Device Therapy in Heart Failure (Contemporary Cardiology)
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The risk of cardiovascular death and hospitalization for HF were also significantly reduced. Broadening of recommendations for cardiac resynchronization therapy in relation to the main trials. There is a significant heterogeneity in the definition of wide vs narrow QRS. Thus, it is important to recognize these differences for proper comparison between studies..
In an early study published in , 44 38 patients with a wide QRS complex and 14 patients with a narrow QRS complex were compared. In contrast, withholding CRT for 4 weeks resulted in loss of echocardiographic benefits. In both groups, LV reverse remodeling was determined to a similar extent by the degree of baseline mechanical dyssynchrony. In a similar study, 46 33 consecutive patients with a narrow QRS complex were prospectively compared with 33 consecutive patients with a wide QRS complex. These small pilot studies demonstrated that patients selected on the basis of echocardiography-based dyssynchrony criteria may benefit from CRT independently of QRS duration..
Worth mentioning is the observational, longitudinal study by Gasparini et al.
Promising brand-new developments
Although the findings were consistent in all of these small studies, all were limited by lack of hard endpoints, small sample size, and short duration of follow-up. The initial enthusiasm for a possible benefit of CRT in patients with narrow QRS was subsequently tempered by the outcome of multicenter trials that followed.. All patients received a defibrillator and were on optimized medical therapy.
The later is considered the most important determinant of HF symptoms. Furthermore, the same general concerns apply as for RethinQ. On one hand, the tissue Doppler imaging criteria employed may not have depicted patients suitable for CRT. More importantly, however, the single-arm design, low patient number, and short follow-up period limit the validity of the study to assess the long-term effects of CRT on LV remodeling and eventually morbidity and mortality.
Moreover, in contrast to single-center studies, interobserver variations in the assessment of dyssynchrony may be considerably higher across different centers in multicenter trials, which may have prevented uniform selection of appropriate patients. The trial is expected to report in — Last year the results of the Ablate and Pace for Atrial Fibrillation 53 trial were published. The study included patients indicated for AV node ablation because of severe symptomatic permanent AF. The patients were randomized to BiV pacing 97 patients or RV pacing only 89 patients. The average LVEF was 0.
The median follow-up was 20 months. In spite of the nonsignificant results in mortality, its positive clinical results can encourage the initiative for more studies in this direction.. Very recently, Berruezo et al.
Gaps in the Heart Failure Guidelines
Although the study population was too small and larger randomized controlled trials are required, these promising results tell us that BiV pacing could be considered when surgical or ablative treatment are contraindicated or rejected by the patient.. To date, there is no formal contraindication to CRT.
However, great caution should be taken in particular clinical settings. There is progressive evidence of limited CRT benefit in acutely decompensated patients or catecholamine-dependent patients. The presence of extensive scarring of lateral wall may be considered a relative contraindication. Although no formal study has prospectively addressed this specific condition, several retrospective small studies have reported lack of significant benefit in patients with large scars over the free wall of LV..
The idea that the lateral wall is the target for the position of the LV lead is being challenged by some groups. Recently, Derval et al. Of note, no ventricular region could be correlated to the best pacing site. Therefore, the best pacing site to deliver CRT appears to be patient-specific; an individually based approach to pacing at the best possible location proved to be superior to other pacing strategies pacing from within the coronary sinus, at the lateral wall, or at the most delayed wall region identified by myocardial strain measures.. However, to conceive a patient-specific approach for LV lead positioning, some technical development is needed.
More targeted delivery of pacing can be achieved with the use of an endocardial LV lead. This avoids the limited choice of placement, the phrenic nerve stimulation commonly encountered with epicardial leads, and eventually multiple LV pacing sites.
Recent preclinical work simulating different clinical settings has provided the first evidence that LV endocardial pacing is superior to epicardial pacing. Even in a dog model with myocardial infarction or in which chronic rapid ventricular pacing added to LBBB determined severe HF, endocardial pacing significantly increased LV contractility compared to epicardial pacing.
The mechanism by which endocardial pacing is superior to epicardial pacing is not fully elucidated although some hypotheses may be generated. LV endocardial pacing site is more natural, follows intrinsic activation, and produces a more homogenous spread of activation than epicardial pacing. The difficulty of endocardial pacing lies in access to the LV cavity. So far, most endocardial leads have been placed with a transseptal approach that accesses the LV cavity by passing from the right atrium through the left atrium.
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More recently, leadless pacing has been proposed. This approach has the potential advantage to simplify implantation procedures, to improve access to CRT in patients with unfavorable coronary sinus anatomy, and eventually to greatly increase the ability to pace children. Use of ultrasound or induction transfer of energy 58 to a receiver electrode has been recently reported. This technology is currently under investigation in the Wireless Endocardial CRT study, a prospectively controlled study designed to evaluate the safety and feasibility of this novel pacing modality..
CRT has represented a revolution in the treatment of HF. Modern goals of CRT are to enhance response to CRT in those patients who respond to the therapy as well as to reduce the proportion of patients not responding to therapy. Home Articles in press Current Issue Archive.
ISSN: Previous article Next article. Issue 9. Pages September Cardiac Resynchronization Therapy. Indications and Contraindications.
Indicaciones y contraindicaciones. Download PDF. Corresponding author. This item has received. Article information. To achieve this, further studies and new implant techniques are under investigation. Palabras clave:. Introduction Heart failure HF is one of the most disabling, deadly, and costly cardiovascular diseases in western countries.
Current goals of CRT are a to improve the rate of patients responding to the therapy, and b to enhance the response to the therapy in those individuals who benefit from CRT. It is worth notice that, as of today, no exclusion or contraindication to CRT has been formally established. Indications of cardiac resynchronization therapy. Patients in atrial fibrillation HF patients with atrial fibrillation AF usually have more comorbidities and a worse prognosis despite optimal pharmacological treatment than those in sinus rhythm.
The greater severity of symptoms in this population can be explained by lack of atrial active filling and related atrioventricular AV synchrony, and irregular RR interval and relatively higher mean heart rate, both of which significantly shorten ventricular filling time. The high patient drop-out rate limited the statistical power of this trial. Mechanical volume and pressure unloading induced by LVADs allows a reversal of stress-related compensatory responses leading to full cardiac recovery and device removal in few selected patients.
Device Therapy in Heart Failure (Contemporary Cardiology) | Mayday Sell Book
Colombo's research team has provided the first evidence that myocardial recovery during LVAD support is a spectrum of improvement rather than a binary clinical endpoint, being partial recovery much more frequent than full recovery. These results raised the possibility that patients who achieved only partial recovery may be further improved to complete recovery if treated aggressively with reverse remodeling therapy.
Incidence and predictors of myocardial recovery on long-term left ventricular assist device support: Results from the united network for organ sharing database. J Heart Lung Transplant. Circ Heart Fail. LVAD therapy has revolutionized the treatment of patients with advanced heart failure and my research has focused on defining clinical and pathophysiologic parameters of LVAD function, the hemodynamic and metabolic response to LVAD placement and the specific determinants of clinical outcomes in this patient population.
Adrenergic activation, fuel substrate availability, and insulin resistance in patients with congestive heart failure. J Heart Lung Transpl , Circ Heart Fail , J Am Coll Cardiol.
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