Integrative and quantitive evaluation of the efficacy of his bundle related pacing in comparison with conventional right ventricular pacing: a meta-analysis.
ABSTRACT: Long-term RVP could bring adverse problems to cardiac electro-mechanics and result in inter- and intra-ventricular asynchrony, impaired labor force, and aggravation of cardiac function. HBRP including direct His bundle pacing and para-His bundle pacing was regarded as a novel physiological pacing pattern to avoid devastating cardiac function. This synthetic study was conducted to integratively and quantitatively evaluate the efficacy of His bundle related pacing (HBRP) in comparison with conventional right ventricular pacing (RVP).Published studies on comparison of left ventricular ejection fraction (LVEF), left ventricular end diastolic volume (LVEDV), left ventricular end systolic volume (LVESV), New York Heart Association (NYHA) class, inter-ventricular asynchrony, and QRS duration, etc. between HBRP and RVP were collected and for meta-analysis.HBRP showed higher LVEF (WMD = 3.9%, 95% CI: 1.6% - 6.1%), lower NYHA class (WMD = -0.5, 95% CI: -0.7 - -0.3), WMD of LVESV = -0.1 ml, 95% CI: -3.0 - 2.8 ml), less inter-ventricular asynchrony (WMD = -13.2 ms, 95% CI: -16.4 - -10.0 ms), and shorter QRS duration for long-term (WMD = -36.9 ms, 95% CI: -40.0 - -33.8 ms), however, no significant difference of ventricular volume (WMDLVEDV = -2.4 ml, 95% CI: -5.0 - 0.2 ml; WMDLVESV = -0.1 ml, 95% CI: -3.0 - 2.8 ml) compared to RVP.The efficacy of HBRP was firstly verified by meta-analysis to date. Compared with RVP, HBRP markedly preserve LVEF, NYHA class, and QRS duration. However, it seemed to have less effect on ventricular volume.
Project description:Conventional cardiac resynchronization therapy (CRT, Bi-V) is associated with no response in about 40% patients due to an insufficient resynchronization. Some studies showed triple-site ventricular (Tri-V) pacing had greater benefits compared with Bi-V pacing, but the results of these studies were conflicting. We hypothesized that Tri-V pacing had greater benefits on long-term outcomes compared with Bi-V pacing in patients with heart failure.PubMed, EMBASE, and the Cochrane Library were searched for clinical studies with related outcomes. Weighted mean differences (WMD) and 95% confidence intervals (CIs) were calculated to compare the change in left ventricular ejection fraction (LVEF), left ventricular geometry, functional capacity, and quality of life between Tri-V pacing group and control group.Five trials with 251 patients were included in the analysis. Patients in the Tri-V pacing group had a greater improvement in LVEF (WMD 4.04; 95% CI 2.15-5.92, P < .001) and NYHA classes (WMD -0.27; 95% CI -0.42 to -0.11, P = .001) compared with control group. However, there were no significant differences in left ventricular geometry, six-min walk distance, or Minnesota Living With Heart Failure Questionnaire score between the two groups. The subgroup analyses showed there might be a greater improvement in LVEF in the Tri-V pacing group in patients with QRS duration ? 155 ms (WMD 5.60; 95% CI 3.09-8.10, P < .001).The present analysis suggests that Tri-V pacing has greater benefits in terms of an improvement in LVEF and functional capacity in patients with systolic heart failure, especially in patients with the duration of QRS ? 155 ms.
Project description:<b>Background: </b>The left bundle branch pacing (LBBP) makes the ventricular depolarization closer to the physiological state and shortens QRS duration. The purpose of this study is to explore the ventricular systolic mechanical synchronization after LBBP in comparison with traditional right ventricular pacing (RVP) using two-dimensional strain echocardiography (2D-STE).<br><br><b>Methods: </b>Thirty-two patients who received LBBP (n = 16) or RVP (n = 16) from October 2018 to October 2019 and met the inclusion criteria were included in this retrospective study. Electrocardiogram (ECG) characteristics, pacing parameters, pacing sites, and safety events were assessed before and after implantation. Acquisition and analysis of ventricular systolic synchronization were implemented using 2D-STE.<br><br><b>Results: </b>In RVP group, ECG showed left bundle branch block patterns. At LBBP, QRS morphology was in the form of right bundle branch block, and QRS durations were significantly shorter than that of the RVP QRS (109.38?±?12.89 vs 149.38 \±?19.40?ms, P?<?.001). Both the maximum time differences (TD) and SDs of the 18-segments systolic time to peak systolic strain were significantly shorter under LBBP than under RVP (TD, 66.62?±?37.2 vs 148.62?±?43.67?ms, P?<?.01; SD, 21.80 ±?12.13 vs 52.70?±?17.72?ms, P?<?.01), indicating that LBBP could provide better left ventricular mechanical synchronization. Left and right ventricular pre-ejection period difference was significantly longer in RVP group than in LBBP group (10.23?±?3.07 vs 39.94?±?14.81?ms, P?<?.05), indicating left and right ventricular contraction synchronization in LBBP group being better than in RVP group.<br><br><b>Conclusion: </b>LBBP is able to provide a physiologic ventricular activation pattern, which results in ventricular mechanical contraction synchronization.
