Left bundle branch pacing set to outshine biventricular pacing for cardiac resynchronization therapy?

The deleterious effects of long-term right ventricular pacing necessitated the search for alternative pacing sites which could prevent or alleviate pacinginduced cardiomyopathy.Until recently,biventricular pacing(BiVP)was the only modality which could mitigate or prevent pacing induced dysfunction.Further,BiVP could resynchronize the baseline electromechanical dssynchrony in heart failure and improve outcomes.However,the high non-response rate of around 20%-30%remains a major limitation.This non-response has been largely attributable to the direct non-physiological stimulation of the left ventricular myocardium bypassing the conduction system.To overcome this limitation,the concept of conduction system pacing(CSP)came up.Despite initial success of the first CSP via His bundle pacing(HBP),certain drawbacks including lead instability and dislodgements,steep learning curve and rapid battery depletion on many occasions prevented its widespread use for cardiac resynchronization therapy(CRT).Subsequently,CSP via left bundle branch-area pacing(LBBP)was developed in 2018,which over the last few years has shown efficacy comparable to BiVP-CRT in small observational studies.Further,its safety has also been well established and is largely free of the pitfalls of the HBP-CRT.In the recent metanalysis by Yasmin et al,comprising of 6 studies with 389 participants,LBBPCRT was superior to BiVP-CRT in terms of QRS duration,left ventricular ejection fraction,cardiac chamber dimensions,lead thresholds,and functional status amongst heart failure patients with left bundle branch block.However,there are important limitations of the study including the small overall numbers,inclusion of only a single small randomized controlled trial(RCT)and a small follow-up duration.Further,the entire study population analyzed was from China which makes generalizability a concern.Despite the concerns,the meta-analysis adds to the growing body of evidence demonstrating the efficacy of LBBP-CRT.At this stage,one must acknowledge that the fact that still our opinions on this technique are largely based on observational data and there is a dire need for larger RCTs to ascertain the position of LBBPCRT in management of heart failure patients with left bundle branch block.

Cardiac Resynchronization Therapy in Heart Failure in Sub-Saharan Africa Environment: Experience of the Principal Hospital of Dakar (Senegal)

Background: Heart failure is a major public health challenge in sub-Saharan Africa. In patients with chronic Heart Failure and cardiac desynchrony, studies have suggested that cardiac resynchronization, can improve cardiac function and the quality of life of patients. However, in Sub-Saharan Africa, very few studies have been done on cardiac resynchronization which is in its infancy. The aim of this study is to report the local data from our hospital. Method: It was a transversal, descriptive and analytical study conducted from November 2019 to September 2022 at the Cardiology Department of the Principal Hospital of Dakar. Results: Twelve patients were implanted for Cardiac Resynchronization Therapy (CRT). The sex ratio was 8 males/4 females. The average age was 67 ± 11 years. Ten patients had non-ischemic heart disease and the two others had ischemic one. All of them had NYHA III or IV scores before CRT. The Quality of Life (QOL) was judged as poor by all of the patients. The average duration of QRS was 156 ± 9 ms. 27.9% ± 5% was the mean Left Ventricular ejection fraction (LVEF). Complications occur in 3/12 patients (25%). It was one CS vein dissection, one micro LV lead dislodgement and one phrenic nerve stimulation. Nine patients, who were considered as responders, had an improvement of QOL and NYHA, the LVEF increased and the end-diastolic dimension, and the duration of the QRS interval all decreased. Two patients do not respond and one (1) who had permanent atrial fibrillation, was a secondary responder after an atrioventricular junction ablation. Conclusion: Cardiac resynchronization is a therapy that improves the QOL of patients, the LVEF and reduces the duration of the QRS interval. However, this procedure is not without risk of complications. In sub-Saharan Africa, the major challenge is to improve the financial accessibility of this therapy for the population.

High sensitivity C-reactive protein and cardfiac resynchronization therapy in patients with advanced heart failure

