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QRS-Based Optimization of Cardiac Resynchronization Background Optimization of atrioventricular (AV) and interventricular (VV) intervals may improve cardiac resynchronization therapy (CRT) response but is a complex task. Fusion with intrinsic conduction may increase the benefit of CRT. The aim was to describe fusion-optimized intervals (FOI), a new method of optimizing CRT based on QRS duration. Methods and Results Seventy-six consecutive patients with preserved AV conduction who received CRT were prospectively included. The AV interval was optimized by searching the narrowest QRS obtained within the fusion band during left ventricular (LV) pacing. The VV interval was then adjusted, comparing QRS duration in simultaneous biventricular, LV preexcitation (−30 milliseconds), right ventricular (RV) preexcitation (−30 milliseconds) and LV-only pacing. A substudy in 31 patients evaluated the invasive LV +dP/dtmax. The best fusion-optimized AV interval was 136 ± 30 milliseconds during atrial sensing and 192 ± 35 milliseconds during atrial pacing. The best QRS was obtained with simultaneous biventricular pacing in 28 patients (37%), LV preexcitation in 22 (29%), LV-only in 20 (26%), and RV preexcitation in 6 (8%). Baseline QRS was shortened more by FOI (59 ± 19 milliseconds) than by nominal settings (40 ± 21 milliseconds; P < 0.001). Sixty-five patients (86%) showed >10% shortening of the baseline QRS with FOI; none prolonged the QRS duration by FOI compared to nominal settings. All echocardiographic asynchrony parameters were corrected by FOI. Baseline +dP/dtmax improvement was greater in FOI (127 ± 95 mmHg/seconds) than in nominal settings (102 ± 71 mmHg/seconds; P = 0.05). Conclusion The FOI method is feasible, further reduces QRS duration, and improves acute hemodynamic response compared to nominal programming of CRT. [ABSTRACT FROM AUTHOR]

Aim Current guidelines recommend atrioventricular junction (AVJ) ablation in patients with atrial fibrillation (AF) treated with cardiac resynchronization therapy (CRT). Our study compared the CRT response of patients in sinus rhythm (SR) vs. AF. Methods and results In this observational, prospective, multicentre study, patients were grouped by intrinsic rhythm. For the first 2 months, the negative chronotropic drug was optimized in the AF group. If ventricular pacing was ≤85%, AVJ ablation was recommended. Responders were defined as patients who survived without requiring heart transplant and had a ≥ 10% reduction in left ventricular end-systolic volume (LVESV) at 12 months after implantation. Of 202 patients included, 156 (77%) were in SR and 46 (23%) had AF. After drug optimization, only 13/46 (28%) of the AF patients required AVJ ablation (AF + AVJ). The percentage of responders was 83/156 (53%) for SR vs. 22/46 (48%) AF (P = 0.4). Among AF patients the response was 16/33 (48%) for AF with non-AVJ ablation vs. 6/13 (46%) AF + AVJ, P = 0.56. The LVESV decreased in all three groups: –30 ± 39 mL, –24 ± 43 mL, and –22 ± 36 mL, respectively (P = 0.75). Mortality was higher in patients with AF compared with SR: 10/46 (21%) vs. 9/156 (5.7%), log rank 10.6, P <0.05. Conclusion Although only 28% of the patients in AF had the AVJ ablated, there were no differences in the percentage of response and echo improvement between patients in SR and AF. However, mortality was higher in patients with AF compared with patients in SR. [ABSTRACT FROM PUBLISHER]

This study was conducted to investigate the clinical impact of cardiac resynchronization device optimization. A series of 100 consecutive patients received cardiac resynchronization therapy. In the first 49 patients, an empirical atrioventricular delay of 120 ms was set, with simultaneous biventricular stimulation (interventricular [VV] interval = 0 ms). In the next 51 patients, systematic atrioventricular optimization was performed. VV optimization was also performed, selecting 1 VV delay: right or left ventricular preactivation (+30 or −30 ms) or simultaneous (VV interval = 0 ms), according to the best synchrony obtained by tissue Doppler–derived wall displacement. At follow-up, patients who were alive without cardiac transplantation and showed improvement of ≥10% in the distance walked in the 6-minute walking test were considered responders. There were no differences between the 2 groups at baseline. Left ventricular ejection fraction improved in the 2 groups, but left ventricular cardiac output improved only in the optimized group. At 6 months, patients with optimized devices walked slightly further in the 6-minute walking test (497 ± 167 vs 393 ± 123 m, p <0.01), with no differences in New York Heart Association functional class or quality of life compared with nonoptimized patients. Overall, the number of nonresponders were similar in the 2 groups (27% vs 23%, p = NS). In conclusion, the echocardiographic optimization of cardiac resynchronization devices provided a slight incremental clinical benefit at midterm follow-up. Simple and rapid methods to routinely optimize the devices are warranted. [Copyright &y& Elsevier]

