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New Pacing Techniques and Non-invasive Methods That May Improve Response...
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New Pacing Techniques and Non-invasive Methods That May Improve Response and Patient Selection to Cardiac Resynchronization Therapy

A special issue of Journal of Cardiovascular Development and Disease (ISSN 2308-3425). This special issue belongs to the section "Cardiovascular Clinical Research".

Deadline for manuscript submissions: closed (31 January 2024) | Viewed by 18935

Special Issue Editor

Dr. András Vereckei

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Guest Editor
Department of Medicine and Hematology, Semmelweis University, 1088 Budapest, Hungary
Interests: wide QRS complex tachycardia; ventricular tachycardia; supraventricular tachycardia; heart failure; cardiac resynchronization therapy; acute pulmonary embolism; electrocardiography; echocardiography; experimental electrophysiology; antioxidants; oxidative stress; free radical reactions; amiodarone toxicity

Special Issue Information

Dear Colleagues,

Although cardiac resynchronization therapy (CRT) proved to be an effective management of symptomatic heart failure with reduced ejection fraction associated with intraventricular conduction disturbance and refractory to optimal medical therapy, the non-response rate to CRT is still 20-40%.  The still non-negligible non-response to CRT is due to the fact that patient selection for CRT with the currently recommended criteria (QRS duration and morphology, left ventricular ejection fraction) is not optimal, and the application of other pacing techniques than the currently applied CRT technique might be preferred in some patients. The aim of this Special Issue is to provide an overview about the promising results of newer pacing techniques, such as conduction system pacing (His bundle pacing, left bundle branch area pacing), which can be applied for CRT and to present new non-invasive (electrocardiographic, echocardiographic) methods that may improve patient selection for CRT. These non-invasive methods may improve patient selection for CRT by better assessing the main determinant of CRT response, the presence or absence of significant electrical (and consequential mechanical) ventricular dyssynchrony and the ability of the applied CRT technique to eliminate it, than the currently recommended criteria. By reading this Special Issue cardiologists get insight into the latest promising methods that may improve response to CRT.

Dr. András Vereckei
Guest Editor

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Keywords

  • conduction system pacing
  • His bundle pacing
  • left bundle branch area pacing
  • vectorcardiographic QRS area
  • electrocardiographic dyssynchrony criteria
  • electrocardiographic imaging
  • echocardiographic mechanical dyssynchrony criteria
  • septal flash
  • apical rocking
  • mechanical dispersion
  • myocardial work
  • electrocardiography
  • echocardiography

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Published Papers (8 papers)

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Editorial

Jump to: Review

4 pages, 200 KiB  
Editorial
New Pacing Techniques and Non-Invasive Methods That May Improve Response to Cardiac Resynchronization Therapy
by András Vereckei
J. Cardiovasc. Dev. Dis. 2024, 11(7), 208; https://doi.org/10.3390/jcdd11070208 - 3 Jul 2024
Viewed by 859
Abstract
Although cardiac resynchronization therapy (CRT) is an evidence-based effective therapy of symptomatic heart failure with reduced ejection fraction (HFrEF), refractory to optimal medical treatment and associated with intraventricular conduction disturbance, the non-response rate to CRT is still around 30% [...] Full article
(This article belongs to the Special Issue New Pacing Techniques and Non-invasive Methods That May Improve Response and Patient Selection to Cardiac Resynchronization Therapy)