Background The data on the prognostic values of high sensitivity C-reactive protein （hsCRP） levels in patients with advanced symp-tomatic heart failure （HF） receiving cardiac resynchronization therapy （CRT） are scarce. The aim of present study was to investigate the association of serum hsCRP levels with left ventricle reverse remodeling after six months of CRT as well as long-term outcome. Methods A total of 232 CRT patients were included. The assessment of hsCRP values, clinical status and echocardiographic data were performed at baseline and after six months of CRT. Long-term follow-up included all-cause mortality and hospitalizations for HF. Results During the mean follow-up periods of 31.3 ± 31.5 months, elevated hsCRP （〉3 mg/L） prior to CRT was associated with a significant 2.39-fold increase （P=0.006） in the risk of death or HF hospitalizations. At 6-month follow-up, patients who responded to CRT showed significant reductions or maintained low in hsCRP levels （–0.5 ± 4.1 mg/L reduction） compared with non-responders （1.7 ± 6.1 mg/L increase, P=0.018）. Com-pared with patients in whom 6-month hsCRP levels were reduced or remained low, patients in whom 6-month hsCRP levels were increased or maintained high experienced a significantly higher risk of subsequent death or HF hospitalizations （Log-rank P〈0.001）. The echocardio-graphic improvement was also better among patients in whom 6-month hsCRP levels were reduced or remained low compared to those in whom 6-month hsCRP levels were raised or maintained high. Conclusions Our findings demonstrated that measurement of baseline and follow-up hsCRP levels may be useful as prognostic markers for timely potential risk stratification and subsequent appropriate treatment strategies in patients with advanced HF undergoing CRT.

Predictors of super-response to cardiac resynchronization therapy： the significance of heart failure medication, pre-implant left ventricular geometry and high percentage of biventricular pacing

Background Super-responders （SRs） are defined as patients who show crucial cardiac function improvement after cardiac resynchro- nization therapy （CRT）. The purpose of this study is to identify and validate predictors of SRs after CRT. Methods This study enrolled 201 patients who underwent CRT during the period from 2010 to 2014. Clinical and echocardiographic evaluations were conducted before CRT and 6 months after. Patients with a decrease in New York Heart Association （NYHA） fimctional class 〉 1, a decrease in left ventricular end-systolic volume （LVESV） ≥ 15%, and a final left ventricular ejection fraction （LVEF） ≥ 45% were classified as SRs. Results 29% of the 201 patients who underwent CRT were identified as SRs. At baseline, SRs had significantly smaller left atrial diameter （LAD）, LVESV, left ventricular end-diastolic volume （LVEDV） and higher LVEF than the non-super-responders （non-SRs）. The percentage of patients using angiotensin-converting enzyme inhibitors or angiotensin receptor blockers （ACEI/ARB） was higher in SRs than non-SRs. Most SRs had Biventricular （BiV） pacing percentage greater than 98% six months after CRT. In the multivariate logistic regression analysis, the independ- ent predictors of SRs were lower LVEDV [odd ratios （OR）： 0.93; confidence intervals （CI）： 0.90-0.97], use of ACEI/ARB （OR： 0.33; CI： 0.13~3.82） and BiV pacing percentage greater than 98% （OR： 0.29; CI： 0.16~.87）. Conclusion Patients with a better compliance of ACEI/ARB and a less ectatic ventricular geometry before CRT tends to have a greater probability of becoming SRs. Higher percentage of BiV pacing is essential for becoming SRs.

Left univentricular pacing for cardiac resynchronization therapy using rate-adaptive atrioventricular delay

Objective To evaluate left univentricular （LUV） pacing for cardiac resynchronization therapy （CRT） using a rate-adaptive atrioven- tricular delay （RAAVD） algorithm to track physiological atrioventricular delay （AVD）. Methods A total of 72 patients with congestive heart failure （CHF） were randomized to RAAVD LUV pacing versus standard biventricular （BiV） pacing in a 1 ： 1 ratio. Echocardiography was used to optimize AVD for both groups. The effects of sequential BiV pacing and LUV pacing with optimized A-V （right atrio-LV） delay using an RAAVD algorithm were compared. The standard deviation （SD） of the S/R ratio in lead VI at five heart rate （HR） segments （Rs/R-SD5）, defined as the ＂tracking index,＂ was used to evaluate the accuracy of the RAAVD algorithm for tracking physiological AVD. Results TheQRS complex duration （132 ± 9.8 vs. 138± 10ms, P 〈 0.05）, the time required for optimization （21 ±5 vs. 50±8min, P〈 0.001）, the mitral regurgitant area （1.9 ± 1.1 vs. 2.5 ± 1.3 em2, P 〈 0.05）, the interventricular mechanical delay time （60.7 ± 13.3 ms vs. 68.3 ± 14.2 ms, P 〈 0.05）, and the average annual cost （13,200 ± 1000 vs. 21,600 ± 2000 RMB, P 〈 0.001） in the RAAVD LUV pacing group were significantly less than those in the standard BiV pacing group. The aortic valve velocity-time integral in the RAAVD LUV pacing group was greater than that in the standard BiV pacing group （22.7 ± 2.2 vs. 21.4 ± 2.1 cm, P 〈 0.05）. The Rs/R-SD5 was 4.08 ± 1.91 in the RAAVD LUV pacing group, and was significantly negatively correlated with improved left ventricular ejection fraction （LVEF） （ALVEF, Pearson＇s r = -0.427, P = 0.009）, and positively correlated with New York Heart Association class （Spearman＇s r - 0.348, P 0.037）. Conclusions RAAVD LUV pacing is as effective as standard BiV pacing, can be more physiological than standard BiV pacing, and can de- crease the average annual cost of CRT.

