Abdul Ghani

Assessment of left ventricular dyssynchrony in pacing-induced left bundle branch block compared with intrinsic left bundle branch block.

AIMS Although electrocardiographic and echocardiographic findings with right ventricular (RV) pacing mimic intrinsic left bundle branch block (LBBB), left ventricular (LV) mechanical activation pattern may differ. We compared mechanical activation pattern of the LV in RV-pacing-induced LBBB with intrinsic LBBB in symptomatic chronic heart failure patients. METHODS AND RESULTS We studied 37 patients with chronic RV-pacing and 37 patients with intrinsic LBBB who were referred for cardiac resynchronization therapy. Echocardiographic study including 2D speckle tracking longitudinal strain and M-mode were performed at baseline. Patients with intrinsic LBBB were younger, had higher prevalence of ischaemic heart disease, and had more severe depressed LV function. The basal-septal segments were the earliest activated sites in 11% of patients in RV-pacing-induced LBBB compared with 30% in intrinsic LBBB (P= 0.04). The mid- and basal-lateral segments were the latest activated sites in 57% of patients in RV-pacing-induced LBBB compared with 30% in intrinsic LBBB (P = 0.03). Left ventricular dyssynchrony, using longitudinal strain, time delay ≥ 130 ms between either mid-septal or apico-septal and either basal or mid-lateral segments was present in 71% of patients with RV-pacing-induced LBBB compared with 59% in intrinsic LBBB (P = 0.03). Using M-mode, LV dyssynchrony was present in 11% of patients with RV-pacing-induced LBBB compared with 59% in intrinsic LBBB (P = 0.02). CONCLUSION Right ventricular-pacing results in less early basal activation and more often early mid-septal and late lateral wall activation in comparison with intrinsic LBBB. Imaging techniques that only visualize the basal- or mid-part of the LV may result in a serious underestimation of dyssynchrony in patients with pacing-induced LBBB.

Lead extractions: the Zwolle experience with the Evolution mechanical sheath

AIMS The Evolution sheath (Cook, USA) is a power sheath with a cutting screw tip operated by mechanical rotation. It has been reported to be an effective tool for chronic lead extraction. We evaluated the safety and efficacy of this system. METHODS AND RESULTS From 2009 to 2014, all lead extractions requiring the use of an Evolution sheath were prospectively examined. In 77 patients, 111 leads were extracted. The first 57 leads were extracted with the original unidirectional sheath, and since 2013, 54 leads were extracted with the bidirectional R/L type. According to the current guidelines, complete procedural success was defined as the removal of all targeted lead material. Clinical success was the retention of a small portion of the lead, and failure was the inability to achieve either complete procedural or clinical success or the development of any permanently disabling complication. The Evolution sheath was used to extract 111 leads in 77 patients. The median age of the lead at time of extraction was 8.0 years (median 6.9, interquartile range 6.4, minimum: 0.6 and maximum: 34.4), with a clinical success rate of 98% and a complete procedural success of 88%. Complete procedural success was higher for the R/L type Evolution sheath (96 vs. 80%, P = 0.006). There were 21 (19%) implantable cardioverter defibrillator leads, 22 (20%) right ventricular pacing leads, 60 (54%) right atrial leads, and 8 (7%) left ventricular leads. There were no major complications and six (8%) minor complications. There was no need for the usage of a femoral tool or snares. CONCLUSION Use of Evolution for lead extractions seems to be safe and effective, with a high clinical success rate.

Success and complication rates of lead extraction with the first- vs. the second-generation Evolution mechanical sheath

Aims The Evolution sheath (Cook Medical, USA) is a power sheath frequently used for chronic lead extraction. In 2013, a novel type (bidirectional) of Evolution sheath (the RL type) was introduced. We evaluated differences in success and complication rates of the two types. Methods and results From 2009 to 2015, all lead extractions requiring the use of an Evolution sheath were prospectively examined. According to the current guidelines, complete procedural success was defined as the removal of all targeted lead materials. Clinical success was the retention of a small portion of the lead, and failure was the inability to achieve either complete procedural or clinical success or the development of any permanently disabling complication. The Evolution sheath was used to extract 149 leads in 103 patients. The first 56 leads were extracted with the original unidirectional sheath, and 93 leads were extracted with the novel bidirectional R/L type. The median age of the lead at the time of extraction was 6.8 vs. 9.1 years (P = 0.007). Complete procedural success was higher for the Evolution R/L (80.0 vs. 98%, P = 0.0004). Clinical success rate was 98 vs. 99%. There were no major complications and 6 (12.0%) vs. 2 (3.8%) minor complications (P = 0.153). We did not observe changes in success rates or complications over time, meaning that the difference cannot be explained by learning curve. Conclusion Use of the novel Evolution R/L sheath vs. the original Evolution sheath was associated with significant higher complete success rates, without major complications and with a trend towards the reduction of minor complications.

