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The Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiovascular Medicine".

Deadline for manuscript submissions: closed (30 June 2023) | Viewed by 12876

Special Issue Editor

Dr. Alexander H. Maass

E-Mail Website
Guest Editor
Department of Cardiology, University Medical Center Groningen, University of Groningen, 9713 Groningen, The Netherlands
Interests: bradycardia; pacing; ICD; CRT; heart failure; exercise; congenital heart disease
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Cardiac resynchronization therapy (CRT) is an established technique to improve morbidity and mortality in selected heart failure patients. This technique has been a game changer for heart failure treatment in patients with conduction delay, who are often non-responders to optimal medical treatment. Unfortunately, rates of non-response to CRT are from 30% to 50% depending on the outcome parameter that is chosen. Non-response rates are due to suboptimal delivery of CRT, patient selection, and device programming. Furthermore, there is controversy on which parameter and cut-off should be used to define the CRT response.

Since we published our previous Special Issue (https://www.mdpi.com/journal/jcm/special_issues/Cardiac_Resynchronization_Therapy), cardiac conduction system (CSP) pacing has evolved as an alternative to CRT. CSP is mainly used in non-responders or if delivery of CRT is not achieved. Transition of CSP to first-line therapy instead of CRT is awaiting landmark trials, but implementation in real-life clinical settings has already progressed.

With this Special Issue, we would like to highlight recent advances in the improvement of CRT response, including, but not restricted to, strategies to optimize implantation techniques, patient selection, or CRT programming. We encourage researchers to submit their results and proposals on how to provide optimal CRT. The measurement of outcome variables such as exercise capacity, quality of life, reverse remodeling, as well as occurrence of atrial and ventricular arrhythmias is essential to evaluate the success of this powerful treatment. We especially encourage investigators to provide their experiences with CSP on these outcome parameters.

Dr. Alexander H. Maass
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • implantation
  • response
  • remodeling
  • arrhythmias
  • risk prediction
  • imaging
  • patient selection
  • alternative pacing sites
  • His bundle
  • left bundle branch

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Published Papers (8 papers)

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Editorial

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5 pages, 205 KiB  
Editorial
Special Issue: Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing
by Alexander H. Maass, Fenna Daniëls, Eva Roseboom, Kevin Vernooy and Michiel Rienstra
J. Clin. Med. 2023, 12(10), 3453; https://doi.org/10.3390/jcm12103453 - 14 May 2023
Viewed by 1431
Abstract
Cardiac Resynchronization Therapy (CRT) is an established technique to improve morbidity and mortality in selected heart failure patients [...] Full article
(This article belongs to the Special Issue The Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing)

Research

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17 pages, 1887 KiB  
Article
One-Year Mortality in Patients Undergoing an Implantable Cardioverter Defibrillator or Cardiac Resynchronization Therapy Pulse Generator Replacement: Identifying Patients at Risk
by Michelle Feijen, Anastasia D. Egorova, Teresa Kuijken, Marianne Bootsma, Martin J. Schalij and Lieselot van Erven
J. Clin. Med. 2023, 12(17), 5654; https://doi.org/10.3390/jcm12175654 - 30 Aug 2023
Cited by 1 | Viewed by 1147
Abstract
Implantable cardioverter defibrillators (ICDs) significantly contribute to the prevention of sudden cardiac death in selected patients. However, it is essential to identify those who are likely to not have benefit from an ICD and to defer a pulse generator exchange. Easily implementable guidelines [...] Read more.
Implantable cardioverter defibrillators (ICDs) significantly contribute to the prevention of sudden cardiac death in selected patients. However, it is essential to identify those who are likely to not have benefit from an ICD and to defer a pulse generator exchange. Easily implementable guidelines for individual risk stratification and decision making are lacking. This study investigates the 1-year mortality of patients who underwent an ICD or cardiac resynchronization therapy with defibrillator function (CRT-D) pulse generator replacement in a contemporary real-world tertiary hospital setting. The cause of death and patient- and procedure-related factors are stratified, and predictive values for 1-year mortality are evaluated. Patients with a follow-up of ≥365 days (or prior mortality) after an ICD or CRT-D exchange at the Leiden University Medical Center from 1 January 2018 until 31 December 2021 were eligible. In total, 588 patients were included (77% male, 69 [60–76] years old, 59% primary prevention, 46% ischemic cardiomyopathy and 37% mildly reduced left ventricular ejection fraction (LVEF)). Patients undergoing a CRT-D replacement or upgrade had a significantly higher 1-year all-cause mortality (10.7% and 11.9%, respectively) compared to patients undergoing ICD (2.8%) exchange (p = 0.002). LVEF ≤ 30%, New York Heart Association class ≥ 3, estimated glomerular filtration rate ≤ 30 mL/min/m2 and haemoglobin ≤ 7 mmol/L were independently associated with mortality within 1 year after pulse generator replacement. There is a growing need for prospectively validated risk scores to weight individualized risk of mortality with the expected ICD therapy benefit and to support a well-informed, shared decision-making process. Full article
(This article belongs to the Special Issue The Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing)
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Graphical abstract