Review

Jump to: Editorial

18 pages, 5757 KiB  
Review
Is Conduction System Pacing a Valuable Alternative to Biventricular Pacing for Cardiac Resynchronization Therapy?
by Davide Castagno, Francesco Zanon, Gianni Pastore, Gaetano Maria De Ferrari and Lina Marcantoni
J. Cardiovasc. Dev. Dis. 2024, 11(5), 144; https://doi.org/10.3390/jcdd11050144 - 2 May 2024
Viewed by 1666
Abstract
Cardiac resynchronization therapy (CRT) significantly improves clinical outcomes in patients with ventricular systolic dysfunction and dyssynchrony. Biventricular pacing (BVP) has a class IA recommendation for patients with symptomatic heart failure with reduced ejection fraction (HFrEF) and left bundle branch block (LBBB). However, approximately [...] Read more.
Cardiac resynchronization therapy (CRT) significantly improves clinical outcomes in patients with ventricular systolic dysfunction and dyssynchrony. Biventricular pacing (BVP) has a class IA recommendation for patients with symptomatic heart failure with reduced ejection fraction (HFrEF) and left bundle branch block (LBBB). However, approximately 30% of patients have a poor therapeutic response and do not achieve real clinical benefit. Pre-implant imaging, together with tailored programming and dedicated device algorithms, have been proposed as possible tools to improve success rate but have shown inconsistent results. Over the last few years, conduction system pacing (CSP) is becoming a real and attractive alternative to standard BVP as it can restore narrow QRS in patients with bundle branch block (BBB) by stimulating and recruiting the cardiac conduction system, thus ensuring true resynchronization. It includes His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Preliminary data coming from small single-center experiences are very promising and have laid the basis for currently ongoing randomized controlled trials comparing CSP with BVP. The purpose of this review is to delve into the emerging role of CSP as an alternative method of achieving CRT. After framing CSP in a historical perspective, the pathophysiological rationale and available clinical evidence will be examined, and crucial technical aspects will be discussed. Finally, evidence gaps and future perspectives on CSP as a technique of choice to deliver CRT will be summarized. Full article
(This article belongs to the Special Issue New Pacing Techniques and Non-invasive Methods That May Improve Response and Patient Selection to Cardiac Resynchronization Therapy)
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14 pages, 3390 KiB  
Review
Ultra-High-Frequency ECG in Cardiac Pacing and Cardiac Resynchronization Therapy: From Technical Concept to Clinical Application
by Uyên Châu Nguyên, Jesse H. J. Rijks, Filip Plesinger, Leonard M. Rademakers, Justin Luermans, Karin C. Smits, Antonius M. W. van Stipdonk, Frits W. Prinzen, Kevin Vernooy, Josef Halamek, Karol Curila and Pavel Jurak
J. Cardiovasc. Dev. Dis. 2024, 11(3), 76; https://doi.org/10.3390/jcdd11030076 - 23 Feb 2024
Viewed by 3406
Abstract
Identifying electrical dyssynchrony is crucial for cardiac pacing and cardiac resynchronization therapy (CRT). The ultra-high-frequency electrocardiography (UHF-ECG) technique allows instantaneous dyssynchrony analyses with real-time visualization. This review explores the physiological background of higher frequencies in ventricular conduction and the translational evolution of UHF-ECG [...] Read more.
Identifying electrical dyssynchrony is crucial for cardiac pacing and cardiac resynchronization therapy (CRT). The ultra-high-frequency electrocardiography (UHF-ECG) technique allows instantaneous dyssynchrony analyses with real-time visualization. This review explores the physiological background of higher frequencies in ventricular conduction and the translational evolution of UHF-ECG in cardiac pacing and CRT. Although high-frequency components were studied half a century ago, their exploration in the dyssynchrony context is rare. UHF-ECG records ECG signals from eight precordial leads over multiple beats in time. After initial conceptual studies, the implementation of an instant visualization of ventricular activation led to clinical implementation with minimal patient burden. UHF-ECG aids patient selection in biventricular CRT and evaluates ventricular activation during various forms of conduction system pacing (CSP). UHF-ECG ventricular electrical dyssynchrony has been associated with clinical outcomes in a large retrospective CRT cohort and has been used to study the electrophysiological differences between CSP methods, including His bundle pacing, left bundle branch (area) pacing, left ventricular septal pacing and conventional biventricular pacing. UHF-ECG can potentially be used to determine a tailored resynchronization approach (CRT through biventricular pacing or CSP) based on the electrical substrate (true LBBB vs. non-specified intraventricular conduction delay with more distal left ventricular conduction disease), for the optimization of CRT and holds promise beyond CRT for the risk stratification of ventricular arrhythmias. Full article