Project description:BACKGROUND:Left bundle branch area pacing (LBBaP) is a new physiological pacing strategy that produces comparable clinical effects to His bundle pacing (HBP). OBJECTIVE:The purpose of this study was to investigate the immediate clinical outcomes of LBBaP vs RVP. METHODS AND RESULTS:From April 2018 to September 2018, we included 44 patients under continuous pacemaker implantation. Patients were randomly divided into the LBBaP group and conventional RVP group. Compared to the RVP group, the LBBaP group displayed significantly increased operative (90.10 ± 19.68 minutes vs 61.57 ± 6.62 minutes, P < .001) and X-ray exposure times (15.55 ± 5.62 minutes vs 4.67 ± 2.06 minutes, P < .001). The lead threshold of the LBBaP group was increased (0.68 ± 0.20 mV vs 0.51 ± 0.0 mV, P = .001), while the R-wave amplitude and ventricular impedance did not significantly differ between the two groups. The conventional RVP procedure significantly widened the QRS complex (93.62 ± 8.28 ms vs 135.19 ± 12.21 ms, P = .001), whereas the LBBaP had no effect on QRS complex (130.13 ± 43.30 ms vs 112.63 ± 12.14 ms, P = .904). Furthermore, the LBBaP procedure significantly narrowed the QRS complex in patients with left bundle branch block (LBBB) (168.43 ± 38.870 ms vs 119.86 ± 6.69 ms, P = .019). CONCLUSION:LBBaP is a new physiological, safe and effective pacing procedure with a high overall success rate. Compared to conventional RVP, LBBaP can correct LBBB, thereby improving cardiac electrical dyssynchrony.
Project description:Background:Cardiac amyloidosis involvement is associated with a detrimental outcome including frequent arrhythmias, heart failure, and conduction disturbances which may need permanent pacing. Cases summary:We report two cases of patients with transthyretin amyloidosis (ATTR) who developed heart failure and depressed left ventricular ejection fraction (LVEF) following permanent right ventricular (RV) pacing but highly responded to cardiac resynchronization therapy (CRT). Discussion:The impact of RV pacing and CRT in cardiac amyloidosis is not known. In our cases, the detrimental effect of permanent RV pacing on left ventricular (LV) systolic function and heart failure symptoms was suggested by both permanent RV pacing mediated functional and LV function decline and LV systolic dysfunction reversal following CRT along with QRS width reduction. Whether cardiac resynchronization should be readily recommended in ATTR patients who need ventricular pacing whatever the LVEF deserves further investigation.
Project description:PURPOSE:It is uncertain whether right ventricular (RV) lead position in cardiac resynchronization therapy impacts response. There has been little detailed analysis of the activation patterns in RV septal pacing (RVSP), especially in the CRT population. We compare left bundle branch block (LBBB) activation patterns with RV pacing (RVP) within the same patients with further comparison between RV apical pacing (RVAP) and RVSP. METHODS:Body surface mapping was undertaken in 14 LBBB patients after CRT implantation. Nine patients had RVAP, 5 patients had RVSP. Activation parameters included left ventricular total activation time (LVtat), biventricular total activation time (VVtat), interventricular electrical synchronicity (VVsync), and dispersion of left ventricular activation times (LVdisp). The direction of activation wave front was also compared in each patient (wave front angle (WFA)). In silico computer modelling was applied to assess the effect of RVAP and RVSP in order to validate the clinical results. RESULTS:Patients were aged 64.6?±?12.2 years, 12 were male, 8 were ischemic. Baseline QRS durations were 157?±?18 ms. There was no difference in VVtat between RVP and LBBB but a longer LVtat in RVP (102.8?±?19.6 vs. 87.4?±?21.1 ms, p?=?0.046). VVsync was significantly greater in LBBB (45.1?±?20.2 vs. 35.9?±?17.1 ms, p?=?0.01) but LVdisp was greater in RVP (33.4?±?5.9 vs. 27.6?±?6.9 ms, p?=?0.025). WFA did rotate clockwise with RVP vs. LBBB (82.5?±?25.2 vs. 62.1?±?31.7 op?=?0.026). None of the measurements were different to LBBB with RVSP; however, the differences were preserved with RVAP for VVsync, LVdisp, and WFA. In silico modelling corroborated these results. CONCLUSIONS:RVAP activation differs from LBBB where RVSP appears similar. TRIAL REGISTRATION:(ClinicalTrials.gov identifier: NCT01831518).