10 pages, 3123 KiB  
Article
Visualization of the SyncAV® Algorithm for CRT Optimization by Non-invasive Imaging of Cardiac Electrophysiology: NICE-CRT Trial
by Philipp Spitaler, Bernhard Erich Pfeifer, Agnes Mayr, Rudolf Bachler, Valentin Bilgeri, Agne Adukauskaite, Axel Bauer, Markus Stühlinger, Fabian Barbieri and Wolfgang Dichtl
J. Clin. Med. 2023, 12(13), 4510; https://doi.org/10.3390/jcm12134510 - 5 Jul 2023
Viewed by 1685
Abstract
(1) Background: Periodic repetitive AV interval optimization using a device-based algorithm in cardiac resynchronization therapy (CRT) devices may improve clinical outcomes. There is an unmet need to successfully transform its application into clinical routine. (2) Methods: Non-invasive imaging of cardiac electrophysiology was performed [...] Read more.
(1) Background: Periodic repetitive AV interval optimization using a device-based algorithm in cardiac resynchronization therapy (CRT) devices may improve clinical outcomes. There is an unmet need to successfully transform its application into clinical routine. (2) Methods: Non-invasive imaging of cardiac electrophysiology was performed in different device programming settings of the SyncAV® algorithm in 14 heart failure patients with left bundle branch block and a PR interval ≤ 250 milliseconds to determine the shortest ventricular activation time. (3) Results: the best offset time (to be manually programmed) permitting automatic dynamic adjustment of the paced atrioventricular interval after every 256 heart beats was found to be 30 and 50 milliseconds, decreasing mean native QRS duration from 181.6 ± 23.9 milliseconds to 130.7 ± 10.0 and 130.1 ± 10.5 milliseconds, respectively (p = 0.01); this was followed by an offset of 40 milliseconds (decreasing QRS duration to 130.1 ± 12.2 milliseconds; p = 0.08). (4) Conclusions: The herein presented NICE-CRT study supports the current recommendation to program an offset of 50 milliseconds as default in patients with left bundle branch block and preserved atrioventricular conduction after implantation of a CRT device capable of SyncAV® optimization. Alternatively, offset programming of 30 milliseconds may also be applied as default programming. In patients with no or poor CRT response, additional efforts should be spent to individualize best offset programming with electrocardiographic optimization techniques. Full article
(This article belongs to the Special Issue The Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing)
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Graphical abstract

13 pages, 2566 KiB  
Article
Cardiac Resynchronization Therapy beyond Nominal Settings: An IEGM-Based Approach for Paced and Sensed Atrioventricular Delay Offset Optimization in Daily Clinical Practice
by Mariëlle Kloosterman, Fenna Daniëls, Eva Roseboom, Michiel Rienstra and Alexander H. Maass
J. Clin. Med. 2023, 12(12), 4138; https://doi.org/10.3390/jcm12124138 - 20 Jun 2023
Cited by 2 | Viewed by 1458
Abstract
Optimization of the atrioventricular (AV) delay has been performed in several landmark trials in cardiac resynchronization therapy (CRT), although it is often not performed in daily practice. Our aim was to study optimal AV delays and investigate a simple intracardiac electrogram (IEGM)-based optimization [...] Read more.
Optimization of the atrioventricular (AV) delay has been performed in several landmark trials in cardiac resynchronization therapy (CRT), although it is often not performed in daily practice. Our aim was to study optimal AV delays and investigate a simple intracardiac electrogram (IEGM)-based optimization approach. 328 CRT patients with paired IEGM and echocardiography optimization data were included in our single-center observational study. Sensed (sAV) and paced (pAV) AV delays were optimized using an iterative echocardiography method. The offset between sAV and pAV delays was calculated using the IEGM method. The mean age of the patients was 69 ± 12 years; 64% were men, 48% had ischemic etiology of heart failure. During echocardiographic optimization, an offset of 73 ± 18 ms was found, differing from nominal AV settings (p < 0.001). Based on the IEGM method, the optimal offset was 75 ± 25 ms. The echocardiographic and IEGM-generated AV offset delays showed good correlation (R2 = 0.62, p < 0.001) and good agreement according to Bland-Altman plot analysis. CRT responders had a near zero offset difference between IEGM and echo optimization (−0.2 ± 17 ms), while non-responders had an offset difference of 6 ± 17 ms, p = 0.006. In conclusion, optimal AV delays are patient-specific and differ from nominal settings. pAV delay can easily be calculated from IEGM after sAV delay optimization. Full article
(This article belongs to the Special Issue The Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing)
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Graphical abstract