(This article belongs to the Special Issue New Pacing Techniques and Non-invasive Methods That May Improve Response and Patient Selection to Cardiac Resynchronization Therapy)
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13 pages, 3148 KiB  
Review
Understanding the Application of Mechanical Dyssynchrony in Patients with Heart Failure Considered for CRT
by Abhishek Dutta, Rakan Radwan M. Alqabbani, Andreas Hagendorff and Bhupendar Tayal
J. Cardiovasc. Dev. Dis. 2024, 11(2), 64; https://doi.org/10.3390/jcdd11020064 - 17 Feb 2024
Cited by 2 | Viewed by 2333
Abstract
Over the past two decades of CRT use, the failure rate has remained around 30–35%, despite several updates in the guidelines based on the understanding from multiple trials. This review article summarizes the role of mechanical dyssynchrony in the selection of heart failure [...] Read more.
Over the past two decades of CRT use, the failure rate has remained around 30–35%, despite several updates in the guidelines based on the understanding from multiple trials. This review article summarizes the role of mechanical dyssynchrony in the selection of heart failure patients for cardiac resynchronization therapy. Understanding the application of mechanical dyssynchrony has also evolved during these past two decades. There is no role of lone mechanical dyssynchrony in the patient selection for CRT. However, mechanical dyssynchrony can complement the electrocardiogram and clinical criteria and improve patient selection by reducing the failure rate. An oversimplified approach to mechanical dyssynchrony assessment, such as just estimating time-to-peak delays between segments, should not be used. Instead, methods that can identify the underlying pathophysiology of HF and are representative of a substrate to CRT should be applied. Full article
(This article belongs to the Special Issue New Pacing Techniques and Non-invasive Methods That May Improve Response and Patient Selection to Cardiac Resynchronization Therapy)
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13 pages, 2289 KiB  
Review
Current Role of Electrocardiographic Imaging in Patient Selection for Cardiac Resynchronization Therapy
by Saer Abu-Alrub, Marc Strik, Peter Huntjens, Michel Haïssaguerre, Romain Eschalier, Pierre Bordachar and Sylvain Ploux
J. Cardiovasc. Dev. Dis. 2024, 11(1), 24; https://doi.org/10.3390/jcdd11010024 - 15 Jan 2024
Viewed by 1968
Abstract
Cardiac resynchronization therapy (CRT) is a recognized therapy for heart failure with altered ejection fraction and abnormal left ventricular activation time. Since the introduction of the therapy, a 30% rate of non-responders is observed and unchanged. The 12-lead ECG remains the only recommended [...] Read more.
Cardiac resynchronization therapy (CRT) is a recognized therapy for heart failure with altered ejection fraction and abnormal left ventricular activation time. Since the introduction of the therapy, a 30% rate of non-responders is observed and unchanged. The 12-lead ECG remains the only recommended tool for patient selection to CRT. The 12-lead ECG is, however, limited in its inability to provide a precise pattern of regional electrical activity. Electrocardiographic imaging (ECGi) provides a non-invasive detailed mapping of cardiac activation and therefore appears as a promising tool for CRT candidates. The non-invasive ventricular activation maps acquired by ECGi have been primarily explored for the diagnosis and guidance of therapy in patients with atrial or ventricular tachyarrhythmia. However, the accuracy of the system in this field is lacking and needs further improvement before considering a clinical application. On the other hand, its use for patient selection for CRT is encouraging. In this review, we introduce the technical considerations and we describe how ECGi can precisely characterize ventricular activation, especially in patients with left bundle branch block, thus identifying the electrical substrate responsive to CRT. Full article
(This article belongs to the Special Issue New Pacing Techniques and Non-invasive Methods That May Improve Response and Patient Selection to Cardiac Resynchronization Therapy)
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11 pages, 743 KiB  
Review
Exploring QRS Area beyond Patient Selection in CRT—Can It Guide Left Ventricular Lead Placement?
by Frederieke Eerenberg, Justin Luermans, Joost Lumens, Uyên Châu Nguyên, Kevin Vernooy and Antonius van Stipdonk
J. Cardiovasc. Dev. Dis. 2024, 11(1), 18; https://doi.org/10.3390/jcdd11010018 - 11 Jan 2024
Viewed by 2006
Abstract
Vectorcardiographic QRS area is a promising tool for patient selection and implantation guidance in cardiac resynchronization therapy (CRT). Research has mainly focused on the role of QRS area in patient selection for CRT. Recently, QRS area has been proposed as a tool to [...] Read more.
