In the major trials of cardiac resynchronization therapy (CRT), the survival benefit of the therapy, relative to control subjects, increases with QRS duration. In the non-CRT heart failure population, however, a wide QRS duration is associated with a shorter survival. Relative survival benefit from a therapy, however, is not synonymous with a longer absolute survival. We sought to determine whether baseline QRS duration relates to the absolute survival after CRT.Methods and Results In this prospective, longitudinal, observational study, 3,319 consecutive patients undergoing CRT (QRS 120-149 ms 26%, QRS 150-199 ms 58%, and QRS >= 200 ms 16%) were assessed in relation to mortality over 10 years. Overall mortality rates (per 100 patient-years) were 9.2%, 9.3%, and 13.3% in the 3 groups, respectively (all P < .001). Cardiac mortality rates were 6.2, 6.0, and 9.9 per 100 patient-years, respectively (all P < .001). Compared with the QRS 120-149 ms group, cardiac mortality was highest in the QRS >= 200 ms group (hazard ratio [HR] 1.72 [95% CI 1.35-2.19], P < .001), independent of age, gender, New York Heart Association class, presence of atrial fibrillation, heart failure etiology, and left ventricular ejection fraction. Median survival after CRT was longest in patients with a width of QRS 120-149 ms and shortest in patients with a QRS >= 200 ms (P < .001). In multivariable analyses, a QRS = 200 ms emerged as a powerful independent predictor of both overall (HR 1.44 [95% CI 1.07-1.94], P = .017) and cardiac mortality (HR 1.59 [95% CI 1.14-2.24], P = .007).Conclusions At long-term follow-up, absolute overall and cardiac survival after CRT is similar in patients with a preimplant QRS duration of 120 to 149 ms and 150 to 199 ms but markedly shorter in patients with a QRS >= 200 ms.

Objectives: To determine whether, in patients with atrial fibrillation (AF) undergoing cardiac resynchronization therapy (CRT), atrioventricular junction ablation (AVJA) is associated with a better outcome than treatment with rate-slowing drugs. Background: Different trial demonstrated that CRT is effective in heart failure (HF) patients who are in sinus rhythm (SR). No trials addressed whether CRT confers similar benefits in AF patients , with/without AVJA. Methods: The clinical outcome of CRT in patients with permanent AF undergoing CRT combined with either AVJA (n = 443) or rate-slowing drugs (n = 895) were compared with SR patients (n = 6,046). Results: Median follow-up of 37 months: total (6.8 vs 6.1 per 100 person year) and cardiac mortality (4.2 vs 4.0) (both p = NS) were similar in patients with AF+AVJA and patients in SR. In contrast, the AF+drugs group had a higher total and cardiac mortality than the SR and the AF+AVJA groups (11.3 and 8.1 , respectively; p Conclusions: Long term survival after CRT in patients with AF+AVJA is similar to that observed in patients in SR. Mortality is higher in AF patients treated with rate-slowing drugs.

BackgroundUntil now, there is no consensus regarding the definition of a clinical response to cardiac resynchronization therapy (CRT) in patients with chronic heart failure (CHF) and systolic left ventricular (LV) dysfunction. The aim of this study was to evaluate if echocardiography is predictive for an objective improvement in exercise capacity during long‐term follow‐up of CRT.MethodsEach patient underwent echocardiography and spiroergometry both at baseline and at last follow‐up. Left ventricular dyssynchrony (LVD) before CRT was defined by tissue Doppler imaging (TDI) as intra‐LV delay ≥40 msec (septal‐lateral or anterior‐posterior). Clinical response to CRT was defined as increase of peakVO2 or as increase of maximal workload >10% as compared to baseline.ResultsMean follow‐up was 69 ± 37 months. From the 238 consecutive patients included in the study, 141 (59%) were classified as clinical responders and 97 (41%) as nonresponders. Baseline data of responders and nonresponders were comparable. However, clinical responders showed more often LVD (64%) than nonresponders (42%, P = 0.004). On multivariate regression analysis, nonischemic origin of CHF (β‐coefficient in the final model 0.1, P = 0.04) and LVD at baseline (β‐coefficient in the final model 0.2, P < 0.001) were independently associated with clinical response during long‐term follow‐up. Patients with LVD at baseline had significant more often an improvement of left ventricular ejection fraction >10% (P = 0.02) and a reduction of left ventricular end‐diastolic diameter (LVEDD) >10% (P < 0.01) than patients without LVD at baseline.ConclusionsLVD at baseline as assessed by a straightforward echocardiographic approach predicts the long‐term clinical response to CRT and is associated with a more pronounced reverse LV remodeling.

