Vol 28, No 5 (2021)
Original Article
Published online: 2020-01-09

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Long-term follow-up after cardiac resynchronization therapy-optimization in a real-world setting: A single-center cohort study

Raphael Korach1, Peter C. Kahr1, Frank Ruschitzka1, Jan Steffel1, Andreas J. Flammer1, Stephan Winnik1
Pubmed: 31960943
Cardiol J 2021;28(5):728-737.


Background: Suboptimal device programming is among the reasons for reduced response to cardiac resynchronization therapy (CRT). However, whether systematic optimization is beneficial remains unclear, particularly late after CRT implantation. The aim of this single-center cohort study was to assess the effect of systematic atrioventricular delay (AVD) optimization on echocardiographic and device parameters.
Methods: Patients undergoing CRT optimization at the University Hospital Zurich between March 2011 and January 2013, for whom a follow-up was available, were included. AVD optimization was based on 12-lead electrocardiography (ECG) and echocardiographic left ventricular inflow characteristics. Parameters were assessed at the time of CRT optimization and follow-up, and were compared between patients with AVD optimization (intervention group) and those for whom no AVD optimization was deemed necessary (control group).
Results: Eighty-one patients with a mean age of 64 ± 11 years were included in the analysis. In 73% of patients, AVD was deemed suboptimal and was changed accordingly. After a median follow-up time of 10.4 (IQR 6.2 to 13.2) months, the proportion of patients with sufficient biventricular pacing (> 97% pacing) was greater in the intervention group (78%) compared to controls (50%). Furthermore, AVD adaptation was associated with an improvement in interventricular mechanical delay (decrease of 6.6 ± 26.2 ms vs. increase of 4.3 ± 17.7 ms, p = 0.034) and intraventricular septal-to-lateral delay (decrease of 0.9 ± 48.1 ms vs. increase of 15.9 ± 15.7 ms, p = 0.038), as assessed by tissue Doppler imaging. Accordingly, a reduction was observed in mitral regurgitation along with a trend towards reduced left ventricular volumes.
Conclusions: In this “real-world” setting systematic AVD optimization was associated with beneficial effects regarding biventricular pacing and left ventricular remodeling. These data show that AVD optimization may be advantageous in selected CRT patients.

