Targeted cluster ablation of non-CTI-dependent atrial arrhythmias in congenital heart disease using ultrahigh-definition mapping.

BACKGROUND: Ablation of atrial arrhythmias in patients with congenital heart disease (CHD) has markedly improved with advanced mapping systems. However, recurrence rates remain high. The linear ablation strategy is not uncommonly practiced necessitating prolonged ablation times. We report the outcomes of adopting a strategy of minimal, cluster delivery of radiofrequency (RF) energy at critical substrates identified by ultrahigh-definition mapping for atrial arrhythmias in patients with CHD. METHODS: Non-cavotricuspid isthmus (non-CTI) atrial tachycardias were ablated with a targeted ablation cluster technique (TACT) using an ultrahigh-density mapping system combined with multielectrode monitoring and endpoint determination in preference to linear ablation. The arrhythmia substrates, RF times, and acute- and medium-term success rates were studied. RESULTS: Fifty-eight tachycardias were mapped and ablated in 42 procedures: 34 non-CTIs and 24 CTIs. A targeted ablation cluster was performed for non-CTI tachycardias, with a median ablation time of 3.1 min. In 53% of non-CTI tachycardias, arrhythmia termination was achieved with ≤2 RF applications. After a mean follow-up of 23.6 months, 27 (80%) patients were free of recurrent atrial arrhythmias. One of 34 targeted non-CTI tachycardia recurred, with a final success rate of 91%. Linear ablation was performed for CTI flutters with a median ablation time of 6.8 min (vs. non-CTIs, p = .006). Three of 21 tachycardias recurred due to reconnection of the ablation line but the final success rate was 100%. CONCLUSIONS: The TACT approach for non-CTI atrial arrhythmias in congenital patients as guided by the ultrahigh-density mapping is an effective method with short ablation times and excellent medium-term outcomes.

Standard care vs. TRIVEntricular pacing in Heart Failure (STRIVE HF): a prospective multicentre randomized controlled trial of triventricular pacing vs. conventional biventricular pacing in patients with heart failure and intermediate QRS left bundle branch block.

AIMS: To determine whether triventricular (TriV) pacing is feasible and improves CRT response compared to conventional biventricular (BiV) pacing in patients with left bundle branch block (LBBB) and intermediate QRS prolongation (120-150 ms). METHODS AND RESULTS: Between October 2015 and November 2019, 99 patients were recruited from 11 UK centres. Ninety-five patients were randomized 1:1 to receive TriV or BiV pacing systems. The primary endpoint was feasibility of TriV pacing. Secondary endpoints assessed symptomatic and remodelling response to CRT. Baseline characteristics were balanced between groups. In the TriV group, 43/46 (93.5%) patients underwent successful implantation vs. 47/49 (95.9%) in the BiV group. Feasibility of maintaining CRT at 6 months was similar in the TriV vs. BiV group (90.0% vs. 97.7%, P = 0.191). All-cause mortality was similar between TriV vs. BiV groups (4.3% vs. 8.2%, P = 0.678). There were no significant differences in echocardiographic LV volumes or clinical composite scores from baseline to 6-month follow-up between groups. CONCLUSION: Implantation of two LV leads to deliver and maintain TriV pacing at 6 months is feasible without significant complications in the majority of patients. There was no evidence that TriV pacing improves CRT response or provides additional clinical benefit to patients with LBBB and intermediate QRS prolongation and cannot be recommended in this patient group. CLINICAL TRIAL REGISTRATION NUMBER: Clinicaltrials.gov: NCT02529410.

High mean entropy calculated from cardiac MRI texture analysis is associated with antitachycardia pacing failure.