Project description:BACKGROUND: Cardiac resynchronization Therapy (CRT) is an effective therapy for chronic heart failure with beneficial hemodynamic effects leading to a reduction of morbidity and mortality. The responder rates, however, are low. There are various and contentious echocardiographic parameters of myocardial asynchrony. Patient selection by echocardiographic assessment of asynchrony is thought to improve responder rates. METHODS: In this small single-center pilot-study, seven established parameters of myocardial asynchrony were used to select patients for CRT: (1) interventricular electromechanical delay (IMD, cut-off > or = 40 ms), (2) Septal-to-posterior wall motion delay (SPWMD, > or = 130 ms), (3) maximal difference in time-to-peak velocities between any two of twelve LV segments (Ts-12 > or = 104 ms), (4) standard deviation of time to peak myocardial velocities (Ts-12-SD, > or = 34.4 ms), (5) difference between the septal and basal time-to-peak velocity (TDId, > or = 60 ms), (6) left ventricular electromechanical delay (LVEMD, > 140 ms) and (7) delayed longitudinal contraction (DLC, > 2 segments).16 chronic heart failure patients (NYHA III-IV, LVEF < 0.35, QRS > or = 120 ms) at least two out of seven parameters of myocardial asynchrony received cardiac resynchronization therapy (CRT-ICD). Follow-up echo examination was after 6 months. The control group was a historic group of CRT patients (n = 38) who had not been screened for echocardiographic signs of myocardial asynchrony prior to device implantation. RESULTS: Based on reverse remodeling (relative reduction of LVESV > 15%, relative increase of LVEF > 25%), the responder rate to CRT was 81.2% in patients selected for CRT according to our protocol as compared to 47.4% in the control group (p = 0.04). At baseline, there were on average 4.1 +/- 1.6 positive parameters of asynchrony (follow-up: 3.7 [+/- 1.6] parameters positive, p = 0.52). Only the LVEMD decreased significantly after CRT (p = 0.027). The remaining parameters showed a non-significant trend towards reduction of myocardial asynchrony. CONCLUSION: The implementation of different markers of asynchrony in the selection process for CRT improves the hemodynamic response rate to CRT.
Project description:Stem cell transplantation (SCT) has become a promising way to treat ischemic heart failure (IHF). We performed a large-scale meta-analysis of randomized clinical trials to investigate the efficacy and safety of SCT in IHF patients. Randomized controlled trials (RCTs) involving stem cell transplantation for the treatment of IHF were identified by searching the PubMed, EMBASE, SpringerLink, Web of Science, and Cochrane Systematic Review databases as well as from reviews and the reference lists of relevant articles. Fourteen eligible randomized controlled trials were included in this study, for a total of 669 IHF patients, of which 380 patients were treated with SCT. The weighted mean difference (WMD) was calculated for changes in the New York Heart Association (NYHA) class, left ventricular ejection fraction (LVEF), left ventricular end-diastolic and end-systolic volumes (LVEDV and LVESV), and Canadian Cardiovascular Society (CCS) angina grade using a fixed effects model, while relative risk (RR) was used for mortality. Compared with the control group, SCT significantly lowered the NYHA class (MD = - 0.73, 95% CI - 1.32 to - 0.14, P < 0.05), LVESV (MD = - 14.80, 95% CI - 20.88 to - 8.73, P < 0.05), and CCS grade (MD = - 0.81, 95% CI - 1.45 to - 0.17, P < 0.05). Additionally, SCT increased LVEF (MD = 6.55, 95% CI 5.93 to 7.16, P < 0.05). However, LVEDV (MD = - 0.33, 95% CI - 1.09 to 0.44, P > 0.05) and mortality (RR = 0.86, 95% CI 0.45 to 1.66, P > 0.05) did not differ between the two groups. This meta-analysis suggests that SCT may contribute to the improvement of LVEF, as well as the reduction of the NYHA class, CCS grade, and LVESV. In addition, SCT does not affect mortality.