Objectives The purpose of this study is to determine whether, in patients with atrial fibrillation (AF) undergoing cardiac resynchronization therapy (CRT), atrioventricular junction ablation (AVJA) is associated with a better outcome than treatment with rate-slowing drugs.Background Different trials have demonstrated that CRT is effective in treating heart failure (HF) patients who are in sinus rhythm (SR). No trials have addressed whether CRT confers similar benefits on AF patients, with or without AVJA.Methods The clinical outcomes of CRT for patients with permanent AF undergoing CRT combined with either AVJA (n = 443) or rate-slowing drugs (n = 895) were compared with those of SR patients (n = 6,046).Results Median follow-up was 37 months. Total mortality (6.8 vs. 6.1 per 100 person-years) and cardiac mortality (4.2 vs. 4.0) were similar for patients with AF+AVJA and patients in SR (both p = NS). In contrast, the AF+drugs group had a higher total and cardiac mortality than the SR group and the AF+AVJA group (11.3 and 8.1, respectively; p < 0.001). On multivariable analysis, AF+AVJA had total mortality (hazard ratio [HR]: 0.93, 95% confidence interval [Cl]: 0.74 to 1.67) and cardiac mortality (HR: 0.88, 95% Cl: 0.66 to 1.17) similar to that of the SR group, independent of known confounders. The AF+drugs group, however, had a higher total mortality (HR: 1.52, 95% Cl: 1.26 to 1.82) and cardiac mortality (HR: 1.57, 95% Cl: 1.27 to 1.94) than both the SR group and the AF+AVJA group (both p <0.001).Conclusions Long-term survival after CRT among patients with AF+AVJA is similar to that observed among patients in SR. Mortality is higher for AF patients treated with rate-slowing drugs. (1 Am Coll Cardiol HF 2013;1:500-7) 2013 by the American College of Cardiology Foundation

Objective: To analyze whether left ventricular dyssynchrony (LVD) at baseline is predictive for long-term outcome in heart failure (CHF) patients with left ventricular (LV) dysfunction and conduction disturbances treated with cardiac resynchronization therapy (CRT).Methods: In 535 consecutive individuals with CHF scheduled for implantation of a CRT device, LVD was assessed by tissue Doppler imaging (TDI), defined as an electromechanical delay (EMD) difference of >= 40 ms in 2 opposed left ventricular wall regions (septal vs. lateral, anterior vs. inferior). All-cause mortality, heart transplantation, or assist device implantation was defined as combined primary end point. Secondary end points were measures of reverse LV remodeling and of symptomatic improvement.Results: Mean follow-up was 68 +/- 36 [range: 4-150] months. LVD at baseline was present in 308 patients (61%). Of these, 24% reached the combined primary endpoint in contrast to 58% of patients without LVD (p < 0.001). Furthermore, patients with LVD showed pronounced improvement of all secondary end point parameters. In our cohort LVD was an independent predictor for outcome (hazard ratio [95% CI]: 0.30 [0.21-0.42], p < 0.001).Conclusions: LVD at baseline as assessed by TDI is associated with a more pronounced clinical improvement and is a predictor for transplant-free long-term survival in CRT recipients. (C) 2013 Elsevier Ireland Ltd. All rights reserved.

Aim s: To analyze whether left ventricular dyssynchrony (LVD) at baseline is predictive for long-term outcome in heart failure (CHF) patients with left ventricular (LV) dysfunction and conduction disturbances treated with cardiac resynchronization therapy (CRT). Methods: In 504 consecutive individuals with CHF scheduled for implantation of a CRT device, LVD was assessed by tissue Doppler imaging (TDI), defined as an electromechanical delay (EMD) difference of ≥40 ms in 2 opposed left ventricular wall regions (septal vs. lateral, anterior vs. inferior). All-cause mortality, heart transplantation, or assist device implantation was defined as combined primary end point. Secondary end points were measures of reverse LV remodeling and of symptomatic improvement. Results: Mean follow-up was 68±36 months. LVD at baseline was present in 308 patients (61%). Of these, 24% reached the combined primary endpoint in contrast to 58% of patients without LVD (p<0.001). Furthermore, patients with LVD showed pronounced improvement of all secondary end point parameters. An independent association was found between outcome, LVD (β-coefficient in the final model 0.4, p<0.001), and gender (β-coefficient in the final model 0.2, p=0.002). Conclusions: LVD at baseline as assessed by TDI is associated with more pronounced reverse LV remodeling and seems to be a predictor for transplant-free long-term survival in CRT recipients.

