蔡敏思
中国医学科学院阜外医院 心率失常中心
Background:The prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure (HF) is well-established. However, whether it could facilitate the risk stratification of HF patients with implantable cardioverter-defibrillator (ICD) is still unclear.Objective:To determine the associations between baseline NT-proBNP and outcomes of all-cause mortality and first appropriate shock due to sustained ventricular tachycardia/ventricular fibrillation (VT/VF) in ICD recipients.Methods and results:N-terminal pro-B-type natriuretic peptide was measured before ICD implant in 500 patients (mean age 60.2 ± 12.0 years; 415 (83.0%) men; 231 (46.2%) Non-ischemic dilated cardiomyopathy (DCM); 136 (27.2%) primary prevention). The median NT-proBNP was 854.3 pg/ml (interquartile range [IQR]: 402.0 to 1,817.8 pg/ml). We categorized NT-proBNP levels into quartiles and used a restricted cubic spline to evaluate its nonlinear association with outcomes. The incidence rates of mortality and first appropriate shock were 5.6 and 9.1%, respectively. After adjusting for confounding factors, multivariable Cox regression showed a rise in NT-proBNP was associated with an increased risk of all-cause mortality. Compared with the lowest quartile, the hazard ratios (HRs) with 95% CI across increasing quartiles were 1.77 (0.71, 4.43), 3.98 (1.71, 9.25), and 5.90 (2.43, 14.30) for NT-proBNP (p for trend < 0.001). A restricted cubic spline demonstrated a similar pattern with an inflection point found at 3,231.4 pg/ml, beyond which the increase in NT-proBNP was not associated with increased mortality (p for nonlinearity < 0.001). Fine-Gray regression was used to evaluate the association between NT-proBNP and first appropriate shock accounting for the competing risk of death. In the unadjusted, partial, and fully adjusted analysis, however, no significant association could be found regardless of NT-proBNP as a categorical variable or log-transformed continuous variable (all p > 0.05). No nonlinearity was found, either (p = 0.666). Interactions between NT-proBNP and predefined factors were not found (all p > 0.1).Conclusion:In HF patients with ICD, the rise in NT-proBNP is independently associated with increased mortality until it reaches the inflection point. However, its association with the first appropriate shock was not found. Patients with higher NT-proBNP levels might derive less benefit from ICD implant.
Frontiers in cardiovascular medicine 2022
AIMS:This study aimed to develop and validate a competing risk nomogram for predicting all-cause mortality and heart transplantation (HT) before first appropriate shock in non-ischaemic dilated cardiomyopathy (DCM) patients receiving implantable cardioverter-defibrillators (ICD).METHODS AND RESULTS:A total of 218 consecutive DCM patients implanted with ICD between 2010 and 2019 at our institution were retrospectively enrolled. Cox proportional hazards model was primarily built to identify variables associated with death and HT. Then, a Fine-Gray model, accounting for the appropriate shock as a competing risk, was constructed using these selected variables along with implantation indication (primary vs. secondary). Finally, a nomogram based on the Fine-Gray model was established to predict 1-, 3-, and 5-year probabilities of all-cause mortality and HT before first appropriate shock. The area under the receiver operating characteristic (ROC) curve (AUC), Harrell's C-index, and calibration curves were used to evaluate and internally validate the performance of this model. The decision curve analysis was applied to assess its clinical utility. The 1-, 3-, and 5-year cumulative incidence of all-cause mortality and HT without former appropriate shock were 5.3% [95% confidence interval (CI) 2.9-9.9%], 16.6% (95% CI 11-25.0%), and 25.3% (95% CI 17.2-37.1%), respectively. Five variables including implantation indication, left ventricular end-diastolic diameter, N-terminal pro-brain natriuretic peptide, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, and amiodarone treatment were independently associated with it (all P < 0.05) and were used for constructing the nomogram. The 1-, 3-, and 5-year AUC of the nomogram were 0.83 (95% CI 0.73-0.94, P < 0.001), 0.84 (95% CI 0.75-0.93, P < 0.001), and 0.85 (95% CI 0.77-0.94, P < 0.001), respectively. The Harrell's C-index was 0.788 (95% CI 0.697-0.877, P < 0.001; 0.762 for the optimism-corrected C-index), showing the good discriminative ability of the model. The calibration was acceptable (optimism-corrected slope 0.896). Decision curve analysis identified our model was clinically useful within the entire range of potential treatment thresholds for ICD implantation. Three risk groups stratified by scores were significantly different between cumulative incidence curves (P < 0.001). The identified high-risk group composed 17.9% of our population and did not derive long-term benefit from ICD.CONCLUSIONS:The proposed nomogram is a simple, useful risk stratification tool for selecting potential ICD recipients in DCM patients. It might facilitate the shared decision-making between patients and clinicians.