Introduction: Ablation with second‐generation cryoballoon technology evolves as an effective and safe alternative to radiofrequency for atrial fibrillation ablation procedures. Nevertheless, the optimal freezing strategy remains unknown. Our objective was to identify the procedural cryoablation parameters predicting successful peri‐pulmonary vein (PV) lesions by directly analyzing Postablation gaps in late‐gadolinium‐enhanced cardiac magnetic resonance (LGE‐CMR). Methods and Results: Forty‐nine consecutive patients (196 PVs) undergoing ablation with second‐generation cryoballoon at our center were included. The number and duration of cryoballoon application to achieve PV isolation were left to operator discretion. Gap number and length were quantified in all patients with a LGE‐CMR performed 3 months postablation. Application time (420 ± 217 seconds), number of applications (2.1 ± 1.2), application time after electrical isolation (311 ± 194 seconds) and minimum temperature (−45.8 ± 6.5°C) were similar in the 4 PVs. Gaps were observed in 148 PVs (76%), averaging 1.3 ± 1 gaps per vein. Gaps were longer and more frequent in the right PVs (91% vs 59% in left PVs, P <.001). Neither the number, total duration of applications, nor postisolation application time predicted relative length or number of gaps. Conclusions: After successful PV isolation was achieved in patients undergoing cryoablation, increasing the number of applications, the total application time or application time postisolation did not result in a reduction in the number or the relative length of gaps. [ABSTRACT FROM AUTHOR]

Left Atrial Sphericity Predicts AF Ablation Outcome Background Atrial fibrillation (AF) ablation outcome is mainly determined by atrial remodeling that, nowadays, is only estimated through clinical presentation (persistent vs. paroxysmal) and left atrial (LA) dimension. The aim of the study was to stage the atrial remodeling process using the Left Atrial Sphericity (LASP) and determine whether this technique may help to predict AF ablation outcome. Methods Consecutive patients who underwent contrast-enhanced cardiac magnetic resonance angiography before AF ablation were included in the study. Three-dimensional reconstruction of LA excluding pulmonary veins and the LA appendage was used to define the LA cavity. The LASP was automatically obtained with self-customized software. Results 106 patients were included and categorized in 3 groups (Gs): discoid-LA (G1), intermediate-LA (G2), and spherical-LA (G3). The G3 patients had larger LA anteroposterior diameter than G1 and G2 patients (47 ± 7 vs 43 ± 6 and 39 ± 5mm; P < 0.001), greater LA volume (90 ± 39 vs 86 ± 24 and 73 ± 20 mm; P = 0.012), and higher prevalence of persistent AF (75% vs 48% and 29%; P = 0.034) structural heart disease (75% vs 19% and 19%; P < 0.001), and AF recurrence at 12 months follow-up (58% vs 29% and 5%, P < 0.001). The LASP had linear correlation to predicted probability of recurrence. Multivariate analysis identified LASP (OR 1.320 [1.096-1.591], P = 0.004) and hypertension (OR 3.694 [1.282-10.645]; P = 0.016) as independent risk factors for arrhythmia recurrence. Conclusion Left Atrial Sphericity is a new independent predictor of recurrence after AF ablation and may be useful in selecting the best candidates for AF ablation. [ABSTRACT FROM AUTHOR]

Aim: Current guidelines recommend atrioventricular junction (AVJ) ablation in patients with atrial fibrillation (AF) treated with cardiac resynchronization therapy (CRT). Our study compared the CRT response of patients in sinus rhythm (SR) vs. AF. Methods and Results: In this observational, prospective, multicentre study, patients were grouped by intrinsic rhythm. For the first 2 months, the negative chronotropic drug was optimized in the AF group. If ventricular pacing was ≤85%, AVJ ablation was recommended. Responders were defined as patients who survived without requiring heart transplant and had a ≥ 10% reduction in left ventricular end-systolic volume (LVESV) at 12 months after implantation. Of 202 patients included, 156 (77%) were in SR and 46 (23%) had AF. After drug optimization, only 13/46 (28%) of the AF patients required AVJ ablation (AF + AVJ). The percentage of responders was 83/156 (53%) for SR vs. 22/46 (48%) AF (P = 0.4). Among AF patients the response was 16/33 (48%) for AF with non-AVJ ablation vs. 6/13 (46%) AF + AVJ, P = 0.56. The LVESV decreased in all three groups: -30 ± 39 mL, -24 ± 43 mL, and -22 ± 36 mL, respectively (P = 0.75). Mortality was higher in patients with AF compared with SR: 10/46 (21%) vs. 9/156 (5.7%), log rank 10.6, P <0.05. Conclusion: Although only 28% of the patients in AF had the AVJ ablated, there were no differences in the percentage of response and echo improvement between patients in SR and AF. However, mortality was higher in patients with AF compared with patients in SR. [ABSTRACT FROM AUTHOR]

Background: Best practice for cardiac resynchronization therapy (CRT) device optimization is not established. This study compared Tissue Doppler Imaging (TDI) to study left ventricular (LV) synchrony and left ventricular outflow tract velocity-time integral (LVOT VTI) to assess hemodynamic performance. Methods: LVOT VTI and LV synchrony were tested in 50 patients at three interventricular (VV) delays (LV preactivation at −30 ms, simultaneous biventricular pacing, and right ventricular preactivation at +30 ms), selecting the highest VTI and the greatest degree of superposition of the displacement curves, respectively, as the optimum VV delay. Results: In 39 patients (81%), both techniques agreed (Kappa = 0.65, p < 0.0001) on the optimum VV delay. LV preactivation (VV − 30) was the interval most frequently chosen. Conclusions: Both TDI and LVOT VTI are useful CRT programming methods for VV optimization. The best hemodynamic response correlates with the best synchrony. In most patients, the optimum VV interval is LV preactivation. (PACE 2011; 34:984-990) [ABSTRACT FROM AUTHOR]