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CRT-P versus CRT-D Outcomes Background Cardiac resynchronization therapy (CRT) is commonly used to manage heart failure, yet published guidelines do not distinguish between recommendations for pacemakers (CRT-P) and defibrillators (CRT-D) despite significant differences in size, longevity, and cost between these devices. The purpose of this study is to compare the clinical characteristics and outcomes between elderly recipients of CRT-P and CRT-D. Methods and Results Data from 512 patients (405 CRT-D, 107 CRT-P) aged ≥75 years with LV ejection fraction ≤35% and QRS duration >120 milliseconds were retrospectively analyzed for baseline characteristics and followed to the primary outcome of all-cause mortality. Cox proportional hazards models were used to adjust for possible confounders. Results were further validated through propensity matching cohorts. Compared to CRT-D recipients, CRT-P patients were older (83 years vs. 81 years, P < 0.001) and had more comorbid conditions (Charlson index = 5 [3-6] vs. 4 [3-5], P = 0.007). During 40.8 months of follow-up, there were 280 deaths. Compared to CRT-D patients, CRT-P recipients had higher unadjusted mortality (HR 1.54, 95% CI 1.15-2.08, P = 0.004). However, this difference lost significance after adjusting for baseline differences between the groups (HR 1.18, 95% CI 0.78-1.77, P = 0.435). Conclusion Higher all-cause mortality in older CRT-P versus CRT-D patients is largely explained by baseline clinical and demographic differences between the two groups, which are likely the drivers of device selection in real-world clinical practice, where the published guidelines remain ambiguous. There is a need for randomized studies to determine optimal CRT device selection. [ABSTRACT FROM AUTHOR]

Focal But Not Diffuse Fibrosis Burden Predicts CRT Remodeling Response Introduction Many heart failure patients with dyssynchrony do not reverse remodel (RR) in response to cardiac resynchronization therapy (CRT). The presence of focal and diffuse interstitial myocardial fibrosis may explain this high nonresponse rate. T1 mapping is a new cardiac magnetic resonance imaging (CMR) technique that overcomes the limitations of conventional contrast CMR and provides reliable quantitative assessment of diffuse myocardial fibrosis. The study tested the hypothesis that focal and diffuse fibrosis quantification would correlate with a lack of left ventricular (LV) RR to CRT. Methods and Results In a prospective study of 48 consecutive patients (27 ischemic cardiomyopathy, 21 dilated cardiomyopathy) LV scar burdens were quantified (scar core and gray zone using late gadolinium enhancement LGE CMR; interstitial fibrosis using T1 mapping) before CRT implant. LV RR was defined by a ≥ 15% reduction in LV end-systolic volume 6 months postimplant. Twenty-seven (56%) patients were responders with RR. Association between scar quantification and LV RR was assessed using the Poisson regression model. Univariate analysis showed that QRS duration/morphology, scar core, and gray zone volumes expressed as % of LV mass and extracellular volume index (ECV) (a measure of interstitial fibrosis from T1 mapping) to be significant predictors of LV RR. Multivariable-adjusted analyses demonstrated scar core quantification (≥13.7% LV mass) to be the only independent predictor of LV RR (prevalence ratio 0.40, P = 0.038). Conclusions Focal scar burden detected by LGE CMR is associated with a poor response to CRT. Diffuse interstitial fibrosis assessment by T1 mapping, however, is not independently predictive of CRT response. [ABSTRACT FROM AUTHOR]

