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BACKGROUND: Left bundle branch area pacing (LBBAP) has emerged as a physiological alternative pacing strategy to biventricular pacing (BIVP) in cardiac resynchronization therapy (CRT). We aimed to assess the impact of LBBAP vs. BIVP on all-cause mortality and heart failure (HF)-related hospitalization in patients undergoing CRT. METHODS: Studies comparing LBBAP and BIVP for CRT in patients with HF with reduced left ventricular ejection fraction (LVEF) were included. The coprimary outcomes were all-cause mortality and HF-related hospitalization. Secondary outcomes included procedural and fluoroscopy time, change in QRS duration, and change in LVEF. RESULTS: Thirteen studies (12 observational and 1 RCT, n = 3239; LBBAP = 1338 and BIVP = 1901) with a mean follow-up duration of 25.8 months were included. Compared to BIVP, LBBAP was associated with a significant absolute risk reduction of 3.2% in all-cause mortality (9.3% vs 12.5%, RR 0.7, 95% CI 0.57-0.86, p < 0.001) and an 8.2% reduction in HF-related hospitalization (11.3% vs 19.5%, RR 0.6, 95% CI 0.5-0.71, p < 0.00001). LBBAP also resulted in reductions in procedural time (mean weighted difference- 23.2 min, 95% CI - 42.9 to - 3.6, p = 0.02) and fluoroscopy time (- 8.6 min, 95% CI - 12.5 to - 4.7, p < 0.001) as well as a significant reduction in QRS duration (mean weighted difference:- 25.3 ms, 95% CI - 30.9 to - 19.8, p < 0.00001) and a greater improvement in LVEF of 5.1% (95% CI 4.4-5.8, p < 0.001) compared to BIVP in the studies that reported these outcomes. CONCLUSION: In this meta-analysis, LBBAP was associated with a significant reduction in all-cause mortality as well as HF-related hospitalization when compared to BIVP. Additional data from large RCTs is warranted to corroborate these promising findings.

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Abstract Background: Cardiac resynchronization therapy (CRT) has been established as an effective therapy for heart failure with reduced ejection fraction. Randomized clinical trials have shown its impact on mortality and HF hospitalizations, as well as improvement of symptoms and quality of life. Objectives: Finding clinical, electrocardiographic, and echocardiographic variables that may predict the response to cardiac resynchronization therapy (CRT). Methods: We performed a single-center, observational, analytic, and retrospective study that included 102 patients with heart failure (HF) diagnosis who underwent CRT according to guideline-directed therapy from January 2010 to April 2020 in a third-level center. CRT response was defined as an improvement of New York Heart Association functional class in at least 1 category associated with a recovery of ≥ 5% in the left ventricular ejection fraction (LVEF). Results: Our study population was 102 patients of which 61 (59.8%) were men. The mean age at HF diagnosis was 54 ± 18.7 years. Ischemic heart disease was the etiology in 37 (36.3%) cases. Fifty-one (50%) patients were classified as responders. Responders had wider QRS, and lower LVEF and right ventricular fractional area change at baseline. After CRT, responders had a greater reduction of QRS duration, and improvement in LVEF, global longitudinal strain, and echocardiographic dyssynchrony parameters. Multivariate regression analysis showed that left bundle branch block (LBBB), left ventricular end-diastolic volume (LVEDV), tricuspid annular plane systolic excursion (TAPSE), and baseline difference of pre-ejection periods were predictors of a positive response to CRT in this population. Conclusions: LBBB, TAPSE, LVEDV, and pre-ejection time difference are independent variables that can predict adequate response to CRT.