ESC heart failure 2022
AIMS:Low blood pressure (BP) has been shown to be associated with increased mortality in patients with chronic heart failure. This study was designed to evaluate the relationships between diagnosed hypertension and the risk of ventricular arrhythmia (VA) and all-cause death in chronic heart failure (CHF) patients with implantable cardioverter-defibrillators (ICD), including those with preserved left ventricular ejection fraction (HFpEF) and indication for ICD secondary prevention. We hypothesized that a stable hypertension status, along with an increasing BP level, is associated with a reduction in the risk of VA in this population, thereby limiting ICD efficacy.METHODS:We retrospectively enrolled 964 CHF patients, with hypertension diagnosis and hospitalized BP measurements obtained before ICD implantation. The primary outcome measure was defined as the composite of SCD, appropriate ICD therapy, and sustained VT. The secondary endpoint was time to death or heart transplantation (HTx). We performed multivariable Cox proportional hazard regression and entropy balancing to calculate weights to control for baseline imbalances with or without hypertension. The Fine-Gray subdistribution hazard model was used to confirm the results. The effect of random BP measurements on the primary outcome was illustrated in the Cox model with inverse probability weighting.RESULTS:The 964 patients had a mean (SD) age of 58.9 (13.1) years; 762 (79.0%) were men. During the interrogation follow-up [median 2.81 years (interquartile range: 1.32-5.27 years)], 380 patients (39.4%) reached the primary outcome. A total of 244 (45.2%) VA events in non-hypertension patients and 136 (32.1%) in hypertension patients were observed. A total of 202 (21.0%) patients died, and 31 (3.2%) patients underwent heart transplantation (incidence 5.89 per 100 person-years; 95% CI: 5.16-6.70 per 100 person-years) during a median survival follow-up of 4.5 (IQR 2.8-6.8) years. A lower cumulative incidence of VA events was observed in hypertension patients in the initial unadjusted Kaplan-Meier time-to-event analysis [hazard ratio (HR): 0.65, 95% confidence interval (CI): 0.53-0.80]. The protective effect was robust after entropy balancing (HR: 0.71, 95% CI: 0.56-0.89) and counting death as a competing risk (HR: 0.71, 95% CI: 0.51-1.00). Hypertension diagnosis did not associate with all-cause mortality in this population. Random systolic blood pressure was negatively associated with VA outcomes (p = 0.065).CONCLUSIONS:In hospitalized chronic heart failure patients with implantable cardioverter-defibrillators, the hypertension status and higher systolic blood pressure measurements are independently associated with a lower risk of combined endpoints of ventricular arrhythmia and sudden cardiac death but not with all-cause mortality. Randomized controlled trials are needed to confirm the protective effect of hypertension on ventricular arrhythmia in chronic heart failure patients.
