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Implantable Device Therapy in Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Maxwell Eyram Afari, Lana Tsao
The timing and pattern of ventricular conduction can dictate the efficiency of cardiac output in a failing heart. Electrical conduction defects, such as wide QRS complexes, can result in a phasic intraventricular delay resulting in ventricular dyssynchrony. The mechanism of LV dyssynchrony is attributed to temporal delay in electrical activation of different regions of the heart. In left bundle branch block (LBBB), there is a temporal delay between the activation of the septum and the eventual activation of the lateral wall.2 Ventricular dyssynchrony results in discoordination of myocardial shortening, resulting in suboptimal ventricular filling, prolonged duration of mitral regurgitation, paradoxical septal wall motion, and decreased left ventricular (LV) contractility.2
Indications for Permanent Pacing and Cardiac Resynchronization Therapy
Published in Andrea Natale, Oussama M. Wazni, Kalyanam Shivkumar, Francis E. Marchlinski, Handbook of Cardiac Electrophysiology, 2020
Shiv Bagga, J. David Burkhardt, Mandeep Bhargava
Most of these adverse effects stem from ventricular dyssynchrony related to perturbed ventricular depolarization as a consequence of RV apical pacing. Strategies to overcome these limitations of conventional RV apical pacing have included alternative site RV pacing and biventricular pacing. However, there are conflicting data on the potential advantages of alternative site pacing such as the RV outflow tract and RV septal pacing.77,78 Similarly, recent trials of biventricular pacing in patients with normal/low normal LV function have shown mixed results.79,80 Furthermore, randomized comparison of RV pacing with biventricular pacing in patients with preserved LV function have not shown any significant differences in mortality, hospitalization for HF, or quality of life despite a greater decline in LV ejection fraction and increased chamber enlargement in RV pacing group.81,82 In addition to the well-known fact that up to one-third of patients treated with biventricular pacing do not derive clinical or echocardiographic benefit; recent evidence indicates that CRT has limited benefits in patients with non-LBBB and severely reduced ejection fraction (EF) and those with LV dysfunction and narrow QRS.27–30,83
Heart failure
Published in Ian Mann, Christopher Critoph, Caroline Coats, Peter Collins, The Junior Doctor’s Guide to Cardiology, 2017
Ian Mann, Christopher Critoph, Caroline Coats, Peter Collins
ECG. An entirely normal ECG makes heart failure unlikely. Often there will be voltage criteria for LVH, with or without evidence of left ventricular strain. There may be evidence of ventricular dyssynchrony which is demonstrated by prolonged QRS duration. Voltage size may be very small. Q waves may indicate previous MI. Look carefully as the ECG can give clues to the underlying aetiology.
Real-time three-dimensional echocardiography for detection of cardiac sarcoidosis in the early stage: a cross-sectional single-centre study
Published in Acta Cardiologica, 2022
One of the best parameters of ventricular dyssynchrony is SDI; and it shows deterioration of ventricular contractility in the early stage. The measurement of 3DE SDI is also highly reproducible with good to excellent inter-observer and intra-observer correlation coefficients [33,34]. SDI has been used in numerous studies to identify affected cardiac functions in different clinical scenarios [35–37]. Many studies also revealed that 3DE SDI was a feasible and reliable tool to predict response to CRT cardiac resynchronisation therapy (CRT), and furthermore it was independently associated with long-term prognosis after CRT [38,39]. 3DE SDI was also investigated as a predictive measurement for specific patient populations such as its role in the prediction of LV remodelling after acute myocardial infarction [40], predictive role on mechanical intraventricular resynchronization after surgical ventricular reconstruction in patients with ventricular aneurysm [41].
Updates in the management of congenital heart disease in adult patients
Published in Expert Review of Cardiovascular Therapy, 2022
Danielle Massarella, Rafael Alonso-Gonzalez
The role of device therapy in combatting maladaptive ventricular remodeling has yet to be elucidated in the adult congenital heart failure population, though it has been identified as a major evidence gap which warrants further investigation [8,82]. Well recognized parametric indications for cardiac resynchronization therapy (CRT) in those with left ventricular dyssynchrony not related to an underlying congenital anomaly may not apply to the more heterogeneous congenital population. Those patients with a systemic left ventricle and pacing-induced cardiomyopathy likely represent the most analogous subset of the congenital population, and CRT upgrade should be considered as it may confer a similar benefit. Otherwise, CRT is typically considered in symptomatic congenital cardiac patients with QRS prolongation in the setting of systemic ventricular dilation and dysfunction, and this currently represents the most common indication for the application of this technology [71,91,92]. There is some evidence to suggest that, compared to propensity-matched controls, CRT improves transplant-free (as well as overall) survival in younger congenital patients with symptomatic systemic ventricular dysfunction [93]. However, efficacy and degree of reverse ventricular remodeling are variable across anatomic and pathophysiologic substrates [94]. Of note, lead implantation is more challenging in the congenital heart disease population, in whom systemic venous anomalies and post-operative anatomy may preclude conventional transvenous approaches [62,92,94,95].
Cost-effectiveness of cardiac resynchronization therapy
Published in Journal of Medical Economics, 2020
Cristian Martignani, Giulia Massaro, Igor Diemberger, Matteo Ziacchi, Andrea Angeletti, Nazzareno Galiè, Mauro Biffi
Implantable cardioverter defibrillators (ICD) represent the main tool for primary and secondary prevention of sudden cardiac death due to ventricular arrhythmias in selected patients affected from cardiac dysfunction; in fact, a relevant reduction in all-cause mortality was observed in numerous clinical trials on ICDs compared to optimal medical therapy1–3. Despite their relevant contribution in survival improvement, ICDs per se have no impact on clinical outcomes related to congestive heart failure (CHF). Subjects with left ventricular conduction delay and consequent electromechanical ventricular dyssynchrony may develop ventricular dysfunction4. The advent of cardiac resynchronization therapy (CRT) ushered the era of device-based treatment of CHF on top of optimal medical regimen, considerably changing treatment and outcomes of patients suffering from CHF. In particular, CRT is a treatment of proven efficacy for patients with CHF, low left ventricular ejection fraction (LVEF <35%) and ventricular dyssynchrony due to intraventricular conduction delay, mainly left bundle branch block (LBBB, resulting in a QRS duration >130 ms). On top of optimal medical therapy, in such patients CRT may significantly improve New York Heart Association (NYHA) functional class, quality of life and survival; it promotes reverse left ventricular remodelling and reduces hospitalizations5–8.