BACKGROUND: Antitachycardia pacing (ATP), which may avoid unnecessary implantable cardioverter-defibrillator (ICD) shocks, does not always terminate ventricular arrhythmias (VAs). Mean entropy calculated using cardiac magnetic resonance texture analysis (CMR-TA) has been shown to predict appropriate ICD therapy. We examined whether scar heterogeneity, quantified by mean entropy, is associated with ATP failure and explore potential mechanisms using computer modeling. METHODS: A subanalysis of 114 patients undergoing CMR-TA where the primary endpoint was delivery of appropriate ICD therapy (ATP or shock therapy) was performed. Patients receiving appropriate ICD therapy (n = 33) were dichotomized into "successful ATP" versus "shock therapy" groups. In silico computer modeling was used to explore underlying mechanisms. RESULTS: A total of 16 of 33 (48.5%) patients had successful ATP to terminate VA, and 17 of 33 (51.5%) patients required shock therapy. Mean entropy was significantly higher in the shock versus successful ATP group (6.1 ± 0.5 vs 5.5 ± 0.7, P = .037). Analysis of patients receiving ATP (n = 22) showed significantly higher mean entropy in the six of 22 patients that failed ATP (followed by rescue ICD shock) compared to 16 of 22 that had successful ATP (6.3 ± 0.7 vs 5.5 ± 0.7, P = .048). Computer modeling suggested inability of the paced wavefront in ATP to successfully propagate from the electrode site through patchy fibrosis as a possible mechanism of failed ATP. CONCLUSIONS: Our findings suggest lower scar heterogeneity (mean entropy) is associated with successful ATP, whereas higher scar heterogeneity is associated with more aggressive VAs unresponsive to ATP requiring shock therapy that may be due to inability of the paced wavefront to propagate through scar and terminate the VA circuit.

Evidence of reverse electrical remodelling by non-invasive electrocardiographic imaging to assess acute and chronic changes in bulk ventricular activation following cardiac resynchronisation therapy.

INTRODUCTION: Cardiac resynchronisation therapy (CRT) corrects electrical dyssynchrony. However, the temporal changes in the electrical timing according to substrate are unclear. We used electrocardiographic imaging (ECGi) for serial non-invasive assessment of the underlying electrical substrate and its response to resynchronisation. MATERIAL AND METHODS: ECGi activation maps were constructed 1 day and 6 months post CRT implant. ECGi maps were analysed offline to determine the total ventricular activation time (TVaT) and the time for the bulk of ventricular activation (10th to 90th percentile activation; VaT10-90 Index). Statistical analysis was performed using repeated measures ANOVA with post-hoc pairwise comparisons using paired t-tests. The % relative change within each time point was also calculated and compared between the two time points. RESULTS: Eleven CRT patients were studied. Both total and bulk ventricular activation significantly decreased with CRT turned ON at day 1. Intrinsic (CRT OFF) TVaT and VaT10-90 Index at day 1 were 143 ± 23 and 84 ± 20 ms, respectively, and they significantly decreased post CRT to 115 ± 26 ms (P < 0.001) and 49 ± 17 ms (P < 0.05), respectively. The relative change at day 1 was also statistically significant for TVaT (19 ± 12%, P < 0.001) and VaT10-90 Index (39 ± 25%, P < 0.001). After 6 months, the relative decrease in TVaT with CRT ON remained stable (19% vs. 18% at day 1 and 6 months, respectively) whereas reduction the in VaT10-90 Index was decreased 39% vs. 26% at day 1 and 6 months, respectively. In non-ischaemic patients both total and bulk activation times reduced following CRT. Volumetric responders exhibited an electrical remodelling for bulk activation not apparent in Non-responders, after 6 months of CRT ON. CONCLUSIONS: Intrinsic bulk myocardium activation becomes more rapid and synchronous with CRT. The bulk activation time is more susceptible to improvement by CRT in ischaemic patients and volumetric responders. These observations are consistent with CRT causing reverse electrophysiological remodelling in the bulk myocardium, but not in late-activating ischaemic or fibrotic regions.

Transvenous lead extraction in patients with cardiac resynchronization therapy devices is not associated with increased 30-day mortality.