Resumen Antecedentes: La terapia de resincronización cardíaca (TRC) se ha establecido como una terapia efectiva para la insuficiencia cardíaca con fracción de eyección reducida. Ensayos clínicos aleatorizados han demostrado su impacto en la mortalidad y hospitalizaciones por insuficiencia cardíaca, así como la mejora de los síntomas y la calidad de vida. Objetivos: Determinar las variables clínicas, electrocardiográficas y ecocardiográficas que puedan predecir la respuesta a la terapia de resincronización cardíaca (TRC). Método: Estudio unicéntrico, observacional, analítico, retrospectivo, que incluyó 102 pacientes con diagnóstico de IC sometidos a TRC y terapia dirigida por guías, de enero de 2010 a abril de 2020, en un centro de tercer nivel. La respuesta a TRC fue definida como mejoría de la clase funcional de la New York Heart Association en al menos 1 categoría, asociado con una recuperación ≥ 5% en la fracción de expulsión del ventrículo izquierdo (FEVI). Resultados: Incluimos a 102 pacientes, 61 (59.8%) fueron hombres. El promedio de edad al diagnóstico de IC fue 54 ± 18.7 años. La cardiopatía isquémica fue la etiología en 37 (36.3%) pacientes. 51 (50%) pacientes, fueron clasificados como respondedores. Los respondedores presentaron QRS amplio, menor FEVI y menor fracción de acortamiento del ventrículo derecho al inicio del estudio. Después de la TRC, los respondedores tuvieron una mayor reducción en la duración del QRS, mejoría en la FEVI, strain longitudinal global y parámetros de disincronía ecocardiográfica. El análisis de regresión multivariado mostró que el bloqueo de rama izquierdo (BRI), el volumen telediastólico del ventrículo izquierdo (VTDVI) la excursión sistólica del plano anular tricuspídeo (TAPSE) y la diferencia basal del período expulsivo fueron predictores de respuesta positiva a TRC. Conclusiones: BRI, TAPSE, VTDVI y la diferencia basal de períodos preexpulsivos son variables independientes que predicen respuesta adecuada a TRC.

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BACKGROUND: Cardiac resynchronization therapy (CRT) has been established as an effective therapy for heart failure with reduced ejection fraction. Randomized clinical trials have shown its impact on mortality and HF hospitalizations, as well as improvement of symptoms and quality of life. OBJECTIVES: Finding clinical, electrocardiographic, and echocardiographic variables that may predict the response to cardiac resynchronization therapy (CRT). METHODS: We performed a single-center, observational, analytic, and retrospective study that included 102 patients with heart failure (HF) diagnosis who underwent CRT according to guideline-directed therapy from January 2010 to April 2020 in a third-level center. CRT response was defined as an improvement of New York Heart Association functional class in at least 1 category associated with a recovery of ≥ 5% in the left ventricular ejection fraction (LVEF). RESULTS: Our study population was 102 patients of which 61 (59.8%) were men. The mean age at HF diagnosis was 54 ± 18.7 years. Ischemic heart disease was the etiology in 37 (36.3%) cases. Fifty-one (50%) patients were classified as responders. Responders had wider QRS, and lower LVEF and right ventricular fractional area change at baseline. After CRT, responders had a greater reduction of QRS duration, and improvement in LVEF, global longitudinal strain, and echocardiographic dyssynchrony parameters. Multivariate regression analysis showed that left bundle branch block (LBBB), left ventricular end-diastolic volume (LVEDV), tricuspid annular plane systolic excursion (TAPSE), and baseline difference of pre-ejection periods were predictors of a positive response to CRT in this population. CONCLUSIONS: LBBB, TAPSE, LVEDV, and pre-ejection time difference are independent variables that can predict adequate response to CRT.

ANTECEDENTES: La terapia de resincronización cardíaca (TRC) se ha establecido como una terapia efectiva para la insuficiencia cardíaca con fracción de eyección reducida. Ensayos clínicos aleatorizados han demostrado su impacto en la mortalidad y hospitalizaciones por insuficiencia cardíaca, así como la mejora de los síntomas y la calidad de vida. OBJETIVOS: Determinar las variables clínicas, electrocardiográficas y ecocardiográficas que puedan predecir la respuesta a la terapia de resincronización cardíaca (TRC). MÉTODO: Estudio unicéntrico, observacional, analítico, retrospectivo, que incluyó 102 pacientes con diagnóstico de IC sometidos a TRC y terapia dirigida por guías, de enero de 2010 a abril de 2020, en un centro de tercer nivel. La respuesta a TRC fue definida como mejoría de la clase funcional de la New York Heart Association en al menos 1 categoría, asociado con una recuperación ≥ 5% en la fracción de expulsión del ventrículo izquierdo (FEVI). RESULTADOS: Incluimos a 102 pacientes, 61 (59.8%) fueron hombres. El promedio de edad al diagnóstico de IC fue 54 ± 18.7 años. La cardiopatía isquémica fue la etiología en 37 (36.3%) pacientes. 51 (50%) pacientes, fueron clasificados como respondedores. Los respondedores presentaron QRS amplio, menor FEVI y menor fracción de acortamiento del ventrículo derecho al inicio del estudio. Después de la TRC, los respondedores tuvieron una mayor reducción en la duración del QRS, mejoría en la FEVI, strain longitudinal global y parámetros de disincronía ecocardiográfica. El análisis de regresión multivariado mostró que el bloqueo de rama izquierdo (BRI), el volumen telediastólico del ventrículo izquierdo (VTDVI) la excursión sistólica del plano anular tricuspídeo (TAPSE) y la diferencia basal del período expulsivo fueron predictores de respuesta positiva a TRC. CONCLUSIONES: BRI, TAPSE, VTDVI y la diferencia basal de períodos preexpulsivos son variables independientes que predicen respuesta adecuada a TRC.