Multiple Bursts for Fast Ventricular Tachycardia Introduction An empirical sequence of burst antitachycardia pacing (ATP) is effective in terminating fast ventricular tachycardias (FVT) in patients with implantable cardioverter-defibrillators (ICDs). We aimed to determine whether multiple ATP bursts for termination of FVT results in shock reduction compared to a single ATP burst. Methods and Results We analyzed data from the Umbrella trial, a multicenter prospective observational study of ICD patients followed by the CareLink Monitoring System. We compared the safety and effectiveness of a single ATP burst (Group 1) with a strategy of successive ATP sequences (Group 2) for termination of FVT episodes (cycle lengths 250-320 milliseconds) before shock therapy. Over a mean follow-up of 35 months, a total of 650 FVT episodes were detected in 154 patients (mean cycle length: 299 ± 18 milliseconds). Effectiveness of the first burst ATP in Group 1 was 73% and shocks were required in 27% of episodes. Effectiveness of the first burst ATP in Group 2 was 77%, and this increased to 91% with the third or successive ATP bursts. Shocks were required in 9% of episodes in group 2, representing a 67% reduction in the need of high-energy shocks. Median duration of FVT episodes and mortality in both groups were similar. Multivariate analysis indicated that programming multiple ATP bursts (OR 3.4, 95%CI 1.7-6.8, P = 0.001) was an independent predictor of ATP effectiveness. Conclusion This study provides first evidence that a strategy of multiple burst ATP sequences for termination of FVT episodes leads to a clinically meaningful reduction in the need for shocks. [ABSTRACT FROM AUTHOR]

Interventricular Electrical Delay Introduction The left ventricular (LV) pacing site and the magnitude of the electrical delay within the LV, as expressed by prolonged QRS duration, are major determinants of cardiac resynchronization therapy (CRT) efficacy. We investigated the incremental value of positioning the LV lead in areas of late activation in order to enhance the response to CRT in patients with different degrees of QRS complex lengthening. Methods and Results This analysis was performed on 301 heart failure patients who received a CRT defibrillator. On implantation, the right ventricular (RV)-to-LV interval was measured as the delay between local activations recorded through the RV and LV leads in the final position. After 1 year, 171 (57%) patients displayed reverse LV remodeling, as measured by a ≥15% reduction in the LV end-systolic volume. Both the RV-to-LV interval and its percentage value corrected for the QRS duration were significantly associated with a positive response to CRT. An RV-to-LV interval >80 milliseconds and an RV-to-LV interval/QRS >58% yielded the best prediction of reverse remodeling. Although the response to CRT decreased with shorter QRS duration in the overall population, patients with an RV-to-LV interval >80 milliseconds showed a response rate >65% in all QRS subgroups. Conclusion A longer RV-to-LV interval is associated with reverse LV remodeling after CRT. On implantation attempts could be made to maximize it when selecting the LV lead position, especially in patients with shorter QRS duration, and thus less likely to respond positively to CRT. [ABSTRACT FROM AUTHOR]

Late Gadolinium Enhancement and Arrhythmias. Introduction : The extent of left ventricular (LV) scar, characterized by late gadolinium enhancement cardiac MRI (LGE-CMR), has been shown to predict the occurrence of ventricular arrhythmias in implantable cardioverter defibrillator (ICD) recipients. However, the specificity of LGE-CMR for sudden cardiac death (SCD) versus non-SCD is unclear. The aim of this retrospective, observational study was to evaluate this relationship in a cohort of ICD recipients. Methods and Results : We included consecutive patients who had undergone LGE-CMR before ICD implantation over a 4-year period (2006-2009). Scar (defined as myocardium with a signal intensity ≥50% of the maximum in scar tissue) was characterized in terms of percent scar and number of transmural LV scar segments in a 17-segment model. The endpoints were appropriate ICD therapy and all-cause mortality. Sixty-four patients (average age 66 ± 11 years, 51 male, median LVEF 30%) were included. During 42 ± 13 months follow-up, appropriate ICD therapy occurred in 28 patients (44%), and 14 patients (22%) died. Number of transmural scar segments (P = 0.005) and percentage LV scar (P = 0.03) were both significantly associated with appropriate ICD therapy. However, neither number of transmural scar segments (P = 0.32) or percent LV scar (P = 0.59) was significantly associated with all-cause mortality. Conclusion : In this observational study, in medium-term follow-up, the extent of LV scar characterized by LGE-CMR was strongly associated with the occurrence of spontaneous ventricular arrhythmias but not all-cause mortality. We hypothesize that scar quantification by LGE-CMR may be more specific for SCD than non-SCD, and may prove a valuable tool for the selection of patients for ICD therapy. (J Cardiovasc Electrophysiol, Vol. 24, pp. 430-436, April 2013) [ABSTRACT FROM AUTHOR]