AIMS: Transvenous lead extraction (TLE) may be necessary due to system infection/erosion or lead malfunction. Cardiac resynchronization therapy (CRT) patients undergoing TLE may be at greater risk due to increased comorbidities. We examined whether patients with CRT systems undergoing TLE had more comorbidities and higher 30-day mortality than those with non-CRT devices. METHODS AND RESULTS: All TLEs between October 2000 and December 2016 were prospectively collected. During this period 925 TLEs occurred (CRT group 231, non-CRT group 694). Cardiac resynchronization therapy patients were older (68.1 ± 10.8 years vs. 64.3 ± 16.1 years, P = 0.024); more likely male (85.7% vs. 69%, P < 0.001); had lower mean left ventricular ejection fraction (34.1 ± 12.7% vs. 48.3 ± 12.9%, P < 0.001); had higher prevalence of renal impairment (33.8% vs. 13.7%, P < 0.001) and were more likely to have ≥2 comorbidities (84% vs. 40.1%, P < 0.001). Mean lead dwell time was lower in the CRT group (5.6 ± 5.5 years vs. 7.6 ± 7.1 years, P = 0.002). There was no significant difference in all-cause 30-day mortality rates between CRT (3.0%, n = 7) and non-CRT patients (2.0%, n = 14) (P = 0.443). The majority of deaths in both groups were due to sepsis. Univariate and multivariate analysis showed age, renal impairment and sepsis were associated with increased risk of 30-day mortality. Transvenous lead extraction of a CRT system did not predict 30-day mortality. CONCLUSION: Transvenous lead extraction in CRT patients was not associated with increased 30-day mortality when compared with non-CRT patients. Age, renal impairment and sepsis were independent predictors of 30-day mortality. Sepsis was the main cause of 30-day mortality.

Procedural outcomes associated with transvenous lead extraction in patients with abandoned leads: an ESC-EHRA ELECTRa (European Lead Extraction ConTRolled) Registry Sub-Analysis.

AIMS: The decision to abandon or extract superfluous leads remains controversial. We sought to compare procedural outcome of patients with and without abandoned leads undergoing transvenous lead extraction (TLE). METHODS AND RESULTS: An analysis of the ESC-EHRA European Lead Extraction ConTRolled ELECTRa registry was conducted. Patients were stratified into two groups based on the presence (Group 1) or absence (Group 2) of abandoned leads at the time for extraction. Out of 3508 TLE procedures, 422 patients (12.0%) had abandoned leads (Group 1). Group 1 patients were older and more likely to have implantable cardioverter-defibrillator devices, infection indication (78.8% vs. 49.8%), and vegetations (24.6% vs. 15.3%). Oldest lead dwelling time was longer in Group 1 (10.9 vs. 6.3 years) as was the number of extracted leads per patient (3.2 vs. 1.7). Manual traction failure (94.5% vs. 78.8%), powered sheath use (50.7% vs. 28.4%), and femoral approach were higher in Group 1 (P < 0.0001). Procedural success rate and clinical success (89.8% vs. 96.6%, P < 0.0001) were lower in Group 1. Major complication including deaths (5.5% vs. 2.3%, P = 0.0007) and procedure related major complications (3.3% vs. 1.4%, P = 0.0123) were higher in Group 1. The presence of abandoned leads at the time of TLE was an independent predictor of clinical failure [odds ratio (OR) 2.31, confidence interval (CI) 1.57-3.40] and complications [OR 1.69, CI 1.22-2.35]. receiver-operating characteristic curve analysis showed a dwell time threshold of 9 years for radiological failure and major complications. CONCLUSIONS: Previously abandoned leads at the time of TLE were associated with increased procedural complexity, clinical failure, and major complication, which may have important implications for future studies regarding managing of lead failures.

Transvenous lead extraction procedures in women based on ESC-EHRA EORP European Lead Extraction ConTRolled ELECTRa registry: is female sex a predictor of complications?