We sought to determine whether correction of mechanical left ventricular (LV) dyssynchrony as defined by tissue Doppler imaging (TDI) is predictive for transplant-free long-term survival in patients (pts.) undergoing cardiac resynchronization therapy (CRT). In 76 CRT recipients TDI curves from the septal, lateral, anterior, and inferior basal LV were obtained at baseline and after 6 ± 4 months. A time difference between regional electromechanical delays (EMD) of ≥40 ms was considered dyssynchronous. At follow-up, pts. were classified as TDI-responders (TDI-R: dyssynchrony at baseline, corrected by CRT) versus non-responders (TDI-NR: either not dyssynchronous at baseline, or persisting dyssynchrony). Pts. were then followed by standard echocardiography over 21 ± 6 months and were re-classified as LV remodelers (LV-R: LV volume reduction of >10%) versus non-remodelers (LV-NR). The end-point during clinical long-term follow-up of 65 ± 38 months was all-cause mortality or heart transplantation. 44 out of the 76 pts. (58%) were classified as TDI-R, 32 (42%) as TDI-NR. Significant reverse LV remodeling was observed in 41 (54%) pts., while 35 (46%) did not improve LV size and function. TDI-R was associated with LV-R in 35 pts. (85%; P < 0.001). During long-term follow-up, 38 pts. (50%) reached the end point, 11 (30%) in the TDI-R group, and 27 (70%) in the TDI-NR group (P < 0.0003). Mechanical resynchronization as defined by TDI translates into a significant survival benefit in CRT recipients.

BACKGROUND:Multi-slice computed tomography (MSCT) was proved to provide precise cardiac volumetric assessment. Cardiac resynchronization therapy (CRT) is an effective treatment for selected patients with heart failure and reduced ejection fraction (HFREF). In HFREF patients we investigated the potential of MSCT based wall motion analysis in order to demonstrate CRT-induced reversed remodeling. METHODS:Besides six patients with normal cardiac pump function serving as control group seven HFREF patients underwent contrast enhanced MSCT before and after CRT. Short cardiac axis views of the left ventricle (LV) in end-diastole (ED) and end-systole (ES) served for planimetry. Pre- and post-CRT MSCT based volumetry was compared with 2D echo. To demonstrate CRT-induced reverse remodeling, MSCT based multi-segment color-coded polar maps were introduced. RESULTS:With regard to the HFREF patients pre-CRT MSCT based volumetry correlated with 2D echo data for LV-EDV (MSCT 278.3+/-75.0mL vs. echo 274.4+/-85.6mL) r=0.380, p=0.401, LV-ESV (MSCT 226.7+/-75.4mL vs. echo 220.1+/-74.0mL) r=0.323, p=0.479 and LV-EF (MSCT 20.2+/-8.8% vs. echo 20.0+/-11.9%) r=0.617, p=0.143. Post-CRT MSCT correlated well with 2D echo: LV-EDV (MSCT 218.9+/-106.4mL vs. echo 188.7+/-93.1mL) r=0.87, p=0.011, LV-ESV (MSCT 145+/-71.5mL vs. echo 125.6+/-78mL) r=0.84, p=0.018 and LV-EF (MSCT 29.6+/-11.3mL vs. echo 38.6+/-14.6mL) r=0.89, p=0.007. There was a significant increase of the mid-ventricular septum in terms of absolute LV wall thickening of the responders (pre 0.9+/-2.1mm vs. post 3.3+/-2.2mm; p<0.0005). CONCLUSION:MSCT based volumetry involving multi-segment color-coded polar maps offers wall motion analysis to demonstrate CRT-induced reverse remodeling which needs to be further validated.

The purpose of this study is to assess the incremental value of tissue Doppler (TDI) derived displacement curves (TDint) compared to TDI velocity curves (TDvel) for the evaluation of left ventricular (LV) dyssynchrony (LVD). About 25 patients (pts.) with systolic heart failure were studied by TDvel and TDint. Four TDI sample volumes were placed at the basal and four at the mid ventricular myocardium, utilising two imaging planes. LV dyssynchrony (LVD) was defined as an interregional delay of >40 ms corrected for heart rate. 10 pts. had synchronous contraction, 15 pts. LVD as defined by two experts (EC). To determine diagnostic accuracy and intra-observer variability two identical sets of 100 documents (25 pts. x two imaging planes x two modalities) were produced and presented in random order to one trained (TR) and two untrained (UR) readers. The TR more frequently classified documents as unreadable (7.5 vs. 3.5%, P < 0.05) but more often as correct, i.e., consistent with EC (72.0 vs. 57.8%, P < 0.001). 8.7% of the documents were classified as unreadable using TDvel, 1.0% when applying TDint (P < 0.001). The mean value of correct classification of all 3 readers was 54.3% (TDvel only), 70.7% (TDint only), and 77.7% (combining both modalities), (P < 0.001). The kappa value for TR and TDint was 0.68, for TDvel 0.29. For UR, kappa did not differ (TDint: 0.58; TDvel 0.51). TDint is superior to TDvel in accuracy, reproducibility, and applicability for skilled and unskilled investigators when evaluating LVD by TDI. The combined application of TDint and TDvel is optimal.