Project description:BACKGROUND/AIM:Despite the well-established benefits of cardiac resynchronization therapy (CRT) in heart failure (HF) patients with left ventricular ejection fraction (LVEF) ?35%, many patients with less reduced EF remain refractory to optimized medical treatment and at high risk of morbidity and mortality. The objective of the study is to evaluate the effects of CRT in optimally treated patients with New York Heart Association (NYHA) classes II-IV, LVEF of 36-45%, and left bundle branch (LBBB), including clinical, structural and biochemical response. METHODS:A selected group of HF patients have been implanted with CRT-P devices and were followed up for 6 months at 4, 12 and 24 weeks. Clinical assessment included NYHA class, quality of life and 6-min walk distance (6 MWD) test. Echocardiographic assessment included LV dimensions and function and left atrial volume. Serum N-terminal pro b-type natriuretic peptide (NT-ProBNP) was measured at the same intervals. RESULTS:This prospective single center study included 23 patients. NYHA functional class significantly improved after CRT-P (p < 0.0001), associated with improvement in QOL (p < 0.0001) and 6 MWD, which increased, from 145.7 ± 20.1 m to 219.5 ± 42.2 m (p < 0.0001). Mean QRS duration showed significant shortening from 164.4 ± 13.2 ms to 126.4 ± 13.6 ms (p < 0.0001). CRT induced reverse remodeling with reduction in both left ventricular end diastolic diameter (LVEDD) from 68.95 ± 5.05 mm to 62.8 ± 4.47 mm, p = 0.0002 and left ventricular end systolic diameter (LVESD) from 54.1 ± 4.5 mm to 46.5 ± 4.1 mm, p < 0.0001, and significant increase in LVEF (from 40.3 ± 2.8 to 48.3 ± 4.2 mm, p < 0.0001). The biochemical response to CRT showed significant reduction in serum NT-ProBNP from 1025.6 ± 363.1 pg/ml to 594.9 ± 263.5 pg/ml (p < 0.0001). CONCLUSIONS:Symptomatic HF patients on maximal optimized medical treatment who have LBBB and baseline LVEF 35-45% appeared to derive significant clinical and structural benefit from CRT.
Project description:Background Conventional right ventricular pacing (RVP) has been associated with an increased incidence of atrial fibrillation (AF). We sought to compare the occurrence of new-onset AF and assessed AF disease progression during long-term follow-up between His bundle pacing (HBP) and RVP. Methods and Results We included patients undergoing initial dual-chamber pacemaker implants at Rush University Medical Center between January 1, 2016, and June 30, 2019. A total of 360 patients were evaluated, and 225 patients (HBP, n=105; RVP, n=120) were included in the study. Among the 148 patients (HBP, n=72; RVP, n=76) with no history of AF, HBP demonstrated a lower risk of new-onset AF (adjusted hazard ratio [HR], 0.53; 95% CI, 0.28-0.99; <i>P</i>=0.046) compared with traditional RVP. This benefit was observed with His or RVP burden exceeding 20% (HR, 0.29; 95% CI, 0.13-0.64; <i>P</i>=0.002), ?40% (HR, 0.31; <i>P</i>=0.007), ?60% (HR, 0.35; <i>P</i>=0.015), and ?80% (HR, 0.40; <i>P</i>=0.038). There was no difference with His or RV pacing burden <20% (HR, 0.613; 95% CI, 0.213-1.864; <i>P</i>=0.404). In patients with a prior history of AF, there was no difference in AF progression (<i>P</i>=0.715); however, in a subgroup of patients with a pacing burden ?40%, HBP demonstrated a trend toward a lower risk of AF progression (HR, 0.19; 95% CI, 0.03-1.16; <i>P</i>=0.072). Conclusions HBP demonstrated a lower risk of new-onset AF compared with RVP, which was primarily observed at a higher pacing burden.
Project description:BACKGROUND: The pacing site has been shown to influence functional improvement with cardiac resynchronization therapy. We evaluated the effects of the pacing site on left ventricular (LV) function in an animal model. METHODS AND RESULTS: Equilibrium radionuclide angiography was acquired in sinus rhythm (NSR) and with ventricular pacing, from three pacing sites in seven normal and eight infarcted dogs. QRS duration, electrical activation pattern, wall motion, LV ejection fraction (EF), synchrony of ventricular contraction, and mean arterial pressure (MAP), were related to the pacing site and infarct size, during each of 120 episodes. Little changed during pacing in normals. In infarcted dogs, LV wall motion, and synchrony worsened, LVEF and MAP often fell. These changes related to altered activation patterns which were influenced by the pacing site but were not related to infarct size. CONCLUSIONS: Hemodynamic and functional LV changes after infarction were found to vary with the pacing site and associated conduction and synchrony.