AIMS: Female sex is considered an independent risk factor of transvenous leads extraction (TLE) procedure. The aim of the study was to evaluate the effectiveness of TLE in women compared with men. METHODS AND RESULTS: A post hoc analysis of risk factors and effectiveness of TLE in women and men included in the ESC-EHRA EORP ELECTRa registry was conducted. The rate of major complications was 1.96% in women vs. 0.71% in men; P = 0.0025. The number of leads was higher in men (mean 1.89 vs. 1.71; P < 0.0001) with higher number of abandoned leads in women (46.04% vs. 34.82%; P < 0.0001). Risk factors of TLE differed between the sexes, of which the major were: signs and symptoms of venous occlusion [odds ratio (OR) 3.730, confidence interval (CI) 1.401-9.934; P = 0.0084], cumulative leads dwell time (OR 1.044, CI 1.024-1.065; P < 0.001), number of generator replacements (OR 1.029, CI 1.005-1.054; P = 0.0184) in females and the number of leads (OR 6.053, CI 2.422-15.129; P = 0.0001), use of powered sheaths (OR 2.742, CI 1.404-5.355; P = 0.0031), and white blood cell count (OR 1.138, CI 1.069-1.212; P < 0.001) in males. Individual radiological and clinical success of TLE was 96.29% and 98.14% in women compared with 98.03% and 99.21% in men (P = 0.0046 and 0.0098). CONCLUSION: The efficacy of TLE was lower in females than males, with a higher rate of periprocedural major complications. The reasons for this difference are probably related to disparities in risk factors in women, including more pronounced leads adherence to the walls of the veins and myocardium. Lead management may be key to the effectiveness of TLE in females.

Variation in activation time during bipolar vs extended bipolar left ventricular pacing.

BACKGROUND: Cardiac resynchronization therapy (CRT) is typically delivered via quadripolar leads that allow stimulation using either true bipolar pacing, where stimulation occurs between two electrodes (BP) on the quadripolar lead, or extended bipole (EBP) left ventricular (LV) pacing, with the quadripolar electrodes and right ventricular coil acting as the cathode and anode, respectively. True bipolar pacing is associated with reductions in mortality and it has been postulated that these differences are the result of enhanced electrical activation. MATERIALS AND METHODS: Patients undergoing a CRT underwent an electrocardiographic imaging study where electrical activation data were recorded while different LV pacing vectors were temporarily programmed. RESULTS: There were no differences in the total electrical activation times or dispersion of electrical activation between biventricular pacing with bipolar or corresponding EBP LV vector configurations (left ventricular total activation time [LVtat] BP 74.70 ± 18.07 vs EBP 72.4 ± 22.64; P = 0.45). When dichotomized according to etiology, no difference was observed in the activation time with either BP or EBP pacing (LVtat BP ischemic cardiomyopathy 72.2 ± 17.4 vs BP dilated cardiomyopathy 79.9 ± 18.9; P = 0.38). CONCLUSIONS: Bipolar pacing alters the mechanical activation sequence of the LV and is associated with reductions in all-cause mortality. It has been postulated these benefits derive from improvements in electromechanical activation of the LV. Our study would suggest that true bipolar pacing does not necessarily result in more favorable activation of the LV or improved electrical resynchronization and other mechanisms should be explored.

Electrical latency predicts the optimal left ventricular endocardial pacing site: results from a multicentre international registry.

Aims: The optimal site for biventricular endocardial (BIVENDO) pacing remains undefined. Acute haemodynamic response (AHR) is reproducible marker of left ventricular (LV) contractility, best expressed as the change in the maximum rate of LV pressure (LV-dp/dtmax), from a baseline state. We examined the relationship between factors known to impact LV contractility, whilst delivering BIVENDO pacing at a variety of LV endocardial (LVENDO) locations. Methods and results: We compiled a registry of acute LVENDO pacing studies from five international centres: Johns Hopkins-USA, Bordeaux-France, Eindhoven-The Netherlands, Oxford-United Kingdom, and Guys and St Thomas' NHS Foundation Trust, London-UK. In all, 104 patients incorporating 687 endocardial and 93 epicardial pacing locations were studied. Mean age was 66 ± 11 years, mean left ventricular ejection fraction 24.6 ± 7.7% and mean QRS duration of 163 ± 30 ms. In all, 50% were ischaemic [ischaemic cardiomyopathy (ICM)]. Scarred segments were associated with worse haemodynamics (dp/dtmax; 890 mmHg/s vs. 982 mmHg/s, P < 0.01). Delivering BiVENDO pacing in areas of electrical latency was associated with greater improvements in AHR (P < 0.01). Stimulating late activating tissue (LVLED >50%) achieved greater increases in AHR than non-late activating tissue (LVLED < 50%) (8.6 ± 9.6% vs. 16.1 ± 16.2%, P = 0.002). However, the LVENDO pacing location with the latest Q-LV, was associated with the optimal AHR in just 62% of cases. Conclusions: Identifying viable LVENDO tissue which displays late electrical activation is crucial to identifying the optimal BiVENDO pacing site. Stimulating late activating tissue (LVLED >50%) yields greater improvements in AHR however, the optimal location is frequently not the site of latest activation.