Prognostic Impact of Inappropriate Shocks. Introduction: Recent studies suggest a worse impact of inappropriate shock therapies on the outcome of patients with an implantable cardioverter-defibrillator (ICD). However, it is not known whether the worse impact is attributed to the ICD shock itself or due to the underlying heart disease. The aim of the study was to evaluate the impact of inappropriate ICD shocks on clinical outcome by comparing ICD shocks triggered by atrial fibrillation (AF) with shocks caused by lead failure. Methods and Results: A total of 1,411 consecutive patients of the prospective single-center ICD-registry Ludwigshafen who underwent an ICD implantation between 1992 and 2008 for primary or secondary prevention of sudden cardiac death were analyzed. During the median follow-up of 3 years, 297 (21%) patients experienced inappropriate ICD shocks. Sixty percent of patients had inappropriate shocks due to AF and 24% due to lead defect or T-wave oversensing. Multiple ICD shocks (≥2) triggered by AF were associated with a worse prognosis, whereas a single shock due to AF or 1 or multiple shocks resulting from lead failure were not. ICD shocks caused by AF occurred more often in tandem with a serious adverse event than in patients with a lead failure (15% vs 6%, P < 0.05). Conclusion: Multiple ICD shocks triggered by AF are associated with a worse prognosis in ICD patients, whereas a single shock due to AF or shocks resulting from lead failure are not. These data support that the ICD shock itself has no worse impact on the outcome of ICD patients. (J Cardiovasc Electrophysiol, Vol. 23, pp. 735-740, July 2012) [ABSTRACT FROM AUTHOR]

Pacemakers and ICDs in Myotonic Dystrophy. Introduction: We assessed implant rates, indications, characteristics, and outcomes in patients with the neuromuscular disease, myotonic dystrophy type 1 (DM1) receiving a pacemaker or an implantable cardioverter-defibrillator (ICD). Methods and Results: Device use was evaluated in a prospective, multicenter registry of 406 genetically confirmed adult patients followed for 9.5 ± 3.2 years. Forty-six (11.3%) had or received a pacemaker and 21 (5.2%) received an ICD. Devices were primarily implanted for asymptomatic conduction abnormalities and left ventricular (LV) systolic dysfunction. However, 7 (15.2%) pacemakers were implanted for third-degree atrioventricular block and 6 (28.6%) ICDs were implanted for ventricular tachyarrhythmias (ventricular tachycardia [VT] or fibrillation [VF]). Patients receiving devices were older and more frequently had heart failure, LV systolic dysfunction, atrial tachyarrhythmias, and ECG conduction abnormalities compared to nondevice patients. Five (10.9%) pacemaker patients underwent upgrade to an ICD, 3 for LV systolic dysfunction, 1 for VT/VF, and 1 for progressive conduction disease. Seventeen (27.4%) of the 62 patients with devices were pacemaker-dependent at last follow-up. Three (14.3%) ICD patients had appropriate therapies. Twenty-four (52.2%) pacemaker patients died including 13 of respiratory failure and 7 of sudden death. Seven (33.3%) ICD patients died including 2 of respiratory failure and 3 of sudden death. The patients with ICDs and sudden death all had LV systolic dysfunction and 1 death was documented due to inappropriate therapies. Conclusions: DM1 patients commonly receive antiarrhythmia devices. The risk of VT/VF and sudden death suggests that ICDs rather than pacemakers should be considered for these patients. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1369-1375, December 2011) [ABSTRACT FROM AUTHOR]