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BACKGROUND: Left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP) are considered to be acceptable as LBBAP strategies. Differences in clinical outcomes between LBBP and LVSP are yet to be determined. OBJECTIVES: The purpose of this study was to compare the outcomes of LBBP vs LVSP vs BIVP for CRT. METHODS: In this prospective multicenter observational study, LBBP was compared with LVSP and BIVP in patients undergoing CRT. The primary composite outcome was freedom from heart failure (HF)-related hospitalization and all-cause mortality. Secondary outcomes included individual components of the primary outcome, postprocedural NYHA functional class, and electrocardiographic and echocardiographic parameters. RESULTS: A total of 415 patients were included (LBBP: n = 141; LVSP: n = 31; BIVP: n = 243), with a median follow-up of 399 days (Q1-Q3: 249.5-554.8 days). Freedom from the primary composite outcomes was 76.6% in the LBBP group and 48.4% in the LVSP group (HR: 1.37; 95% CI: 1.143-1.649; P = 0.001), driven by a 31.4% absolute increase in freedom from HF-related hospitalizations (83% vs 51.6%; HR: 3.55; 95% CI: 1.856-6.791; P < 0.001) without differences in all-cause mortality. LBBP was also associated with a higher freedom from the primary composite outcome compared with BIVP (HR: 1.43; 95% CI: 1.175-1.730; P < 0.001), with no difference between LVSP and BIVP. CONCLUSIONS: In patients undergoing CRT, LBBP was associated with improved outcomes compared with LVSP and BIVP, while outcomes between BIVP and LVSP are similar.

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Epidemiological studies suggest that approximately half of the patients with heart failure (HF) have reduced ejection fraction, while the other half have normal ejection fraction (EF). Currently, international guidelines consider QRS duration greater than 130 ms, in the presence of ventricular dysfunction (EF < 35%), as a criterion for selecting patients for cardiac resynchronization therapy (CRT). CRT helps restore intraventricular and auriculoventricular synchrony, improving left ventricular (LV) performance, reducing functional mitral regurgitation, and inducing reverse LV remodeling. This is evidenced by increased LV filling time and left ventricular ejection fraction, decreased LV end-diastolic and end-systolic volumes, mitral regurgitation, and septal dyskinesia. Because the mechanisms of dyssynchrony may be heterogeneous, no single measure may accurately predict response to CRT. Finally, CRT has been progressively shown to be safe and feasible, improves functional status and quality of life, reversely remodels the LV, decreases the number of hospitalizations, total mortality in patients with refractory HF, LV dysfunction, and intraventricular conduction disorders; is a pacemaker-based therapy for HF and thanks to current technology, safe remote monitoring of almost all types of cardiac devices is possible and provides useful alerts in clinical practice.

Los estudios epidemiológicos sugieren que aproximadamente la mitad de los pacientes con insuficiencia cardiaca (IC) tiene fracción de eyección reducida, mientras que la otra mitad, fracción de eyección (FE) normal. Actualmente, las guías internacionales consideran la duración de QRS mayor a 130 ms, en presencia de disfunción ventricular (FE < 35%), como criterio para selección de pacientes a terapia de resincronización cardiaca (TRC). La TRC ayuda a restaurar la sincronía intraventricular y auriculoventricular, mejorando el rendimiento del ventrículo izquierdo (VI), reduciendo la regurgitación mitral funcional e induciendo la remodelación inversa del VI. Esto se evidencia en el aumento del tiempo de llenado del VI y la fracción de eyección del VI, la disminución de los volúmenes telediastólico y telesistólico del VI, y la regurgitación mitral y discinesia septal. Como los mecanismos de la disincronía pueden ser heterogéneos, es posible que ninguna medida prediga con exactitud la respuesta a la TRC. Finalmente, la TRC cardiaca ha demostrado progresivamente ser segura y factible, mejora el estado funcional y la calidad de vida, remodela inversamente el VI, disminuye el número de hospitalizaciones, la mortalidad total en pacientes con IC refractaria, la disfunción ventricular izquierda y los trastornos de conducción intraventricular; es una terapia basada en marcapasos para la IC y gracias a la tecnología actual es posible realizar una supervisión remota y segura de casi todos los tipos de dispositivos cardiacos y obtener alertas útiles en la práctica clínica.