Journal of clinical medicine 2022
PURPOSE:We aimed to evaluate the electrical characteristics and pacing parameters at different locations of His-Purkinje system pacing.METHODS:Patients who successfully underwent His-Purkinje system pacing with bradycardia indications from April 2018 to August 2019 were retrospectively analyzed according to the lead location confirmed by visualization of the tricuspid value annulus, postoperative echocardiography, and pacing electrocardiogram. The electrical characteristics and pacing parameters were compared among these patients.RESULTS:A total of 135 patients were retrospectively analyzed. Among them, 30 patients received atrial side HBP (aHBP group), 52 received ventricular side HBP (vHBP group), and 53 received left bundle branch pacing (LBBP group). The proportion of non-selective pacing was significantly lower in aHBP group (30.0%) than in vHBP (75.0%) and LBBP group (90.6%). LBBP had significantly shorter procedural and fluoroscopic duration than aHBP and vHBP. The capture threshold was significantly higher (1.07 ± 0.26 V/1.0 ms vs. 0.89 ± 0.22 V/1.0 ms vs. 0.77 ± 0.18 V/0.4 ms, P < 0.01, respectively), and the R-wave amplitude was significantly lower (3.71 ± 1.72 mV vs. 5.81 ± 2.37 mV vs. 10.27 ± 4.71 mV, P < 0.05 respectively) in aHBP group than those in the other two groups at implantation and during 3-month follow-up. No significant differences were observed in complications among groups during 3-month follow-up.CONCLUSION:VHBP and LBBP had better pacing performances than aHBP and might be more ideal pacing methods for bradycardia patients.
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing 2022
BACKGROUND:Left bundle branch pacing (LBBP) is a novel conduction system pacing modality, but pacing lead deployment remains challenging.OBJECTIVES:This study aimed to evaluate the feasibility of visualization-enhanced lead deployment for LBBP implantation and to assess LBBP characteristics on the basis of lead tip location.METHODS:Successful LBBP with a well-defined lead tip location by visualization of the tricuspid value annulus in 20 patients was retrospectively analyzed to develop an image-guided technique to identify the LBBP target site. This technique was then prospectively tested in 60 patients who were randomized into 2 groups, one using the standard approach (the standard group) and the other using the image-guided technique (the visualization group). The procedural details, electrophysiological characteristics, and short-term follow-up were compared between groups.RESULTS:LBBP was successfully achieved in 28 patients in the standard group and in 29 in the visualization group. The procedural and fluoroscopic durations in the visualization group (66.76 ± 14.62 and 7.83 ± 2.05 minutes) were significantly shorter than those in the standard group (85.46 ± 20.19 and 11.11 ± 3.51 minutes) (P < .01). The number of lead deployment attempts in the visualization group was lower than that in the standard group (2.03 ± 1.18 vs 2.96 ± 1.17; P < .01), and the proportion of left bundle branch potential recorded was higher (79.3% vs 46.4%; P = .01).CONCLUSION:Using a visualization technique, the procedural and fluoroscopic durations for LBBP implantation were significantly shortened with fewer lead repositioning attempts.
Heart rhythm 2021
Introduction: Left bundle branch pacing (LBBP) is a rapidly growing conduction system pacing technique. However, little is known regarding the electrophysiological characteristics of different types of LBBP. We aimed to evaluate the electrophysiological characteristics and anatomic lead location with pacing different branches of the left bundle branch. Methods: Consecutive bradycardia patients with successful LBBP were enrolled and classified into groups according to the paced electrocardiogram and the lead location. Electrocardiogram, pacing properties, vectorcardiogram, and lead tip location were analyzed. Results: Ninety-one patients were enrolled, including 48 with the left bundle trunk pacing (LBTP) and 43 with the left bundle fascicular pacing (LBFP). The paced QRS duration in the LBTP group was significantly shorter than that in the LBFP group (108.1 ± 9.9 vs. 112.9 ± 11.2 ms, p = 0.03), with a more rightward QRS transition zone (p = 0.01). The paced QRS area in the LBTP group was similar to that during intrinsic rhythm (35.1 ± 15.8 vs. 34.7 ± 16.6 μVs, p = 0.98), whereas in the LBFP group, the paced QRS area was significantly larger compared to intrinsic rhythm (43.4 ± 15.8 vs. 35.7 ± 18.0 μVs, p = 0.01). The lead tip site for LBTP was located in a small fan-shaped area with the tricuspid valve annulus summit as the origin, whereas fascicular pacing sites were more likely in a larger and more distal area. Conclusions: Pacing the proximal left bundle main trunk produced better electrical synchrony compared with pacing the distal left bundle fascicles. A visualization technique can facilitate achieving LBTP.