Predictors and outcomes of patients requiring repeat transvenous lead extraction of pacemaker and defibrillator leads.

BACKGROUND: A proportion of patients who undergo an initial lead extraction procedure will require a second, repeat extraction. Data regarding this clinical entity are scarce and neither the predisposing risk factors for, nor outcomes from, these procedures have been described previously. We sought to determine the incidence, risk factors, and outcomes of repeat lead extraction. METHODS: A database of extraction procedures from 2001 to 2015 was analyzed. Repeat extraction procedures were identified and the indication for extraction was dichotomized into infection and lead-related problems. Univariate and multivariate analyses were performed to identify predictors of repeat extraction. RESULTS: 807 extraction procedures were identified in 755 patients of whom 6% required a repeat extraction. At multivariate analysis, only suffering a major complication at the initial extraction procedure (odds ratio [OR] 21.5, 95% confidence interval [CI] 2.69-171.92; P < 0.01), complexity of device (cardiac resynchronization devices/implantable cardioverter defibrillators) (OR 2.58, 95% CI 1.2-5.2; P = 0.01), and age (OR 1.02 per year, 95% CI 1.0-1.4; P  =  0.03) were significant predictors of repeat extraction. When repeat extraction was required for infection there was a significant increase in mortality compared with those who did not require a second procedure (36% vs 23%; P  =  0.02). CONCLUSIONS: Repeat lead extraction is required in 6% of cases. Complexity of device, age at extraction, and a major complication at the first extraction were predictors of repeat extraction. Mortality is significantly increased where the repeat procedure is for infection. Clinicians should alert patients to the potential need for further extraction and the increased risks of repeat procedures when indicated for infection.

Relationship between vectorcardiographic QRSarea, myocardial scar quantification, and response to cardiac resynchronization therapy.

PURPOSE: To investigate the relationship between vectorcardiography (VCG) and myocardial scar on cardiac magnetic resonance (CMR) imaging, and whether combining these metrics may improve cardiac resynchronization therapy (CRT) response prediction. METHODS: Thirty-three CRT patients were included. QRSarea, Tarea and QRSTarea were derived from the ECG-synthesized VCG. CMR parameters reflecting focal scar core (Scar2SD, Gray2SD) and diffuse fibrosis (pre-T1, extracellular volume [ECV]) were assessed. CRT response was defined as ≥15% reduction in left ventricular end-systolic volume after six months' follow-up. RESULTS: VCG QRSarea, Tarea and QRSTarea inversely correlated with focal scar (R = -0.44--0.58 for Scar2SD, p ≤ 0.010), but not with diffuse fibrosis. Scar2SD, Gray2SD and QRSarea predicted CRT response with AUCs of 0.692 (p = 0.063), 0.759 (p = 0.012) and 0.737 (p = 0.022) respectively. A combined ROC-derived threshold for Scar2SD and QRSarea resulted in 92% CRT response rate for patients with large QRSarea and small Scar2SD or Gray2SD. CONCLUSION: QRSarea is inversely associated with focal scar on CMR. Incremental predictive value for CRT response is achieved by a combined CMR-QRSarea analysis.

