ECG-imaging is a comprehensive non-invasive mapping system which allows to express the amount of electrical asynchrony of a CRT candidate. Non-invasive body surface mapping technologies enables excellent prediction of acute and chronic CRT response before implantation. When performed during CRT or LV-pacing, the added value of these mapping systems remains unclear.

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Section: Traditional Determinants Of Crt Responsementioning

confidence: 99%

Non-invasive cardiac mapping for non-response in cardiac resynchronization therapy

et al. 2019

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“…Additionally, we do not have strict diagnosis of whether bundle branch block was evident at higher QRS durations in our population. Cardiac myocyte gap junction uncoupling as a consequence of LV hypertrophy or fibrosis can give rise to a wide QRS complex with morphological features that are similar to ECGderived LBBB but are not LBBB [25,26].…”

Section: Discussionmentioning

confidence: 99%

Baseline Framingham risk score does not predict future ECG-derived QRS duration over an average of 3.3 years

et al. 2020

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Background Prolonged electrocardiogram (ECG) QRS duration has been associated with increased cardiovascular risk. It is unclear whether the main predictor of cardiovascular risk, the Framingham risk score also predicts short-term changes in ECG QRS duration. Our aim is to determine whether baseline Framingham risk score is associated with baseline or changes in QRS duration. Methods A retrospective cross-sectional analysis was performed using observational data obtained from two hundred two participants. Framingham risk score was calculated using an online risk calculator. QRS duration was obtained using a 10 s trace from a Welch Allyn PC-based 12-lead ECG system. Results Average follow-up duration was 3.3 ± 1.1 years. Mean QRS change was 1.8 ± 11.4 ms. Specifically, among two hundred two participants, there are 104 subjects with a greater QRS duration at follow-up, while 98 subjects had the same or a shorter follow-up QRS duration. Baseline Framingham risk score did not significantly predict an increase in QRSd with an odds ratio of 1.04 (P = 0.230). Regression analysis of QRS duration at baseline and Framingham risk at baseline had a weak association (R2 = 0.020; P = 0.043). The Framingham risk score at follow-up was likewise has a weak association with follow-up QRS duration (R2 = 0.045; P = 0.002). Conclusions Our results do not demonstrate a statistically significant association between Framingham risk parameters and future QRS duration changes over longitudinal time. QRS duration had variable changes between baseline and follow-up. This might suggest that a longer period of follow-up is required to document more stable increases in QRS duration associated with ventricular pathology. A larger population study is needed to confirm our observations.

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“…Cardiac resynchronization therapy (CRT) is an effective treatment that reduces mortality and hospitalization and improves cardiac function in patients with left bundle branch block (LBBB) [1]. However, about 30% of patients passing the current clinical guidelines do not benefit or benefit only a little from CRT [2]. The prediction of CRT outcome based on the ECG signal is an important task.…”

Section: Introductionmentioning

confidence: 99%

The relationship between ECG predictors of cardiac resynchronization therapy benefit

et al. 2019

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Introduction Cardiac resynchronization therapy (CRT) is an effective treatment that reduces mortality and improves cardiac function in patients with left bundle branch block (LBBB). However, about 30% of patients passing the current criteria do not benefit or benefit only a little from CRT. Three predictors of benefit based on different ECG properties were compared: 1) “strict” left bundle branch block classification (SLBBB); 2) QRS area; 3) ventricular electrical delay (VED) which defines the septal-lateral conduction delay. These predictors have never been analyzed concurrently. We analyzed the relationship between them on a subset of 602 records from the MADIT-CRT trial. Methods & results SLBBB classification was performed by two experts; QRS area and VED were computed fully automatically. High-frequency QRS (HFQRS) maps were used to inspect conduction abnormalities. The correlation between SLBBB and other predictors was R = 0.613, 0.523 and 0.390 for VED, QRS area in Z lead, and QRS duration, respectively. Scatter plots were used to pick up disagreement between the predictors. The majority of SLBBB subjects– 295 of 330 (89%)–are supposed to respond positively to CRT according to the VED and QRS area, though 93 of 272 (34%) non-SLBBB should also benefit from CRT according to the VED and QRS area. Conclusion SLBBB classification is limited by the proper setting of cut-off values. In addition, it is too “strict” and excludes patients that may benefit from CRT therapy. QRS area and VED are clearly defined parameters. They may be used to optimize biventricular stimulation. Detailed analysis of conduction irregularities with CRT optimization should be based on HFQRS maps.

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Why QRS Duration Should Be Replaced by Better Measures of Electrical Activation to Improve Patient Selection for Cardiac Resynchronization Therapy

Cited by 25 publications

References 59 publications

Non-invasive cardiac mapping for non-response in cardiac resynchronization therapy

Non-invasive cardiac mapping for non-response in cardiac resynchronization therapy

Baseline Framingham risk score does not predict future ECG-derived QRS duration over an average of 3.3 years

The relationship between ECG predictors of cardiac resynchronization therapy benefit

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