Cardiac resynchronization therapy for heart failure induced by left bundle branch block after transcatheter closure of ventricular septal defect

A 54-year-old female patient with congenital heart disease had a persistent complete left bundle branch block three months after closure by an Amplatzer ventricular septal defect occluder. Nine months later, the patient suffered from chest distress, palpitation, and sweating at daily activities, and her 6-min walk distance decreased significantly （155 m）. Her echocardiography showed increased left ventricular end-diastolic diameter with left ventricular ejection fraction of 37%. Her symptoms reduced significantly one week after received cardiac resynchronization therapy. She had no symptoms at daily activities, and her echo showed left ventricular ejection fraction of 46%and 53%. Moreover, left ventricular end-diastolic diameter decreased 6 and 10 months after cardiac resynchronization therapy, and 6-min walk dis-tance remarkably increased. This case demonstrated that persistent complete left bundle branch block for nine months after transcatheter closure with ventricular septal defect Amplatzer occluder could lead to left ventricular enlargement and a significant decrease in left ventricular systolic function. Cardiac resynchronization therapy decreased left ventricular end-diastolic diameter and increased left ventricular ejection fraction, thereby improving the patient’s heart functions.

Effect of serum γ-glutamyltranferase and albumin levels on the response to cardiac resynchronization therapy in the elderly

Background Several liver function tests have been identified as predictors of hospitalization for heart failure(HF) and death in patients with chronic HF. The relationship between serum γ-glutamyltranferase(GGT) and albumin(SA) levels with the response to cardiac resynchronization therapy(CRT) has not been reliably determined. The aim of the study was to evaluate the impact of liver function tests on the results of CRT in the elderly. Methods Baseline GGT and SA were assessed before CRT device implantation in the elderly(> 70-year-old) patients. The endpoints were:(1) CRT response defined as > 5% left ventricular ejection fraction improvement and no hospitalization for HF or cardiovascular death;(2) hospitalizations;and(3) mortality. Results Eighty of 138(58%) included patients were responders at nine months. Compared to responders, the SA levels were not significantly different(35.1 ± 5.4 vs. 33.6 ± 5.5 g/L, P = 0.103);but the GGT levels, higher(81.6 ± 69.3 vs. 54.7 ± 49.6 U/L, P = 0.013) in non-responders to CRT. GGT level was independently associated with non-response to CRT(P < 0.001, OR = 0.17;95% CI: 0.08–0.38, P < 0.001). GGT cut-off value ≥ 55 U/L was highly predictive of non-response [AUC = 0.65, 64% Sensitivity, 69% Specificity(95% CI: 0.56–0.74)]. GGT ≥ 55 U/L was also associated with higher risk of hospitalization for atrial fibrillation(AF)(95% vs. 83%, P = 0.024). Both SA and GGT had no impact on overall(P = 0.220, P = 0.723) mortality. Conclusions Higher level of GGT is an independent predictor of non-response to CRT in patients over age 70 years and is associated with higher risk of hospitalization for AF. Baseline serum levels of albumin and GGT and have no impact on mortality in elderly patients undergoing CRT.

The role of electrocardiography in the elaboration of a new paradigm in cardiac resynchronization therapy for patients with nonspecific intraventricular conduction disturbance