Substrate-dependent risk stratification for implantable cardioverter defibrillator therapies using cardiac magnetic resonance imaging: The importance of T1 mapping in nonischemic patients.

INTRODUCTION: The role of implantable cardioverter defibrillators (ICDs) in nonischemic cardiomyopathy is unclear and better risk-stratification is required. We sought to determine if T1 mapping predicts appropriate defibrillator therapy in patients with nonischemic cardiomyopathy. We studied a mixed cohort of ischemic and nonischemic patients to determine whether different cardiac magnetic resonance (CMR) applications (T1 mapping, late gadolinium enhancement, and Grayzone) were selectively predictive of therapies for the different arrhythmic substrates. METHODS AND RESULTS: We undertook a prospective longitudinal study of consecutive patients receiving defibrillators in a tertiary cardiac center. Participants underwent CMR myocardial tissue characterization using T1 mapping and conventional CMR scar assessment before device implantation. QRS duration and fragmentation on the surface electrocardiogram were also assessed. The primary endpoint was appropriate defibrillator therapy. One-hundred thirty patients were followed up for a median of 31 months (IQR ± 9 months). In nonischemic patients, T1_native was the sole predictor of the primary endpoint (hazard ratio [HR] 1.12 per 10 millisecond increment in value [95% confidence interval [CI] 1.04-1.21; P ≤ 0.01]). In ischemic patients, Grayzone_2SD-3SD was the strongest predictor of appropriate therapy (HR 1.34 per 1% left ventricular increment in value [95% CI 1.03-1.76; P = 0.03]). QRS fragmentation correlated well with myocardial scar core (receiver operating characteristic area under the curve [ROC AUC] 0.64; P = 0.02) but poorly with T1_native (ROC AUC 0.4) and did not predict appropriate therapy. CONCLUSIONS: In the medium-long term, T1_native mapping was the only independent predictor of therapy in nonischemic patients, whereas Grayzone was a better predictor in ischemic patients. These findings suggest a potential role for T1_native mapping in the selection of patients for ICDs in a nonischemic population.

Biophysical Modeling to Determine the Optimization of Left Ventricular Pacing Site and AV/VV Delays in the Acute and Chronic Phase of Cardiac Resynchronization Therapy.

BACKGROUND: Cardiac anatomy and function adapt in response to chronic cardiac resynchronization therapy (CRT). The effects of these changes on the optimal left ventricle (LV) lead location and timing delay settings have yet to be fully explored. OBJECTIVE: To predict the effects of chronic CRT on the optimal LV lead location and device timing settings over time. METHODS: Biophysical computational cardiac models were generated for 3 patients, immediately post-implant (ACUTE) and after at least 6 months of CRT (CHRONIC). Optimal LV pacing area and device settings were predicted by pacing the ACUTE and CHRONIC models across the LV epicardium (49 sites each) with a range of 9 pacing settings and simulating the acute hemodynamic response (AHR) of the heart. RESULTS: There were statistically significant differences between the distribution of the AHR in the ACUTE and CHRONIC models (P < 0.0005 in all cases). The site delivering the maximal AHR shifted location between the ACUTE and CHRONIC models but provided a negligible improvement (<2%). The majority of the acute optimal LV pacing regions (76-100%) and device settings (76-91%) remained optimal chronically. CONCLUSION: Optimization of the LV pacing location and device settings were important at the time of implant, with a reduced benefit over time, where the majority of the acute optimal LV pacing region and device settings remained optimal with chronic CRT.

Diagnosis and management of iatrogenic cardiac perforation caused by pacemaker and defibrillator leads.

