Cardiac resynchronization therapy and bone marrow cell transplantation in patients with ischemic heart failure and electromechanical dyssynchrony: a randomized pilot study.

Most studies have confirmed the beneficial effects of autologous bone marrow mononuclear cell (BMMC) transplantation on angina, myocardial perfusion, regional wall motion, and LV ejection fraction (LVEF). Cardiac resynchronization therapy (CRT) has also shown a beneficial effect in patients with heart failure (HF) and electrical/mechanical dyssynchrony. However, the relative contribution of BMMC and CRT in patients with ischemic HF and electromechanical dyssynchrony has never been investigated. The aim of this study was to evaluate the benefit of combining BMMC transplantation with CRT in patients with severe ischemic HF, left bundle branch block (LBBB), and mechanical dyssynchrony. Patients with ischemic HF, LVEF < 35%, LBBB, and mechanical dyssynchrony underwent intramyocardial transplantation of BMMC and CRTD system implantation. This randomized, single-blind, crossover study compared clinical and echocardiographic parameters during two follow-up periods: 6 months of active CRT (BMMC + CRTact) and 6 months of inactive CRT (BMMC + CRTinact). Physical performance was assessed by means of a 6-min walking test. Myocardial perfusion was evaluated by SPECT. Quality of Life (QoL) was assessed through the Minnesota Living with HF Questionnaire (MLwHFQ). Twenty-six patients (64 ± 7 years) were enrolled in the study. The distance covered by the patients during the 6-min walking test significantly increased in the BMMC + CRTinact phase (BMMC therapy only) in comparison with the baseline (269 ± 68 vs 206 ± 51; p = 0.007) and in the BMMC + CRTact phase (BMMC therapy + CRT) in comparison with the BMMC + CRTinact (378 ± 59 vs 269 ± 68; p < 0.001). The summed rest and stress score (SPECT) decreased significantly in the BMMC + CRTact and BMMC + CRTinact phases in comparison with the baseline (p ≤ 0.03). Both phases showed equivalent myocardial perfusion in the segments into which BMMC had been injected. QoL score was significantly lower in the BMMC + CRTinact phase than at the baseline (44.1 ± 14 vs 64.8 ± 19; p < 0.001), and in the BMMC + CRTact phase than in the BMMC + CRTinact phase (26.4 ± 12 vs 44.1 ± 14; p = 0.004). BMMC and CRT seem to act independently on myocardial perfusion and electromechanical dyssynchrony, respectively. Combining these two complementary therapies can significantly improve LV performance in patients with severe HF and electromechanical dyssynchrony.

Coronary artery bypass grafting with and without concomitant epicardial cardiac resynchronization therapy in patients with ischemic cardiomyopathy: a randomized study.

BACKGROUND: Epicardial implantation of a cardiac resynchronization therapy (CRT) system during coronary artery bypass grafting (CABG) may be an additional treatment method for improving left ventricle (LV) systolic function and dyssynchrony in patients with ischemic heart failure. OBJECTIVE: The objective was to compare the long-term results in patients with severe ischemic heart failure who underwent CABG alone or CABG combined with concomitant epicardial implantation of a CRT system. METHODS: One hundred sixty-four consecutive patients with severe ischemic heart failure and LV dyssynchrony were enrolled into 2 groups: CABG alone (n = 80) and epicardial CRT implantation during CABG (CABG + CRT) (n = 84). This prospective, randomized, and single-blind study was designed to compare clinical and echocardiography data after 6, 12, and 18 months of follow-up. RESULTS: In the CABG group, LV systolic function, dyssynchrony signs, and quality of life did not change postoperatively, compared with preoperative data. In contrast, these parameters significantly improved in the CABG + CRT group. The 2 treatment groups did not differ with respect to postoperative improvement in Canadian Cardiovascular Society class (P = .68). The improvement in the New York Heart Association functional class was much more pronounced in the CABG + CRT group than in the CABG group (P = .029). In the CABG group, 21 patients (26.2%) had died by the 18-month follow-up, compared with 9 patients (10.7%) in the CABG + CRT group (P = .012, log-rank test). CONCLUSION: Epicardial implantation of a CRT system concomitantly with CABG facilitates the early postoperative period, improves LV systolic function, improves the quality of life, and decreases LV dyssynchrony. Moreover, mortality in the CABG + CRT group was significantly lower than in the CABG group.

Coronary artery bypass grafting with concomitant cardiac resynchronisation therapy in patients with ischaemic heart failure and left ventricular dyssynchrony.

OBJECTIVE: We have tested the hypothesis that epicardial implantation of cardiac resynchronisation therapy (CRT) system during coronary artery bypass grafting (CABG) may be an additional treatment method, which can decrease the mortality and improve left ventricle (LV) systolic function in patients with ischaemic heart failure (HF) and LV dyssynchrony. METHODS: One hundred and seventy-eight consecutive patients with severe ischaemic HF and LV dyssynchrony were enrolled in two groups: CABG alone (n=87) and epicardial CRT implantation during CABG (n=91). The primary end point of the study was the comparison of mortality between two groups at 18 months of follow-up. RESULTS: Twenty-three patients (26.1%) in the CABG group died at 18 months of follow-up compared with nine (10%) in CABG+CRT group (log-rank test, p=0.006). The Cox regression analysis revealed that LV dyssynchrony (hazard ratio (HR) 2.634 (1.206-5.751), p=0.015) was the independent predictor of all-cause death and HF hospitalisation. LV systolic function, dyssynchrony signs and quality of life did not change significantly post-CABG compared to pre-CABG data in CABG group patients. On the contrary, echocardiography revealed an improved LV ejection fraction (42±1.9 vs 28±2.7; p<0.001), smaller LV end-systolic volume (120±57.5 vs 164±61.4; p=0.04) and improved LV synchrony in the CABG+CRT group compared with the CABG group. In the CABG+CRT group, more patients improved by two NYHA classes (NYHA, New York Heart Association; 49 vs 0; p=0.028), had a longer 6-min-walk test distance (452±65 vs 289±72; p<0.001) and a better quality of life (22.9±5 vs 46.4±11; p<0.001) compared with the CABG group. CONCLUSION: For majority of the patients with ischaemic HF and evidence of LV dyssynchrony, CABG neither eliminates dyssynchrony nor improves systolic function. Epicardial implantation of a CRT system concomitant with CABG facilitates patient management in the early postoperative period, improves LV systolic function and quality of life and is associated with low mortality at 18 months of follow-up.