(1) Comparative Analysis of Response to Cardiac Resynchronisation Therapy Upgrades in Patients with Implantable Cardioverter-Defibrillators and Pacemakers, (2) Observational Study of Trans-Septal Endocardial Left Ventricle Lead Implant for Effective Cardiac Resynchronisation Therapy in Patients with Heart Failure and Challenging Coronary Sinus Anatomy, (3) Trans-septal left ventricular endocardial lead in a patient with extensive anterior myocardial infarction and left ventricle (LV) apical endoventriculoplasty using a Vascutek patch-case report
- Programme
- HSST
- Specialty
- Cardiac Science
- Project published
- 01/09/2024
1. Comparative Analysis of Response to Cardiac Resynchronisation Therapy Upgrades in Patients with Implantable Cardioverter-Defibrillators and Pacemakers abstract
Introduction: The efficacy of de novo cardiac resynchronisation therapy (CRT) in patients with heart failure (HF), left ventricular systolic dysfunction (LVSD), and a broad QRS morphology is well established. However, the optimal stage for upgrading patients with existing pacemakers (PPMs) or implantable cardioverter-defibrillators (ICDs) and HF with high-burden right ventricular (RV) pacing remains uncertain. Thus, this multicentre retrospective analysis compared patients with pre-existing PPMs or ICDs who underwent CRT upgrades to investigate the appropriate stage for CRT implantation in these patients and to assess the validity of treating both PPM and ICD recipients under the same recommendation level in the current guidelines.
Materials and methods: A total of 151 participants underwent analysis in this study, comprising 93 upgrades to cardiac resynchronisation therapy with pacemaker (CRT-P) and 58 upgrades to cardiac resynchronisation therapy with defibrillator (CRT-D) across three centres in the UK. The aim of the study was to investigate the safety and efficacy of upgrading to CRT from an existing conventional pacemaker or an ICD in the context of high-burden RV pacing. The analysis was conducted separately for each group, assessing changes in echocardiographic parameters, functional New York Heart Association (NYHA) class, and procedure-related complications.
Results: The PPM group had a higher percentage RVP burden compared to the ICD group. Post-upgrade, NYHA functional class and EF and LV volumes improved in both groups; however, the response to an upgrade from a pacemaker was greater compared to an upgrade from an ICD. Post-procedural complication risks were similar across the two subgroups but significantly higher compared to de novo implantation.
Conclusions: Within the CRT-P subgroup, participants exhibited better responses than their CRT-D counterparts, evident both in echocardiographic improvements and clinical outcomes. Furthermore, patients with non-ischemic cardiomyopathy (NICM) were better responders than those with ischaemic cardiomyopathy. These findings suggest that international guidelines should consider approaching each subgroup separately in the future.
2. Observational Study of Trans-Septal Endocardial Left Ventricle Lead Implant for Effective Cardiac Resynchronisation Therapy in Patients with Heart Failure and Challenging Coronary Sinus Anatomy abstract
Background: When conventional trans-venous CS lead placement fails, trans-septal endocardial left ventricle lead placement is an alternative technique used to capture the left ventricle endocardially; however, its use is limited due to a lack of evidence, practice uptake, and clinical trials.
Methods: In this single-centre cohort study, we evaluated the efficiency of the procedure, post-procedural complication rate, rate of thromboembolic events, overall survival rate, and changes in the echocardiographic parameters, brain natriuretic peptide (BNP) level, and New York Heart Association (NYHA) class, both before and after TSLV lead implantation.
Results: The TSLV lead implant is safe and improves EF, LVEDV, LVESV, and LVIDd. It significantly reduces the NTproBNP levels and the NYHA class; however, the rate of stroke incidence remains high, at 9%.
Conclusions: We demonstrated a high success rate of trans-septal left ventricular endocardial lead implantation, LV reverse remodeling was noted, and patients had a favourable clinical response; however, there was an increased risk of systemic embolisation after the trans-septal LV lead implant.
3. Trans-septal left ventricular endocardial lead in a patient with extensive anterior myocardial infarction and left ventricle (LV) apical endoventriculoplasty using a Vascutek patch-case report abstract
Background: Cardiac resynchronisation therapy (CRT) implantation has significantly improved quality of life and reduced overall mortality due to heart failure. The conventional method of CRT implantation is implanting a left ventricle (LV) lead into a side branch of the coronary sinus (CS) tributary to pace the epicardial surface and capture the LV. This is safe, and well tolerated with a high success rate. The rate of failure to place an LV lead has decreased over time, however, there are still challenging cases where a conventional CRT implant fails and alternative techniques are being considered, one such technique is trans-septal endocardial LV lead placement used to capture the LV, endocardially but its use is limited due to lack of evidence, practice uptake and clinical trials.
Case description: We present, a case report of a patient for whom we successfully used a trans-septal left ventricle (TSLV) endocardial lead implantation approach following a failed LV lead implant via the CS to get effective cardiac resynchronisation.
Conclusions: Post-TSLV lead implantation follow-up checks were normal with good electrical parameters and appropriate biventricular pacing. No post-procedural complications were reported, and echocardiographic parameters improved at follow-up. We believe, although, TSLV lead implant is more complex and often double operators are required, in selected patients, it can be a safe alternative following a failed traditional LV lead implant via the CS.