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Situs inversus totalis (SIT) is a congenital condition in which the major visceral organs are reversed or in a mirror image from their normal positions that affects one per 10,000 live births. It is associated with dextrocardia (DXC) in which the heart is located on the right side of the chest. We present a challenging cardiac resynchronization therapy (CRT) implantation in a 60-year-old man with SIT-DXC, heart failure, extreme bradycardia, wide QRS, and left ventricular (LV) dysfunction. The procedure was complex due to the mirror-image anatomy and the tortuous origin of the coronary sinus (CS) branches that required a subselection catheter for adequate lead implantation.

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AIMS: Although cardiac resynchronization therapy (CRT) improves functional capacity in heart failure patients, a blunted heart rate (HR) response remains after treatment. So we aimed to evaluate the feasibility of the physiological pacing rate (PPR) in CRT patients. METHODS: A cohort of 30 clinical mildly symptomatic CRT patients underwent the six-minute walk test (6MWT). During the 6MWT, HR, blood pressure, and maximum walking distance were assessed. The measurements were obtained in a pre to post manner, with CRT at nominal settings and with the physiological phase (CRT PPR), in which HR was increased by 10% above the maximum HR achieved previously. The CRT cohort also comprised a matched control group (CRT CG). In the CRT CG, the 6MWT was repeated after the standard evaluation with no PPR. The evaluations were blinded for patients and for the 6MWT evaluator. RESULTS: During the 6MWT, CRT PPR led to an increase in walking distance of 40.5 m (9.2%; P < 0.0001) when compared with baseline trial. Additionally, CRT PPR increased the maximum walking distance compared with CRT CG 479.3 ± 68.9 m vs. 420.3 ± 44.8 m, respectively, P = 0.001. In the CRT CG, CRT PPR increased the variation in walking distance, compared with baseline trials, respectively 2.40 ± 3.8% vs. 9.25 ± 7.0%, P = 0.007. CONCLUSIONS: In mildly symptomatic CRT patients PPR is feasible, leading to improvements in functional capacity. In this regard, the efficacy of PPR must be confirmed by controlled randomized trials.

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BACKGROUND: Left bundle branch area pacing (LBBAP) for cardiac resynchronization therapy (CRT) is an alternative to biventricular pacing (BiVp). OBJECTIVES: The purpose of this study was to compare the outcomes between LBBAP and BiVp as an initial implant strategy for CRT. METHODS: In this prospective multicenter, observational, nonrandomized study, first-time CRT implant recipients with LBBAP or BiVp were included. The primary efficacy outcome was a composite of heart failure (HF)-related hospitalization and all-cause mortality. The primary safety outcomes were acute and long-term complications. Secondary outcomes included postprocedural New York Heart Association functional class and electrocardiographic and echocardiographic parameters. RESULTS: A total of 371 patients (median follow-up of 340 days [IQR: 206-477 days]) were included. The primary efficacy outcome occurred in 24.2% in the LBBAP vs 42.4% in the BiVp (HR: 0.621 [95% CI: 0.415-0.93]; P = 0.021) group, driven by a reduction in HF-related hospitalizations (22.6% vs 39.5%; HR: 0.607 [95% CI: 0.397-0.927]; P = 0.021) without significant difference in all-cause mortality (5.5% vs 11.9%; P = 0.19) or differences in long-term complications (LBBAP: 9.4% vs BiVp: 15.2%; P = 0.146). LBBAP resulted in shorter procedural (95 minutes [IQR: 65-120 minutes] vs 129 minutes [IQR: 103-162 minutes]; P < 0.001) and fluoroscopy times (12 minutes [IQR: 7.4-21.1 minutes] vs 21.7 minutes [IQR: 14.3-30 minutes]; P < 0.001), shorter QRS duration (123.7 ± 18 milliseconds vs 149.3 ± 29.1 milliseconds; P < 0.001), and higher postprocedural left ventricular ejection fraction (34.1% ± 12.5% vs 31.4% ± 10.8%; P = 0.041). CONCLUSIONS: LBBAP as an initial CRT strategy resulted in a lower risk of HF-related hospitalizations compared to BiVp. A reduction in procedural and fluoroscopy times, shorter paced QRS duration, and improvements in left ventricular ejection fraction compared with BiVp were observed.