11 pages, 1003 KiB  
Article
Left Bundle Branch Area Pacing and Atrioventricular Node Ablation in a Single-Procedure Approach for Elderly Patients with Symptomatic Atrial Fibrillation
by Jesse H. J. Rijks, Theo Lankveld, Randolph Manusama, Bernard Broers, Antonius M. W. van Stipdonk, Sevasti Maria Chaldoupi, Rachel M. A. ter Bekke, Ulrich Schotten, Dominik Linz, Justin G. L. M. Luermans and Kevin Vernooy
J. Clin. Med. 2023, 12(12), 4028; https://doi.org/10.3390/jcm12124028 - 13 Jun 2023
Cited by 9 | Viewed by 2373
Abstract
Background: Implantation of a permanent pacemaker and atrioventricular (AV) node ablation (pace-and-ablate) is an established approach for rate and symptom control in elderly patients with symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) is a physiological pacing strategy that might overcome [...] Read more.
Background: Implantation of a permanent pacemaker and atrioventricular (AV) node ablation (pace-and-ablate) is an established approach for rate and symptom control in elderly patients with symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) is a physiological pacing strategy that might overcome right ventricular pacing-induced dyssynchrony. In this study, the feasibility and safety of performing LBBAP and AV node ablation in a single procedure in the elderly was investigated. Methods: Consecutive patients with symptomatic AF referred for pace-and-ablate underwent the treatment in a single procedure. Data on procedure-related complications and lead stability were collected at regular follow-up at one day, ten days and six weeks after the procedure and continued every six months thereafter. Results: 25 patients (mean age 79.2 ± 4.2 years) were included and underwent successful LBBAP. In 22 (88%) patients, AV node ablation and LBBAP were performed in the same procedure. AV node ablation was postponed in two patients due to lead-stability concerns and in one patient on their own request. No complications related to the single-procedure approach were observed with no lead-stability issues at follow-up. Conclusions: LBBAP combined with AV node ablation in a single procedure is feasible and safe in elderly patients with symptomatic AF. Full article
(This article belongs to the Special Issue The Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing)
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14 pages, 2760 KiB  
Article
Feasibility of CMR Imaging during Biventricular Pacing: Comparison with Invasive Measurement as a Pathway towards a Novel Optimization Strategy
by Luuk H. G. A. Hopman, Alwin Zweerink, Anne-Lotte C. J. van der Lingen, Marthe J. Huntelaar, Mark J. Mulder, Lourens F. H. J. Robbers, Albert C. van Rossum, Vokko P. van Halm, Marco J. W. Götte and Cornelis P. Allaart
J. Clin. Med. 2023, 12(12), 3998; https://doi.org/10.3390/jcm12123998 - 12 Jun 2023
Cited by 2 | Viewed by 1311
Abstract
Objectives: This prospective pilot study assessed the feasibility of cardiovascular magnetic resonance (CMR) imaging during biventricular (BIV) pacing in patients with a CMR conditional cardiac resynchronization therapy defibrillator (CRT-D) and compared the results with invasive volume measurements. Methods: Ten CRT-D patients underwent CMR [...] Read more.
Objectives: This prospective pilot study assessed the feasibility of cardiovascular magnetic resonance (CMR) imaging during biventricular (BIV) pacing in patients with a CMR conditional cardiac resynchronization therapy defibrillator (CRT-D) and compared the results with invasive volume measurements. Methods: Ten CRT-D patients underwent CMR imaging prior to device implantation (baseline) and six weeks after device implantation, including CRT-on and CRT-off modes. Left ventricular (LV) function, volumes, and strain measurements of LV dyssynchrony and dyscoordination were assessed. Invasive pressure–volume measurements were performed, matching the CRT settings used during CMR. Results: Post-implantation imaging enabled reliable cine assessment, but showed artefacts on late gadolinium enhancement images. After six weeks of CRT, significant reverse remodeling was observed, with a 22.7 ± 11% reduction in LV end-systolic volume during intrinsic rhythm (CRT-off). During CRT-on, the LV ejection fraction significantly improved from 27.4 ± 5.9% to 32.2 ± 8.7% (p < 0.01), and the strain assessment showed the abolition of the left bundle branch block contraction pattern. Invasively measured and CMR-assessed LV hemodynamics during BIV pacing were significantly associated. Conclusions: Post-CRT implantation CMR assessing acute LV pump function is feasible and provides important insights into the effects of BIV pacing on cardiac function and contraction patterns. LV assessment during CMR may constitute a future CRT optimization strategy. Full article
(This article belongs to the Special Issue The Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing)
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Graphical abstract

