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.

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.

Left bundle branch pacing with optimization of cardiac resynchronization treatment:A case report

BACKGROUND Cardiac resynchronization therapy(CRT)is a well-established therapy for patients with cardiomyopathy.CASE SUMMARY The patient underwent left bundle branch area and left ventricular(reaching the left ventricular lateral vein through the coronary sinus)pacing.The optimal CRT was performed under the right bundle branch of the patient by adjusting the optimal a-v and v-v interphases to achieve the maximal benefit of the treatment.CONCLUSION The patient was diagnosed with left bundle branch block and heart failure.A left bundle branch area pacemaker assisted in correcting the complete left bundle branch block.However,the shorter QRS wave shape after pacemaker implantation through the left bundle branch area indicated a complete right bundle branch block pattern.Hence,the left bundle branch area pacemaker is not always considered as the optimal treatment.The left bundle branch pacing with the optimization of cardiac resynchronization treatment may serve as a new CRT strategy.

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.

Successful upgrade to cardiac resynchronization therapy for cardiac implantation-associated left subclavian vein occlusion:A case report

BACKGROUND Subclavian vein stenosis or occlusion may be caused by a transvenous pacemaker,which makes the reimplantation of a new pacemaker lead difficult.Transvenous pacemaker lead implantation-related subclavian vein occlusion may present difficulty with regard to cardiac resynchronization therapy(CRT)upgrade.CASE SUMMARY We report the case of a 46-year-old man who was admitted with total subclavian vein occlusion caused by a permanent pacemaker that had been implanted 2 years previously.We successfully treated this patient with an upgrade to a CRT pacemaker by utilizing transferable interventional coronary and radiological techniques.The patient recovered uneventfully during the follow-up period.CONCLUSION CRT upgrade is still a viable technique for the treatment of subclavian vein obstruction caused by previous pacemaker implantation.

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.

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.

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.

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.

Role of nuclear cardiology for guiding device therapy in patients with heart failure

Heart failure is a dynamic condition with high morbidity and mortality and its prognosis should be reassessed frequently, particularly in patients for whom critical treatment decisions may depend on the results of prognostication. In patients with heart failure, nuclear cardiology techniques are useful to establish the etiology and the severity of the disease, while fewer studies have explored the potential capability of nuclear cardiology to guide cardiac resynchronization therapy(CRT) and to select patients for implantable cardioverter defibrillators(ICD). Left ventricular synchrony may be assessed by radionuclide angiography or gated singlephoton emission computed tomography myocardial perfusion scintigraphy. These modalities have shown promise as predictors of CRT outcome using phase analysis. Combined assessment of myocardial viability and left ventricular dyssynchrony is feasible using positron emission tomography and could improve conventional response prediction criteria for CRT. Preliminary data also exists on integrated positron emission tomography/computed tomography approach for assessing myocardial viability, identifying the location of biventricular pacemaker leads, and obtaining left ventricular functional data, including contractile phase analysis. Finally, cardiac imaging with autonomic radiotracers may be useful in predicting CRT response and for identifying patients at risk for sudden cardiac death, therefore potentially offering a way to select patients for both CRT and ICD therapy. Prospective trials where imaging is combined with image-test driven therapy are needed to better define the role of nuclear cardiology for guiding device therapy in patients with heart failure.

Temporary coronary sinus pacing to improve ventricular dyssynchrony with cardiogenic shock: A case report

BACKGROUND Temporary transvenous pacing through the coronary sinus is a novel approach rarely used in treating unstable bradycardia.This modality could provide cardiac pacing while achieving better ventricular synchrony.We present a case who received cardiac pacing through the coronary sinus and provide a summary of evidence in the current literature.CASE SUMMARY A 55-year-old woman with a history of advanced heart failure was admitted to the rehabilitation ward after a recent stroke.During hospitalization,she had paroxysmal atrial fibrillation with rapid ventricular response resulting from fluid overload.While atrial fibrillation was spontaneously reversed to sinus rhythm after diuresis,she developed multiple episodes of polymorphic ventricular tachycardia along with sinus bradycardia and prolonged QTc interval.She became hypotensive despite appropriate medical management.Pacing through her implantable cardioverter-defibrillator was attempted but worsened her hypotension.Ventricular dyssynchrony was suspected.Temporary transvenous atrial pacing through the coronary sinus was performed,which stabilized her blood pressure and improved end-organ perfusion.A permanent biventricular pacemaker was later implanted,and she was safely discharged to a nursing home.CONCLUSION Temporary transvenous pacing through the coronary sinus,a novel approach to treat unstable bradycardia,may reduce ventricular dyssynchrony.