Response to cardiac resynchronization therapy as assessed by time-based speckle tracking imaging.

Response to cardiac resynchronization therapy (CRT) is still difficult to predict with previously investigated dyssynchrony indices. The predictive value of speckle tracking strain analysis has not been fully delineated yet. The objective of this study was to assess the predictive value of longitudinal strain (LS) and radial strain (RS) speckle tracking measurements on echocardiographic and clinical response to CRT.

Predictors and long-term outcome of super-responders to cardiac resynchronization therapy

The level of improvement in left ventricular ejection fraction (LVEF) in super‐responders to cardiac resynchronization therapy (CRT) is exceptional. However, the long‐term prognosis remains unknown in a large population.

Septal rebound stretch as predictor of echocardiographic response to cardiac resynchronization therapy

Aim Septal rebound stretch (SRSsept) reflects an inefficient deformation of the septum during systole and is a potential new echocardiographic tool to predict response to Cardiac Resynchronization Therapy (CRT). However, there are only limited data on the potential predictive value of SRSsept on echocardiographic response. We evaluated the predictive value of SRSsept on echocardiographic response to CRT in a large population. Methods and results A total of 138 consecutive patients with functional class II–IV heart failure who underwent CRT were studied. Echocardiography was performed at baseline and after a mean follow-up period of 22 ± 8 months. Echocardiographic response to CRT was defined as a reduction in LV end-systolic volume ≥ 15%. Receiver operating characteristic curve analysis was performed to define the optimal cut-off value for SRSsept. Multivariable analyses were performed to adjust for potential confounders. Mean age was 68 ± 8 years (30% female). Mean baseline LV ejection fraction was 26 ± 7%, 51% had ischemic etiology. LBBB or LBBB like morphology was present in 95% of patients. Mean SRSsept was 4.4 ± 3.2%, 56% of patients had SRSsept ≥ 4%. Ninety six patients (70%) were echocardiographic responders. Baseline SRSsept was significantly higher in responders compared to non-responders (5.1 ± 3.2 vs 3.0 ± 2.7, P < 0.001). The optimal cut-off value for SRSsept to predict response to CRT was 4.0%. After both univariate (OR 3.74, 95% CI 1.72–8.10) and multivariate analyses (OR 3.71, 95% CI 1.49–9.2), baseline SRSsept > 4% independently predicted the response to CRT. Conclusions Baseline septal rebound stretch is independently associated with echocardiographic response to CRT.

Association of apical rocking with super-response to cardiac resynchronisation therapy

BackgroundSuper-responders to cardiac resynchronisation therapy (CRT) show an exceptional improvement in left ventricular ejection fraction (LVEF). Previous studies showed that apical rocking was independently associated with echocardiographic response to CRT. However, little is known about the association between apical rocking and super-response to CRT.ObjectivesTo determine the independent association of LV apical rocking with super-response to CRT in a large cohort.MethodsA cohort of 297 consecutive heart failure patients treated with primary indication for CRT-D were included in an observational registry. Apical rocking was defined as motion of the left ventricular (LV) apical myocardium perpendicular to the LV long axis. ‘Super-response’ was defined by the top quartile of LVEF response based on change from baseline to follow-up echocardiogram. Best-subset regression analysis identified predictors of LVEF super-response to CRT.ResultsApical rocking was present in 45 % of patients. Super-responders had an absolute mean LVEF increase of 27 % (LVEF 22.0 % ± 5.7 at baseline and 49.0 % ± 7.5 at follow-up). Apical rocking was significantly more common in super-responders compared with non-super-responders (76 and 34 %, P < 0.001). In univariate analysis, female gender (OR 2.39, 95 % CI 1.38–4.11), lower LVEF at baseline (OR 0.91 95 % CI 0.87–0.95), non-ischaemic aetiology (OR 4.15, 95 % CI 2.33–7.39) and apical rocking (OR 6.19, 95 % CI 3.40–11.25) were associated with super-response. In multivariate analysis, apical rocking was still strongly associated with super-response (OR 5.82, 95 % CI 2.68–12.61). Super-responders showed an excellent clinical prognosis with a very low incidence of heart failure admission, cardiac mortality and appropriate ICD therapy.ConclusionApical rocking is independently associated with super-response to CRT.

Mechanical power sheath mediated recanalization and lead implantation in patients with venous occlusion: Technique and results

Chronic venous occlusion hampers lead revisions and upgrades in patients with a cardiac implantable electronic devices (CIEDs). This can make cardiothoracic surgery, venoplasty, or contra‐lateral implantation of leads with tunneling necessary. A technique using venous recanalization may be a preferred alternative. We assessed the efficacy and safety of this new technique.