Cardiac resynchronization therapy （CRT） is associated with a favorable outcome only in patients with left bundle branch block （LBBB） pattern and in patients with a QRS duration 〉 150 ms, in patients with non-LBBB pattern with a QRS duration of 120-150 ms usually is not beneficial. After adjusting for QRS duration, QRS morphology was no longer a determinant of the clinical response to CRT. In contrast to the mainstream view, we hypothesized that the unfavorable CRT outcome in patients with non-LBBB and a QRS duration of 120-150 ms is not due to the QRS morphology itself, but to less dyssynchrony and unfavorable patient characteristics in this subgroup, such as more ischemic etiology and greater prevalence of male patients compared with patients with LBBB pattern. Further, the current CRT technique is devised to eliminate the dyssynchrony present in patients with LBBB pattern and inappropriate to eliminate the dyssynchrony in patients with non-LBBB pattern. We also hypothesized that electrocardiography may also provide information about the presence of interventricular and left intraventricular dyssynchrony and the approximate location of the latest activated left ventricular （LV） region. To this end, we devised new ECG criteria to estimate interventricular and LV intraventricular dyssynchrony and the approximate location of the latest activated LV region. Our preliminary data demonstrated that the latest activated LV region in patients with nonspecific intraventricular conduction disturbance （NICD） pattern might be at a remote site from that present in patients with LBBB pattern, which might necessitate the invention of a novel CRT technique for patients with NICD pattern. The application of the new interventricular and LV intraventricular dyssynchrony ECG criteria and a potential novel CRT technique might decrease the currently high nonresponder rate in patients with NICD pattern.

Clinical outcome of cardiac resynchronization therapy in dilated-phase hypertrophic cardiomyopathy

Backgrounds Clinical trials have demonstrated that cardiac resynchronization therapy （CRT） is effective in patients with ＂non-is- chemic cardiomyopathy＂. However, patients with dilated-phase hypertrophic cardiomyopathy （DHCM） have been generally excluded from such trials. We aimed to compare the clinical outcome of CRT in patients with DHCM, idiopathic dilated cardiomyopathy （IDCM）, or ischemic cardiomyopathy （ICM）. Methods A total of 312 consecutive patients （DHCM： n = 16; IDCM： n = 231; ICM： n = 65） undergoing CRT in Fuwai hospital were studied respectively. Response to CRT was defmed as reduction in left ventricular end-systolic volume （LVESV） _〉 15% at 6-month follow-up. Results Compared with DHCM, IDCM was associated with a lower total mortality （HR： 0.35, 95% CI： 0.13-0.90）, cardiac mortality （HR： 0.29; 95% CI： 0.11-0.77）, and total mortality or heart failure （HF） hospitalizations （HR： 0.34, 95% CI： 0.17-0.69）, independent of known confounders. Compared with DHCM, the total mortality, cardiac mortality and total mortality or HF hospitalizations favored ICM but were not statistically significant （HR： 0.59, 95% CI： 0.22-1.61; HR： 0.59, 95% CI： 0.21-1.63; HR： 0.54, 95% CI： 0.26-1.15; respectively）. Response rate to CRT was lower in the DHCM group than the other two groups although the differences didn＇t reach statistical significance. Conclusions Compared with IDCM, DHCM was associated with a worse outcome after CRT. The clinical outcome of DHCM patients receiving CRT was similar to or even worse than that of ICM patients. These indicate that DHCM behaves very differently after CRT.

Cardiac resynchronization therapy improved the clinical outcomes in pacemaker patients upgraded to biventricular device

The right ventricular pacing （RVP） is the standard treat- ment for patients with severe bradyarrhythmias; however, it may cause and exacerbate heart failure symptoms in a long run under some circumstances.{1] In fact, significant left ventricular （LV） systolic dysfimction and symptomatic heart failure （HF） is commonly found in patient population with pacemaker implantations.

Cardiac resynchronization therapy: Dire need for targeted left ventricular lead placement and optimal device programming

Cardiac resynchronization therapy(CRT) effected via biventricular pacing has been established as prime therapy for heart failure patients of New York Heart Association functional class Ⅱ, Ⅲ and ambulatory Ⅳ, reduced left ventricular(LV) function, and a widened QRS complex. CRT has been shown to improve symptoms, LV function, hospitalization rates, and survival. In order to maximize the benefit from CRT and reduce the number of non-responders, consideration should be given to target the optimal site for LV lead implantation away from myocardial scar and close to the latest LV site activation; and also to appropriately program the device paying particular attention to optimal atrioventricular and interventricular intervals. We herein review current data related to both optimal LV lead placement and device programming and their effects on CRT clinical outcomes.