INTRODUCTION:In grading mitral regurgitation (MR) magnetic resonance imaging is the gold standard but 2D echo is mostly used in clinical practice. However, each single echo parameter is prone to confounding influences. With regard to chronic primary and secondary MR the purpose of this study was to compare a new multi-dimensional echo-based grading system with an independent pre-operatively used invasive standard.METHODS:In a retrospective study we analyzed 177 patients with different degrees of MR severity, who were examined both by echocardiography and by cardiac catheterization. For MR grading a combination of four echocardiographic parameters was used: density of the regurgitation velocity profile, peak mitral inflow velocity (Vmax E-wave), radius of the proximal flow convergence zone (PISA), and vena contracta (Vc) width. Invasive grading was based on left ventriculography (Seller's method), V wave hight, and regurgitation fraction. Both methods resulted in an integrative score on an eight point scale (<I-IV in half-steps). Echocardiographic and invasive data were correlated.RESULTS:There was a reasonable overall correlation of r = 0.72 (p = 0.001) between both grading systems. Echo tended to slightly overestimate MR severity. In patients with secondary MR, agreement was worse (p = 0.01) than in primary MR. The most powerful single echo parameter was Vc r = 0.71 (p = 0.001). Presence or absence of sinus rhythm had no significant influence on echo grading.CONCLUSIONS:The proposed echocardiographic multidimensional MR grading system is feasable and shows good correlation with invasive grading.

Aims To investigate the effects of cardiac resynchronization therapy (CRT) on survival in heart failure (HF) patients with permanent atrial fibrillation (AF) and the role of atrio-ventricutar junction (AVJ) ablation in these patients.Methods and results Data from 1285 consecutive patients implanted with CRT devices are presented: 1042 patients were in sinus rhythm (SR) and 243 (19%) in AF Rate control in AF was achieved by either ablating the AVJ in 118 patients (AVJ-abl) or prescribing negative chronotropic drugs (AF-Drugs). Compared with SR, patients with AF were significantly older, more likely to be non-ischaemic, with higher ejection fraction, shorter QRS duration, and less often received ICD back-up. During a median follow-up of 34 months, 170/1042 patients in SR and 39/243 in AF died (mortality: 8.4 and 8.9 per 100 person-year, respectively). Adjusted hazard ratios were similar for all-cause and cardiac mortality [0.9 (0.57-1.42), P = 0.64 and 1.00 (0.60-1.66) P = 0.99, respectively]. Among AF patients, only 11/118 AVJ-abl patients died vs. 28/125 AF-Drugs patients (mortality: 4.3 and 15.2 per 100 person-year, respectively, P < 0.001). Adjusted hazard ratios of AVJ-abl vs. AF-Drugs was 0.26 [95% confidence interval (CI) 0.09-0.73, P = 0.010] for all-cause mortality, 0.31 (95% CI 0.10-0.99, P = 0.048) for cardiac mortality, and 0.15 (95% CI 0.03-0.70, P = 0.016) for HF mortality.Conclusion Patients with HF and AF treated with CRT have similar mortality compared with patients in SR. In AF, AVJ ablation in addition to CRT significantly improves overall survival compared with CRT alone, primarily by reducing HF death.

Mitral regurgitation (MR) can be found in a sizeable percentage of patients with chronic congestive heart failure (CHF) and systolic left ventricular (LV) dysfunction despite a structurally normal valve. This functional or secondary regurgitation results from a dysbalance between closing and opening forces on the mitral leaflets due to reduced LV contractility, geometric distortion of the subvalvular apparatus, and global dilatation of the left ventricle and the mitral annulus. MR in LV dysfunction has a negative impact on both symptoms and prognosis. Surgical correction of secondary MR remained controversial although it was found to be technically feasible and to provide symptomatic benefit in some (mostly) mono-center series. Cardiac resynchronization therapy (CRT) was also found to improve secondary mitral regurgitation. However, the prediction in which patient significant secondary MR will improve with CRT is largely unresolved. The following paper reviews the available data concerning the two major interventional options for significant secondary MR in patients with CHF and systolic LV dysfunction, i.e. mitral valve surgery vs. CRT, and describes our institutional approach to this problem.