AIMS: Cardiac perforations caused by pacemaker or implantable cardioverter-defibrillator (ICD) leads are uncommon but potentially fatal events. The optimal approach to such cases is unclear. The aim of this study was to identify the optimal imaging modality and management strategy for cardiac perforation. METHODS AND RESULTS: All patients presenting to a single institution with cardiac perforation >24 h since implant between 2011 and 2015 were identified retrospectively. Assessment of the diagnostic performance of pre-extraction chest radiography, transthoracic echocardiography (TTE), and computed tomography (CT) was carried out by blinded review. The method of lead extraction and any associated complications were examined. Eighteen cases of cardiac perforation were identified from 426 lead extraction procedures. Sixteen patients had abnormal electrical parameters at device interrogation. In all cases, the perforating lead was an active fixation model, and in four cases, this was an ICD coil. The accuracy of CT imaging for the diagnosis of cardiac perforation was 92.9%, with sensitivity and specificity of 100 and 85.7%, respectively. This was superior to both TTE (accuracy 62.7%, sensitivity and specificity 41.2 and 84.2%, respectively) and chest radiography (accuracy 61.1%, sensitivity and specificity 27.7 and 94.4%, respectively). Transvenous lead extraction (TLE) was performed in 17 patients, and a hybrid surgical approach in 1 patient. Of those who underwent TLE, there was 100% complete procedural success as per Heart Rhythm Society definitions. CONCLUSION: In the setting of cardiac perforation, CT is the imaging modality of choice. Transvenous lead extraction can be recommended as a safe, efficacious, and versatile intervention.

Updates in Cardiac Resynchronization Therapy for Chronic Heart Failure: Review of Multisite Pacing.

PURPOSE OF REVIEW: Cardiac resynchronization therapy (CRT) reduces the morbidity and mortality of patients with left ventricular (LV) systolic dysfunction and intra-ventricular conduction delay. However, its clinical outcomes are heterogeneous and not all patients show a beneficial response. Multisite pacing (MSP), by stimulating the myocardium from more than one locations, is a potential therapeutic option in patients requiring CRT. This article provides a current update in the methods and outcomes of MSP, as well as in challenges in this field and opportunities for further research and development. RECENT FINDINGS: MSP can be delivered either with multiple leads or with quadripolar LV leads which can stimulate the LV from two separate sites. Initial results are promising but not always consistent across studies. Larger patient subgroups and longer follow-up duration are required for more conclusive evaluation of MSP. Routine use of MSP in clinical practice cannot be advocated at present. In selected patient subgroups, however, MSP could be considered. Newer devices and expanding knowledge are expected to facilitate the more widespread implementation of MSP and the assessment of its effects in the clinical outcomes of CRT.

Focal But Not Diffuse Myocardial Fibrosis Burden Quantification Using Cardiac Magnetic Resonance Imaging Predicts Left Ventricular Reverse Modeling Following Cardiac Resynchronization Therapy.

INTRODUCTION: Many heart failure patients with dyssynchrony do not reverse remodel (RR) in response to cardiac resynchronization therapy (CRT). The presence of focal and diffuse interstitial myocardial fibrosis may explain this high nonresponse rate. T1 mapping is a new cardiac magnetic resonance imaging (CMR) technique that overcomes the limitations of conventional contrast CMR and provides reliable quantitative assessment of diffuse myocardial fibrosis. The study tested the hypothesis that focal and diffuse fibrosis quantification would correlate with a lack of left ventricular (LV) RR to CRT. METHODS AND RESULTS: In a prospective study of 48 consecutive patients (27 ischemic cardiomyopathy, 21 dilated cardiomyopathy) LV scar burdens were quantified (scar core and gray zone using late gadolinium enhancement LGE CMR; interstitial fibrosis using T1 mapping) before CRT implant. LV RR was defined by a ≥ 15% reduction in LV end-systolic volume 6 months postimplant. Twenty-seven (56%) patients were responders with RR. Association between scar quantification and LV RR was assessed using the Poisson regression model. Univariate analysis showed that QRS duration/morphology, scar core, and gray zone volumes expressed as % of LV mass and extracellular volume index (ECV) (a measure of interstitial fibrosis from T1 mapping) to be significant predictors of LV RR. Multivariable-adjusted analyses demonstrated scar core quantification (≥ 13.7% LV mass) to be the only independent predictor of LV RR (prevalence ratio 0.40, P = 0.038). CONCLUSIONS: Focal scar burden detected by LGE CMR is associated with a poor response to CRT. Diffuse interstitial fibrosis assessment by T1 mapping, however, is not independently predictive of CRT response.