Frontiers in cardiovascular medicine 2021
BACKGROUND:Arrhythmogenic cardiomyopathy (ACM) is characterized by a high incidence of ventricular tachyarrhythmia and sudden death. Implantable cardioverter-defibrillator (ICD) implantation is the cornerstone of management.OBJECTIVE:This study aims to reveal the prognostic value of the contrast-enhanced cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) amount in predicting varying lethal outcomes among ACM patients with ICDs.METHODS:The 88 patients with definite ACM who were all referred for contrast-enhanced CMR received an ICD and were followed up for a median of 4.0 years.RESULTS:Fifty-four patients had no left ventricular (LV) involvement and sixteen had an LV LGE amount > 15%. During the follow-up time, appropriate ICD therapy was seen in 57, electrical storm (ES) in 19, and cardiac death in 9 patients. Compared with those without LV involvement, patients with LV LGE amount > 15% had a higher risk of cardiac death (log-rank P = 0.021). LV LGE amount was associated with an increased risk of ICD therapy [adjusted hazard ratio (HR) 1.035, 95% confidence interval (CI) 1.008-1.062, P = 0.010], and cardiac death (adjusted HR 1.082, 95% 1.006-1.164, P = 0.034), independently of LV ejection fraction. LV LGE mass of >15% demonstrated an over 2-fold increase in ICD therapy (adjusted HR 2.180, 95%CI 1.058-4.488, P = 0.035) and an over 7-fold increase in cardiac death (unadjusted HR 7.198, 95%CI 1.399-37.043, P = 0.018) than those without LV involvement, respectively.CONCLUSIONS:The LV LGE-CMR in ACM shows a dose-dependent association with ICD therapy and cardiac death. And LV LGE amount of >15% is a strong predictor.
International journal of cardiology 2021
AIMS:Left ventricular ejection fraction (LVEF) is considered an indicator of cardiac resynchronization therapy (CRT). Longitudinal studies on the predictive value of LVEF are scarce. We aimed to comprehensively evaluate the prognostic role of LVEF in the outcomes of Chinese patients with CRT.METHODS AND RESULTS:Three hundred ninety-two patients were divided into three tertiles of LVEF: ≤25%, 25-30%, and 30-35%, and four groups by LVEF changes: <0% (negative response); ≥0% and ≤5% (non-response); >5% and ≤15% (response); and >15% (super-response). One hundred six patients were super-responders. During a median follow-up of 3.6 years, 141 reached the composite endpoint. Odds ratios (ORs) for super-response depicted a reversed U-shaped relationship for baseline LVEF with a peak at 25-30%. Independent predictors of super-response were smaller left atrial diameter [odds ratio 0.897, 95% confidence interval (CI) 0.844-0.955, P = 0.001], smaller left ventricular end-diastolic diameter (OR 0.937, 95% CI 0.889-0.989, P = 0.018), and higher estimated glomerular filtration rate (OR 1.018, 95% CI 1.001-1.035, P = 0.042) in Tertile 1; atrial fibrillation (OR 0.278, 95% CI 0.086-0.901, P = 0.033), left bundle branch block (OR 4.096, 95% CI 1.046-16.037, P = 0.043), and left ventricular end-diastolic diameter (OR 0.929, 95% CI 0.876-0.986, P = 0.016) in Tertile 2; while female sex (OR 2.778, 95% CI 1.082-7.132, P = 0.034) and higher systolic blood pressure (OR 1.045, 95% CI 1.013-1.079, P = 0.006) in Tertile 3. An inverse association with the composite endpoint was found in Tertile 1 vs. Tertile 2 (hazard ratio 1.934, 95% CI 1.248-2.996, P = 0.003). The prognostic effects of CRT response in Tertile 3 and Tertile 1 varied significantly (P for trend = 0.017 and <0.001). Among three tertiles in super-responders, event-free survival was similar (P for trend = 0.143).CONCLUSIONS:Left ventricular ejection fraction of 25-30% is associated with a better prognosis of super-response. Predictors of super-response are different for LVEF tertiles. CRT responses would have better prognostic performance than LVEF tertiles at baseline, which should be considered when clinicians screening eligible patients for CRT.