Review

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15 pages, 2015 KiB  
Review
Cardiac CT in CRT as a Singular Imaging Modality for Diagnosis and Patient-Tailored Management
by Willem Gerrits, Ibrahim Danad, Birgitta Velthuis, Saima Mushtaq, Maarten J. Cramer, Pim van der Harst, Frebus J. van Slochteren, Mathias Meine, Dominika Suchá and Marco Guglielmo
J. Clin. Med. 2023, 12(19), 6212; https://doi.org/10.3390/jcm12196212 - 26 Sep 2023
Viewed by 1311
Abstract
Between 30–40% of patients with cardiac resynchronization therapy (CRT) do not show an improvement in left ventricular (LV) function. It is generally known that patient selection, LV lead implantation location, and device timing optimization are the three main factors that determine CRT response. [...] Read more.
Between 30–40% of patients with cardiac resynchronization therapy (CRT) do not show an improvement in left ventricular (LV) function. It is generally known that patient selection, LV lead implantation location, and device timing optimization are the three main factors that determine CRT response. Research has shown that image-guided CRT placement, which takes into account both anatomical and functional cardiac properties, positively affects the CRT response rate. In current clinical practice, a multimodality imaging approach comprised of echocardiography, cardiac magnetic resonance imaging, or nuclear medicine imaging is used to capture these features. However, with cardiac computed tomography (CT), one has an all-in-one acquisition method for both patient selection and the division of a patient-tailored, image-guided CRT placement strategy. This review discusses the applicability of CT in CRT patient identification, selection, and guided placement, offering insights into potential advancements in optimizing CRT outcomes. Full article
(This article belongs to the Special Issue The Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing)
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Other

15 pages, 911 KiB  
Brief Report
Which Factors Influence the Immensely Fluctuating CRT Implantation Rates in Europe? A Mixed Methods Approach Using Qualitative Content Analysis Based on Expert Interviews
by Christoph Edlinger, Marwin Bannehr, Christian Georgi, David Reiners, Michael Lichtenauer, Anja Haase-Fielitz and Christian Butter
J. Clin. Med. 2023, 12(6), 2099; https://doi.org/10.3390/jcm12062099 - 7 Mar 2023
Viewed by 1413
Abstract
(1) Background: Cardiac resynchronisation therapy (CRT) is nowadays an indispensable treatment option for heart failure. Although the indication is subject to clear cross-national guidelines by the European Society of Cardiology (ESC), there is immense variation in the number of implantations per 100,000 inhabitants [...] Read more.
(1) Background: Cardiac resynchronisation therapy (CRT) is nowadays an indispensable treatment option for heart failure. Although the indication is subject to clear cross-national guidelines by the European Society of Cardiology (ESC), there is immense variation in the number of implantations per 100,000 inhabitants in Europe, especially in German-speaking countries (Germany, Austria and Switzerland). The aim of the present study was to identify possible factors for these differences using a qualitative research approach. (2) Methods: Semi-standardized interviews were conducted with 11 experts in the field of CRT therapy (3 experts from Germany, 4 from Austria and 4 from Switzerland) using a pre-prepared interview template and analysed according to Mayring’s qualitative content analysis. (3) Results: The main factors identified were the costs of purchasing the devices and the financing systems of the respective healthcare systems, although cost pressure still seems to play a subordinate role in the German-speaking countries. Moreover, “lack of implementation of ESC guidelines”, “insufficient training” and “lack of medical infrastructure” could be excluded as potential reasons. (4) Conclusions: Economic factors, but not a lack of adherence to ESC guidelines, seem to have a major influence on the fluctuating implantation figures in German-speaking countries, according to the unanimous assessment of renowned experts. Full article
(This article belongs to the Special Issue The Latest Advances in Delivery and Outcomes of Cardiac Resynchronization Therapy and Conduction System Pacing)
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