Improvement of Right Ventricular Hemodynamics with Left Ventricular Endocardial Pacing during Cardiac Resynchronization Therapy.

BACKGROUND: Cardiac resynchronization therapy (CRT) with biventricular epicardial (BV-CS) or endocardial left ventricular (LV) stimulation (BV-EN) improves LV hemodynamics. The effect of CRT on right ventricular function is less clear, particularly for BV-EN. Our objective was to compare the simultaneous acute hemodynamic response (AHR) of the right and left ventricles (RV and LV) with BV-CS and BV-EN in order to determine the optimal mode of CRT delivery. METHODS: Nine patients with previously implanted CRT devices successfully underwent a temporary pacing study. Pressure wires measured the simultaneous AHR in both ventricles during different pacing protocols. Conventional epicardial CRT was delivered in LV-only (LV-CS) and BV-CS configurations and compared with BV-EN pacing in multiple locations using a roving decapolar catheter. RESULTS: Best BV-EN (optimal AHR of all LV endocardial pacing sites) produced a significantly greater RV AHR compared with LV-CS and BV-CS pacing (P < 0.05). RV AHR had a significantly increased standard deviation compared to LV AHR (P < 0.05) with a weak correlation between RV and LV AHR (Spearman rs = -0.06). Compromised biventricular optimization, whereby RV AHR was increased at the expense of a smaller decrease in LV AHR, was achieved in 56% of cases, all with BV-EN pacing. CONCLUSIONS: BV-EN pacing produces significant increases in both LV and RV AHR, above that achievable with conventional epicardial pacing. RV AHR cannot be used as a surrogate for optimizing LV AHR; however, compromised biventricular optimization is possible. The beneficial effect of endocardial LV pacing on RV function may have important clinical benefits beyond conventional CRT.

Multisite Pacing for Cardiac Resynchronization Therapy: Promise and Pitfalls.

Cardiac resynchronization therapy (CRT) reduces the morbidity and mortality of patients with symptomatic heart failure and intraventricular conduction delay. However, its clinical outcomes are non-uniform and up to one third of treated patients are subsequently classified as non-responders. Multisite pacing (MSP), i.e. stimulating the myocardium from multiple locations, has emerged as a potential therapeutic option in patients requiring CRT. The rationale for MSP is based on the hypothesis that increasing the pacing locations in the left ventricle results in a more physiologic and coordinated myocardial systole. MSP can be achieved by additional leads in the right or left ventricle but this can lead to high battery drain and more frequent generator replacements. Multipolar left ventricular leads can deliver pacing at multiple sites, and therefore, a single lead can be used for MSP. However, the optimal programming settings and the outcomes of this approach remain yet to be determined.

Management of heart failure with preserved ejection fraction.

Heart failure affects nearly one million people in the UK. Half of these patients have normal, or near normal, left ventricular ejection fraction and are classified as heart failure with preserved ejection fraction (HFpEF). Newer imaging techniques have confirmed that systolic function in HFpEF patients is not completely normal, with reduced long axis function and extensive but subtle changes on exercise. Patients are likely to be older women with a history of hypertension. Other cardiovascular risk factors, such as diabetes mellitus, atrial fibrillation and coronary artery disease are prevalent in the HFpEF population. Clinical symptoms and signs in HFpEF are often nonspecific although the primary symptoms are breathlessness, fatigue and fluid retention. There is still no single diagnostic test for HFpEF and the cornerstone in the assessment remains a thorough medical history and physical examination. The duration and extent of the symptoms are relevant and it is useful to classify patients according to the NYHA functional assessment. Physical examination should include the patient's BMI and weight, heart rate and rhythm, lying and standing blood pressure and auscultation to rule out valvular disease and pulmonary congestion. Estimating the jugular venous pressure and the presence of peripheral oedema allows assessment of the patient's volume status. Patients with heart failure should be referred to heart failure nurses and have follow-up with local cardiology services as these have both been shown to reduce mortality.