Right ventricular function assessed by cardiac magnetic resonance predicts the response to resynchronization therapy.

BACKGROUND AND AIM: Cardiac resynchronization therapy (CRT) reduces mortality and morbidity in chronic heart failure symptomatic patients with broad QRS who are already undergoing optimal medical treatment. However, approximately one-third of implanted patients do not show any benefit from this treatment. Right ventricle (RV) dysfunction leads to a worse outcome in patients with heart failure, but its role in predicting the response to CRT has shown conflicting results. The purpose of our study was to investigate how the RV function, assessed by cardiac magnetic resonance (CMR), could influence the outcome of heart failure patients treated with CRT. METHODS AND RESULTS: We retrospectively enrolled 72 heart failure patients, 38 affected by dilated cardiomyopathy (DCM) and 34 by ischemic dysfunction, with left bundle branch block, QRS greater than 120 ms and standard indications to CRT. We defined the response to CRT as an improvement of at least 10% of the left ventricular ejection fraction (LVEF) or at least one of the NYHA functional classes. We stratified the population into two groups based on the right ventricle ejection fraction (RVEF) at CMR: group 1 RVEF at least 55% (n = 32), group 2 RVEF less than 55% (n = 40). After a mean follow-up of 38 ±â€Š12 months, 44 patients (61%) were considered responders whereas 28 (39%) did not show any benefit. Patients in group 1 had a higher rate of response to CRT (75 vs. 50%, P = 0.03). At the univariate analysis RVEF [54 vs. 43%; confidence interval (CI) = 0.907-0.980; hazard ratio = 0.943; P = 0.003], RV end-systolic volume (56 vs. 84 ml; CI = 1.005-1.034; hazard ratio = 1.019; P = 0.008) and tricuspid annular plane systolic excursion (TAPSE) (16.4 vs. 14 mm; CI 0.745-0.976; heart rate = 0.853; P = 0.021) were the parameters most strongly associated with the response to CRT. Male sex, atrial fibrillation, and older age also negatively influenced the outcome. At a multivariate model, RVEF and older age remained significant. CONCLUSION: In our experience, patients with RV dysfunction less likely benefited from CRT. RV assessment, studied with CMR, appears to be a good predictor of the response to biventricular stimulation.

Robotic left ventricular epicardial lead positioning.

Cardiac resynchronization therapy is indicated in advanced heart failure patients with a wide QRS complex, because it restores the synchronicity of the atrioventricular, interventricular and intraventricular contractions. It is performed through endovascular implantation of one or more leads. Left cardiac lead positioning is one of the most challenging procedures in interventional cardiology; unfortunately, in up to 40% of cases no clinical improvements occur. Surgical implantation of a left ventricular lead is indicated in cases of failure or predicted unfeasibility of a transvenous positioning. Several surgical techniques have been described for implantation of left ventricular lead. Minimally invasive approaches, including video-assisted thoracic and robotic surgery, are favoured due to reduced trauma, pain and recovery time. Robotic surgery confers significant advantages for visualization and manoeuverability, which are important in patients with a history of cardiac surgery, in whom scarring and adhesions may render placement challenging. We describe here the surgical technique for robotic implantation of left ventricular leads in candidates for cardiac resynchronization therapy.