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  1. Singh JP, Gras D. Biventricular pacing: current trends and future strategies. Eur Heart J. 2012; 33(3): 305–313.
  2. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009; 119(14): e391–e479.
  3. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC)Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J. 2016; 37(27): 2129–2200.
  4. Cleland JGF, Daubert JC, Erdmann E, et al. Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005; 352(15): 1539–1549.
  5. Abraham WT, Fisher WG, Smith AL, et al. MIRACLE Study Group. Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure. N Engl J Med. 2002; 346(24): 1845–1853.
  6. Bristow M, Saxon L, Boehmer J, et al. Cardiac-Resynchronization Therapy with or without an Implantable Defibrillator in Advanced Chronic Heart Failure. New Engl J Med. 2004; 350(21): 2140–2150.
  7. Ruschitzka F, Abraham WT, Singh JP, et al. Cardiac-resynchronization therapy in heart failure with a narrow QRS complex. N Engl J Med. 2013; 369(15): 1395–1405.
  8. Moss AJ, Hall WJ, Cannom DS, et al. Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med. 2009; 361(14): 1329–1338.
  9. Bax JJ, Gorcsan J. Echocardiography and noninvasive imaging in cardiac resynchronization therapy: results of the PROSPECT (Predictors of Response to Cardiac Resynchronization Therapy) study in perspective. J Am Coll Cardiol. 2009; 53(21): 1933–1943.
  10. Houthuizen P, Bracke FA, van Gelder BM. Atrioventricular and interventricular delay optimization in cardiac resynchronization therapy: physiological principles and overview of available methods. Heart Fail Rev. 2011; 16(3): 263–276.
  11. Mullens W, Grimm RA, Verga T, et al. Insights from a cardiac resynchronization optimization clinic as part of a heart failure disease management program. J Am Coll Cardiol. 2009; 53(9): 765–773.
  12. Sawhney NS, Waggoner AD, Garhwal S, et al. Randomized prospective trial of atrioventricular delay programming for cardiac resynchronization therapy. Heart Rhythm. 2004; 1(5): 562–567.
  13. Morales MA, Startari U, Panchetti L, et al. Atrioventricular delay optimization by doppler-derived left ventricular dP/dt improves 6-month outcome of resynchronized patients. Pacing Clin Electrophysiol. 2006; 29(6): 564–568.
  14. Hardt SE, Yazdi SH, Bauer A, et al. Immediate and chronic effects of AV-delay optimization in patients with cardiac resynchronization therapy. Int J Cardiol. 2007; 115(3): 318–325.
  15. Brugada J, Delnoy PP, Brachmann J, et al. Contractility sensor-guided optimization of cardiac resynchronization therapy: results from the RESPOND-CRT trial. Eur Heart J. 2017; 38(10): 730–738.
  16. Steffel J, Rempel H, Breitenstein A, et al. Comprehensive cardiac resynchronization therapy optimization in the real world. Cardiol J. 2014; 21(3): 316–324.
  17. Brignole M, Auricchio A, Baron-Esquivias G, et al. ESC Committee for Practice Guidelines (CPG), Document Reviewers. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013; 34(29): 2281–2329.
  18. Barold SS, Ilercil A, Herweg B. Echocardiographic optimization of the atrioventricular and interventricular intervals during cardiac resynchronization. Europace. 2008; 10 Suppl 3: iii88–iii95.
  19. Gorcsan J, Abraham T, Agler DA, et al. Echocardiography for cardiac resynchronization therapy: recommendations for performance and reporting--a report from the American Society of Echocardiography Dyssynchrony Writing Group endorsed by the Heart Rhythm Society. J Am Soc Echocardiogr. 2008; 21(3): 191–213.
  20. Bertini M, Delgado V, Bax JJ, et al. Why, how and when do we need to optimize the setting of cardiac resynchronization therapy? Europace. 2009; 11 Suppl 5: v46–v57.
  21. Ellenbogen KA, Gold MR, Meyer TE, et al. Primary results from the SmartDelay determined AV optimization: a comparison to other AV delay methods used in cardiac resynchronization therapy (SMART-AV) trial: a randomized trial comparing empirical, echocardiography-guided, and algorithmic atrioventricular delay programming in cardiac resynchronization therapy. Circulation. 2010; 122(25): 2660–2668.
  22. Brenyo A, Kutyifa V, Moss AJ, et al. Atrioventricular delay programming and the benefit of cardiac resynchronization therapy in MADIT-CRT. Heart Rhythm. 2013; 10(8): 1136–1143.
  23. Delnoy PP, Ritter P, Naegele H, et al. Association between frequent cardiac resynchronization therapy optimization and long-term clinical response: a post hoc analysis of the Clinical Evaluation on Advanced Resynchronization (CLEAR) pilot study. Europace. 2013; 15(8): 1174–1181.
  24. Gasparini M, Galimberti P, Ceriotti C. The importance of increased percentage of biventricular pacing to improve clinical outcomes in patients receiving cardiac resynchronization therapy. Curr Opin Cardiol. 2013; 28(1): 50–54.
  25. Koplan BA, Kaplan AJ, Weiner S, et al. Heart failure decompensation and all-cause mortality in relation to percent biventricular pacing in patients with heart failure: is a goal of 100% biventricular pacing necessary? J Am Coll Cardiol. 2009; 53(4): 355–360.
  26. Hayes DL, Boehmer JP, Day JD, et al. Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival. Heart Rhythm. 2011; 8(9): 1469–1475.
  27. Upadhyay GA, Choudhry NK, Auricchio A, et al. Cardiac resynchronization in patients with atrial fibrillation: a meta-analysis of prospective cohort studies. J Am Coll Cardiol. 2008; 52(15): 1239–1246.
  28. Khadjooi K, Foley PW, Chalil S, et al. Long-term effects of cardiac resynchronisation therapy in patients with atrial fibrillation. Heart. 2008; 94(7): 879–883.
  29. Molhoek SG, Bax JJ, Bleeker GB, et al. Comparison of response to cardiac resynchronization therapy in patients with sinus rhythm versus chronic atrial fibrillation. Am J Cardiol. 2004; 94(12): 1506–1509.
  30. Delnoy PP, Ottervanger JP, Luttikhuis HO, et al. Comparison of usefulness of cardiac resynchronization therapy in patients with atrial fibrillation and heart failure versus patients with sinus rhythm and heart failure. Am J Cardiol. 2007; 99(9): 1252–1257.
  31. Boriani G, Gasparini M, Landolina M, et al. Incidence and clinical relevance of uncontrolled ventricular rate during atrial fibrillation in heart failure patients treated with cardiac resynchronization therapy. Eur J Heart Fail. 2011; 13(8): 868–876.
  32. Santini M, Gasparini M, Landolina M, et al. Device-detected atrial tachyarrhythmias predict adverse outcome in real-world patients with implantable biventricular defibrillators. J Am Coll Cardiol. 2011; 57(2): 167–172.
  33. Barold SS, Herweg B. Cardiac resynchronization in patients with atrial fibrillation. J Atrial Fibrillation. 2015; 8(4): 1383.
  34. Gasparini M, Leclercq C, Lunati M, et al. Cardiac resynchronization therapy in patients with atrial fibrillation: the CERTIFY study (Cardiac Resynchronization Therapy in Atrial Fibrillation Patients Multinational Registry). JACC Heart Fail. 2013; 1(6): 500–507.
  35. Curtis AB, Worley SJ, Chung ES, et al. Improvement in clinical outcomes with biventricular versus right ventricular pacing: the BLOCK HF study. J Am Coll Cardiol. 2016; 67(18): 2148–2157.
  36. Fanaroff AC, Steffel J, Alexander JH, et al. Stroke prevention in atrial fibrillation: re-defining 'real-world data' within the broader data universe. Eur Heart J. 2018; 39(32): 2932–2941.