Vectorcardiographic QRS area is a promising tool for patient selection and implantation guidance in cardiac resynchronization therapy (CRT). Research has mainly focused on the role of QRS area in patient selection for CRT. Recently, QRS area has been proposed as a tool to guide left ventricular lead placement in CRT. Theoretically, vector-based electrical information of ventricular fusion pacing, calculated from the basic 12-lead ECG, can give real-time insight into the extent of resynchronization at any LV lead position, as well as any selected electrode on the LV lead. The objective of this review is to provide an overview of the background of vectorcardiographic QRS area and its potential in optimizing LV lead location in order to optimize the benefits of CRT. Full article
(This article belongs to the Special Issue New Pacing Techniques and Non-invasive Methods That May Improve Response and Patient Selection to Cardiac Resynchronization Therapy)
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22 pages, 3634 KiB  
Review
Conduction System Pacing for Cardiac Resynchronization Therapy
by Óscar Cano, Javier Navarrete-Navarro, Pablo Jover, Joaquín Osca, Maite Izquierdo, Josep Navarro, Hebert D. Ayala and Luis Martínez-Dolz
J. Cardiovasc. Dev. Dis. 2023, 10(11), 448; https://doi.org/10.3390/jcdd10110448 - 31 Oct 2023
Cited by 2 | Viewed by 2881
Abstract
Cardiac resynchronization therapy (CRT) via biventricular pacing (BiVP-CRT) is considered a mainstay treatment for symptomatic heart failure patients with reduced ejection fraction and wide QRS. However, up to one-third of patients receiving BiVP-CRT are considered non-responders to the therapy. Multiple strategies have been [...] Read more.
Cardiac resynchronization therapy (CRT) via biventricular pacing (BiVP-CRT) is considered a mainstay treatment for symptomatic heart failure patients with reduced ejection fraction and wide QRS. However, up to one-third of patients receiving BiVP-CRT are considered non-responders to the therapy. Multiple strategies have been proposed to maximize the percentage of CRT responders including two new physiological pacing modalities that have emerged in recent years: His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Both pacing techniques aim at restoring the normal electrical activation of the ventricles through the native conduction system in opposition to the cell-to-cell activation of conventional right ventricular myocardial pacing. Conduction system pacing (CSP), including both HBP and LBBAP, appears to be a promising pacing modality for delivering CRT and has proven to be safe and feasible in this particular setting. This article will review the current state of the art of CSP-based CRT, its limitations, and future directions. Full article
(This article belongs to the Special Issue New Pacing Techniques and Non-invasive Methods That May Improve Response and Patient Selection to Cardiac Resynchronization Therapy)
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13 pages, 915 KiB  
Review
Useful Electrocardiographic Signs to Support the Prediction of Favorable Response to Cardiac Resynchronization Therapy
by Andras Simon, David Pilecky, Loretta Zsuzsa Kiss and Mate Vamos
J. Cardiovasc. Dev. Dis. 2023, 10(10), 425; https://doi.org/10.3390/jcdd10100425 - 14 Oct 2023
Viewed by 3032
Abstract
Cardiac resynchronization therapy (CRT) is a cornerstone therapeutic opportunity for selected patients with heart failure. For optimal patient selection, no other method has been proven to be more effective than the 12-lead ECG, and hence ECG characteristics are extensively researched. The evaluation of [...] Read more.
Cardiac resynchronization therapy (CRT) is a cornerstone therapeutic opportunity for selected patients with heart failure. For optimal patient selection, no other method has been proven to be more effective than the 12-lead ECG, and hence ECG characteristics are extensively researched. The evaluation of particular ECG signs before the implantation may improve selection and, consequently, clinical outcomes. The definition of a true left bundle branch block (LBBB) seems to be the best starting point with which to select patients for CRT. Although there are no universally accepted definitions of LBBB, using the classical LBBB criteria, some ECG parameters are associated with CRT response. In patients with non-true LBBB or non-LBBB, further ECG predictors of response and non-response could be analyzed, such as QRS fractionation, signs of residual left bundle branch conduction, S-waves in V6, intrinsicoid deflection, or non-invasive estimates of Q-LV which are described in newer publications. The most important and recent study results of the topic are summarized and discussed in this current review. Full article
(This article belongs to the Special Issue New Pacing Techniques and Non-invasive Methods That May Improve Response and Patient Selection to Cardiac Resynchronization Therapy)
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