ESC heart failure 2021
Introduction: For patients who develop atrioventricular block (AVB) following transcatheter aortic valve replacement (TAVR), right ventricular pacing (RVP) may be associated with adverse outcomes. We assessed the feasibility of conduction system pacing (CSP) in patients who developed AVB following TAVR and compared the procedural and clinical outcomes with RVP. Methods: Consecutive patients who developed AVB following TAVR were prospectively enrolled, and were implanted with RVP or CSP. Procedural and clinical outcomes were compared among different pacing modalities. Results: A total of 60 patients were enrolled, including 10 who were implanted with His bundle pacing (HBP), 20 with left bundle branch pacing (LBBP), and 30 with RVP. The HBP group had significantly lower implant success rate, higher capture threshold, and lower R-wave amplitude than the LBBP and RVP groups (p < 0.01, respectively). The RVP group had a significantly longer paced QRS duration (153.5 ± 6.8 ms, p < 0.01) than the other two groups (HBP: 121.8 ± 8.6 ms; LBBP: 120.2 ± 10.6 ms). During a mean follow-up of 15.0 ± 9.1 months, the LBBP group had significantly higher left ventricular ejection fraction (LVEF) (54.9 ± 6.7% vs. 48.9 ± 9.1%, p < 0.05) and shorter left ventricular end-diastolic diameter (LVEDD) (49.7 ± 5.6 mm vs. 55.0 ± 7.7 mm, p < 0.05) than the RVP group. While the HBP group showed trends of higher LVEF (p = 0.016) and shorter LVEDD (p = 0.017) than the RVP group. Four patients in the RVP group died-three deaths were due to progressive heart failure and one was due to non-cardiac reasons. One death in the LBBP group was due to the non-cardiac reasons. Conclusions: CSP achieved shorter paced QRS duration and better cardiac structure and function in post-TAVR patients than RVP. LBBP had a higher implant success rate and better pacing parameters than HBP.
Frontiers in cardiovascular medicine 2021
BACKGROUND:A low appropriate therapy rate indicates that a minority of patients will benefit from their implantable cardioverter defibrillator (ICD). Quantitative measurements from 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) may predict ventricular arrhythmia (VA) occurrence after ICD placement.METHODS:We performed a prospective observational study and recruited patients who required ICD placement. Pre-procedure image scans were performed. Patients were followed up for VA occurrence. Associations between image results and VA were analyzed.RESULTS:In 51 patients (33 males, 53.9 ± 17.2 years) analyzed, 17 (33.3%) developed VA. Compared with patients without VA, patients with VA had significantly larger values in scar area (17.7 ± 12.4% vs. 7.0 ± 7.9%), phase standard deviation (51.4° ± 14.0° vs. 34.0° ± 15.0°), bandwidth (172.9° ± 39.8° vs. 128.7° ± 49.9°), sum thickening score (STS, 29.5 ± 11.1 vs. 17.8 ± 13.2), and sum motion score (42.9 ± 11.5 vs. 33.0 ± 19.0). Cox regression analysis and receiver operating characteristic curve analysis showed that scar size, dyssynchrony, and STS were associated with VA occurrence (HR, 4.956, 95% CI 1.70-14.46).CONCLUSION:Larger left ventricular scar burden, increased dyssynchrony, and higher STS quantified by 18F-FDG PET may indicate a higher VA incidence after ICD placement.
Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology 2021