Intermediate-term mortality and incidence of ICD therapy in octogenarians after cardiac resynchronization therapy

Background Clinical outcomes of cardiac resynchronization therapy （CRT） in patients over the age of 80 have not been well de-scribed.MethodsWe retrospectively identified 96 consecutive patients≥ 80 years old who underwent an initial implant or an upgrade to CRT, with or without defibrillator （CRT-Dvs. CRT-P）, at our institution between January 2003 and July 2008. The control cohort consisted of 177 randomly selected patients 〈 80 years old undergoing CRT implant during the same time period. The primary efficacy endpoint was all-cause mortality at 36 months, assessed by Kaplan-Meier time to first event curves.Results In the octogenarian cohort, mean age at CRT implant was 83.1 ± 2.9 yearsvs. 60.1 ± 8.8 years among controls （P 〈 0.001）. Across both groups, 70% were male, mean left ventricular ejection fraction （LVEF） was 24.8% ± 14.1% and QRS duration was 154 ± 24.8 ms, without significant differences between groups. Octo-genarians were more likely to have ischemic cardiomyopathy （74%vs. 37%,P 〈 0.001） and more likely to undergo upgrade to CRT instead of an initial implant （42%vs. 19%,P 〈 0.001）. The rate of appropriate defibrillator shocks was lower among octogenarians （14%vs. 27%,P = 0.02） whereas the rate of inappropriate shocks was similar （3%vs. 6%,P = 0.55）. At 36 months, there was no significant difference in the rate of all-cause mortality between octogenarians （11%） and controls （8%,P = 0.381）.ConclusionAppropriately selected octogenarians who are candidates for CRT have similar intermediate-term mortality compared to younger patients receiving CRT.

Cardiac resynchronization therapy in China

Congestive heart failure (HF) is a major and growing public health problem. The therapeutic approach includes non-pharmacological measures, pharmacological therapy,mechanical devices, and surgery. Despite the benefits of optimal pharmacologic therapy, the prognosis is still not ideal. At this time, cardiac resynchronization therapy (CRT)has gained wide acceptance as an alternative treatment for HF patients with conduction delay.1……

Cardiac resynchronization therapy in the elderly heart failure patient

Ms. BP is an 83 year old white female with a long history of congestive heart failure (HF). She is now symptomatic with minimal exertion, has a left ventricular ejection fraction (LVEF) of 20%. Her CHF is due to hypertension (HTN) plus coronary artery disease (CAD) and she is on angiotensin converting enzyme inhibitor (ACEI), furosemide, digoxin,spironolactone, low dose beta blocker and nitrates. Her beta-natriuretic peptide (BNP) in clinic is 3030 pg/ml, heart rate (HR) 100, blood pressure (BP) 89/43.

Determination of the optimal atrioventricular and interventricular delays in cardiac resynchronization therapy

Objective In order to provide the maximum benefit of cardiac resynchronization therapy(CRT),we tried to use an echocardiography method to optimize the atrioventricular and interventricular delay.Methods The study included 6 patients who underwent implantation of biventricular pacemakers for drug-resistant heart failure.Two-dimensional echocardiography and tissue Doppler imaging were carried out before and after the pacemaker implantation.The optimal AV delay was defined as the AV delay resulting in maximum timevelocity integral(TVI)of transmitral filling flow,the longest left ventricular filling time(LVFT)and the minimum mitral regurgitation(MR).The optimal VV delay was defined as the VV delay producing the maximum LV synchrony and the largest aortic TVI.Results CRT was successfully performed in all patients.After pacemaker implantation,an acute improvement in left ventricular ejection fraction(LVEF)was observed from 26.5%to 35%.Meanwhile,the QRS duration decreased from 170ms to 150ms.The optimal AV delay was programmed at 130,120,120,120,150 and 110ms respectively with heart rate corrected,LVFT significantly lengthened and TVI of MR decreased(non-optimal vs optimal AV delay:LVFT:469ms vs 523ms;TVI of MR:16.43cm vs 13.06cm,P<0.05).The optimal VV delay was programmed at 4,4,4,8,12 and 8ms with LV preactivation respectively.Programming the optimal VV delay increased the aortic TVI from 17.33cm up to 21.42cm(P<0.05).In the septal and lateral wall,peak systolic velocities improved from2.70cm/s to 3.02cm/s(P>0.05)and froml.31cm/s to 2.50cm/s(P<0.05)respectively.The septal-to-lateral delay in peak velocity improved from 56.4ms to 13.3ms after CRT(P<0.01).Conclusions Optimization of AV and VV delays may further enhance the efficacy of CRT.However,there was interindividual variability of optimal values,warranting individual patient examination.