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Epidemiological studies suggest that approximately half of the patients with heart failure (HF) have reduced ejection fraction, while the other half have normal ejection fraction (EF). Currently, international guidelines consider QRS duration greater than 130 ms, in the presence of ventricular dysfunction (EF < 35%), as a criterion for selecting patients for cardiac resynchronization therapy (CRT). CRT helps restore intraventricular and auriculoventricular synchrony, improving left ventricular (LV) performance, reducing functional mitral regurgitation, and inducing reverse LV remodeling. This is evidenced by increased LV filling time and left ventricular ejection fraction, decreased LV end-diastolic and end-systolic volumes, mitral regurgitation, and septal dyskinesia. Because the mechanisms of dyssynchrony may be heterogeneous, no single measure may accurately predict response to CRT. Finally, CRT has been progressively shown to be safe and feasible, improves functional status and quality of life, reversely remodels the LV, decreases the number of hospitalizations, total mortality in patients with refractory HF, LV dysfunction, and intraventricular conduction disorders; is a pacemaker-based therapy for HF and thanks to current technology, safe remote monitoring of almost all types of cardiac devices is possible and provides useful alerts in clinical practice.

Los estudios epidemiológicos sugieren que aproximadamente la mitad de los pacientes con insuficiencia cardiaca (IC) tiene fracción de eyección reducida, mientras que la otra mitad, fracción de eyección (FE) normal. Actualmente, las guías internacionales consideran la duración de QRS mayor a 130 ms, en presencia de disfunción ventricular (FE < 35%), como criterio para selección de pacientes a terapia de resincronización cardiaca (TRC). La TRC ayuda a restaurar la sincronía intraventricular y auriculoventricular, mejorando el rendimiento del ventrículo izquierdo (VI), reduciendo la regurgitación mitral funcional e induciendo la remodelación inversa del VI. Esto se evidencia en el aumento del tiempo de llenado del VI y la fracción de eyección del VI, la disminución de los volúmenes telediastólico y telesistólico del VI, y la regurgitación mitral y discinesia septal. Como los mecanismos de la disincronía pueden ser heterogéneos, es posible que ninguna medida prediga con exactitud la respuesta a la TRC. Finalmente, la TRC cardiaca ha demostrado progresivamente ser segura y factible, mejora el estado funcional y la calidad de vida, remodela inversamente el VI, disminuye el número de hospitalizaciones, la mortalidad total en pacientes con IC refractaria, la disfunción ventricular izquierda y los trastornos de conducción intraventricular; es una terapia basada en marcapasos para la IC y gracias a la tecnología actual es posible realizar una supervisión remota y segura de casi todos los tipos de dispositivos cardiacos y obtener alertas útiles en la práctica clínica.

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INTRODUCTION AND OBJECTIVE: Cardiac resynchronization may treat severe heart failure (HF) with pharmacological optimization, left branch block, and an ejection fraction<35%. However, 30-40% of patients fail therapy. HBP could replace biventricular pacing (BiV). We compared the effectiveness of HBP versus BiV in HF patients. METHODS: We searched PubMed, Embase, and Cochrane for studies on QRS, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) functional class, left ventricular end-systolic volume (LVESV), and 6-minute walk test. RESULTS: Six publications included 774 patients (mean [± standard deviation] age: 66.9 [14.0] years; 484 (62.5%) were males; 408 [52.71%] underwent HBP; the mean follow-up was 6-12 months. The HBP group had a higher QRS reduction in the meta-analysis (median: -17.54 [-20.46, -14.62]; I2 = 89%). LVEF showed a median of 8.48 (7.55, 9.41) and I2 of 98%, with a higher mean in HBP. The LVESV median was -18.89 (-30.03, -7.75) and I2 was 0%, and the HBP group had a lower mean. HBP had a lower NYHA functional class (median= -0.20 [-0.28, -0.12]). CONCLUSION: After implantation, HBP demonstrated bigger QRS shortening, increased LVEF, lower LVES volume, and lower NYHA class than BiV pacing.

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