Left bundle branch pacing in a ventricular pacing dependent patient with heart failure:A case report

BACKGROUND Left bundle branch pacing(LBBP)is a physiological pacing method that has emerged in recent years.It is an ideal choice for patients with complete left bundle branch block who are in need of cardiac resynchronization therapy(CRT).Moreover,LBBP is superior in maintaining physiological ventricular activation and can effectively improve heart function and quality of life in patients with pacemaker-induced cardiomyopathy.However,LBBP in pacing-dependent patients who already have cardiac dysfunction has not been well assessed.CASE SUMMARY A 69-year-old male patient presented with symptoms of chest tightness,palpitation and systolic heart failure with New York Heart Association class III for 1 mo.The 12-lead electrocardiogram showed atrial fibrillation with third-degree atrioventricular block and ventricular premature beat.Holter revealed a right bundle branch block,atrial fibrillation with third-degree atrioventricular block,frequent multifocal ventricular premature beats,Ron-T and ventricular tachycardia.The echocardiogram documented an enlarged left atrium and left ventricle and a low left ventricular ejection fraction.Coronary angiography indicated a stenosis of 30%in the middle left anterior descending artery.Apparently,a CRT-D pacemaker was the best choice for this patient according to previous findings.However,the patient was worried about the financial burden.A single-chamber pacemaker with LBBP was selected,with the plan to take amiodarone and upgrade with dual-chamber implantable cardioverter-defibrillator or CRT-D at an appropriate time.During the follow-up at 3 mo after LBBP,the patient showed an improvement in cardiac function with slight improvement in echocardiography parameters,and the New York Heart Association functional class was maintained at I.Moreover,the patient no longer suffered from chest tightness and palpitation.Holter showed decreased ventricular arrhythmia of less than 5%.CONCLUSION LBBP might be used in patients with heart failure and a high-degree atrioventricular block as an alternative to conventional CRT.

Validation of a Marker of Atrial Contraction in the SonR Signal

Introduction: The main component of the endocardial acceleration signal (SonR) is today used for cardiac resynchronization therapy (CRT) optimization. This prospective, single center pilot study focuses on another signal component, SonR4 that may provide further information on the atrial activity. Methods and Results: SonR signal and ECG tracings were recorded simultaneously during a CRT-D optimization procedure in 15 patients (12 men, 68 ± 9.5 years, ischemic heart disease 53%) indicated for CRT. Correlation between SonR4 signal, recorded using SonR and atrial contraction, identified by Echo Doppler was evaluated by Pearson and Student’s t tests under different Atrio-Ventricular (AV) delay programming. From 15 consecutive screened patients, 9 had concomitant analyzable SonR4 and ECG recordings and were included in the study population. The presence of the SonR4 component was systematically correlated to the presence of the A wave. A significant correlation was observed between SonR4 and A wave timings (r = 0.75, p = 0.02) according to different AV delays, with a high reproducibility in SonR4 assessment. Conclusion: A strong correlation between SonR4 and atrial contraction timings was observed, further suggesting that SonR4 is a marker of the atrial contraction. Additional assessments in larger populations are required to confirm these results and build further applications.

The role of device therapy in heart failure with reduced ejection fraction(HFrEF) : a narrative review

Heart failure has gained increasing notice due to its high prevalence and mortality rate. The management for heart failure has been emphasized on the role of device therapy. Implantable cardioverter defibrillator(ICD) and cardiac resynchronization therapy(CRT) were given strong recommendation for heart failure with reduced ejection fraction(HFrEF), considering their effectiveness on preventing sudden cardiac death(SCD), improving cardiac function and benefiting survival. In this review, we explained the underlying mechanisms of disease initiation and progression in HFrEF, in order to build the connection between the pathological basis of HFrEF and the rationality of ICD and CRT on terminating ventricular arrhythmia, improving cardiac function, decreasing the rate of adverse clinical outcomes and benefiting survival. In addition, we discussed the high-quality researches with significant values on the discovery of device therapy clinical benefits, and compared the class I recommendations for device therapy in HFr EF, suggested by American Heart Association and European Society of Cardiology.