Does it make sense evaluating cardiac resynchronization therapy in the elderly regardless of the type of the device？

We read the research article entitled Is cardiac resyn- chronisation therapy feasible, safe and beneficial in the very elderly？ with great interest. The authors emphasized that despite the average age of heart failure was 77 years in the general population of UK,patients receiving cardiac re- synchronisation therapy [with pacemaker alone （CRT-P） or with additional defibrillator capabilities （CRT-D）] were on younger ages at 72 and 67 years respectively. In the lights of this data, we agree with the authors that CRT seems to be undemtilized in the elderly patients with heart failure.

Predictors of persistence of functional mitral regurgitation after cardiac resynchronization therapy:Review of literature

Functional mitral regurgitation is a common finding among heart failure patients with ischemic and non-ischemic dilated cardiomyopathies.The presence of moderate or severe mitral regurgitation is associated with higher morbidity and mortality.Heart failure patients meeting electrocardiogram and left ventricle function criteria are good candidates for cardiac resynchronization therapy,which may reduce the degree of functional mitral regurgitation in the short and long term,specifically targeting myocardial dyssynchrony and inducing left ventricle reverse remodeling.In this article,we analyze data from the literature about predictors of mitral regurgitation improvement after cardiac resynchronization therapy implantation.

Six-Year Outcome after Valve Replacement and Resynchronization Therapy in TGA Patient

Patients with complete transposition of the great arteries(TGA)treated by the Senning procedure have a higher risk of developing heart failure due to:a)additional work load of the systemic(morphologic right)ventricle(sRV),b)arrhythmias,mainly caused by surgical implications at the atria as well as c)worsening of systemic tricuspid regurgitation.We present a unique case of a female patient who developed all these complications,who was successfully treated and was able to carry out a twin pregnancy.This breakthrough approach was based on:1.detecting reversibility potential of myocardial systolic dysfunction in a severe valvular lesion combined with continuous systemic afterload settings and permanent tachyarrhythmia,and 2.prevention of subsequently iatrogenic worsening of systemic ventricular function due to permanent pacing.Surgical replacement of systemic tricuspid valve(sTV)and cardiac resynchronization device(CRT)implantation after nodal ablation resulted in recovering of the systolic function and a positive remodeling of the sRV.The reversal of a further decline in systolic function was achieved by permanent arrhythmia control,synchronous pacing with epicardial leads of CRT,sTV replacement as well as echocardiographic monitoring during pregnancy to determine the right time for delivery.Two years after delivery,the patient remains in NYHA Class I.

Exercise Training Post Cardiac Resynchronization Therapy Improves Exercise Tolerance and Quality of Life

Background: Cardiac resynchronization therapy (CRT) results in improved morbidity, mortality, symptoms, quality of life (QOL) and exercise capacity, in appropriate chronic heart failure (CHF) patients. Moreover, combined exercise training (ET) and CRT maximize these improvements in these patients. The study evaluated the effect of ET on these patients in terms of QOL, functional class, exercise capacity and left ventricular ejection fraction (LVEF). Results: There were significant improvements in the QOL, functional class, exercise capacity, and LVEF compared with the Control Group. Comparison of both groups confirmed the cumulative effects of ET with CRT. The QOL improved by the end of training in the exercise group (p = 0.001), compared to the Control Group (p = 0.850). NYHA functional class improved significantly in the Exercise Group (p = 0.013). Percent-predicted peak oxygen consumption (VO2 peak) had significantly improved in the trained (p < 0.001) versus the untrained CRT Group (p= 0.596). There was a mean percent rise of the ejection fraction from 39.2 ± 12.86 to 44.40% ± 14.42% in the Exercise Group compared to a non-significant change in the Control Group. Conclusion: ET in resynchronized CHF patients is feasible and further enhances QOL and exercise tolerance in addition to the improvements seen after CRT. The study therefore recommends for the prescription of ET after implantation in order to maximize the expected benefit.

nitial Experience with MultiPoint Pacing Cardiac Resynchronization Therapy in China

Recently, cardiac resynchronization therapy （CRT） with multipoint left ventricular （LV） pacing in a single coronary sinus branch （MultiPointTM Pacing [MPP], St. Jude Medical, Inc., Sylmar, CA, USA） has been introduced commercially. The CRT system with MPP feature offers a new strategy for physicians to further enhance CRT in patients with heart failure. Early clinical studies have shown that MPP, compared with conventional biventricular （BiV） pacing, provides acute benefits to LV dP/dtmax, LV dyssynchrony, LV peak radial strain, and LV electrical activation, and improves CRT response at 12 months. In this report, we presented two MPP CRT cases in China with acute hemodynamic assessment under various MPP and conventional BiV pacing configurations, demonstrating that MPP can offer further benefits to patients.