ABSTRACT
Since the implementation of cardiac resynchronization therapy (CRT) the prognosis of patients with severe heart failure has been improved owing to a reduction in morbidity and mortality rates, as several multicenter trials have shown. However, several patients treated by CRT still lack improvement or even deteriorate during therapy. In some of them, this might be due to the severity and progression of chronic heart failure. In others, the criteria for the indication of CRT and/or optimized device programming might have not been met. Thus, one important option to improve CRT outcome is to improve CRT patient selection. A lot of publications describing various methods identifying a positive or negative prediction of CRT have been released. In summary, decision making based on all these partly contradictory publications indicate a strong need for guidelines for the use of such expensive therapy. The purpose of this article is to give an overview of CRT and summarize the different methods and the limitations of CRT patient selection parameters. With the focus of the different guidelines, this article tries to give an appropriate overview and aid decision making in CRT patients, including a short view of possible new indications.
Subject(s)
Cardiac Pacing, Artificial/methods , Heart Failure/therapy , Patient Selection , Atrial Fibrillation , Disease Progression , Health Status , Heart Failure/diagnostic imaging , Heart Failure/mortality , Humans , Long QT Syndrome , Prognosis , Risk Assessment , Risk Factors , Severity of Illness Index , Time Factors , Treatment Outcome , Ultrasonography , United StatesSubject(s)
Arrhythmias, Cardiac/diagnosis , Coronary Artery Bypass , Coronary Restenosis/diagnosis , Electrocardiography, Ambulatory , Graft Occlusion, Vascular/diagnosis , Myocardial Infarction/surgery , Postoperative Complications/diagnosis , Aged , Arrhythmias, Cardiac/etiology , Arrhythmias, Cardiac/therapy , Bradycardia/diagnosis , Bradycardia/etiology , Bradycardia/therapy , Combined Modality Therapy , Coronary Restenosis/therapy , Defibrillators, Implantable , Diagnosis, Differential , Graft Occlusion, Vascular/therapy , Humans , Male , Pacemaker, Artificial , Patient Care Team , Postoperative Complications/etiology , Postoperative Complications/therapy , Signal Processing, Computer-Assisted , Tachycardia, Ventricular/diagnosis , Tachycardia, Ventricular/etiology , Tachycardia, Ventricular/therapy , Wolff-Parkinson-White Syndrome/diagnosis , Wolff-Parkinson-White Syndrome/etiology , Wolff-Parkinson-White Syndrome/therapyABSTRACT
Normal ejection fraction (EFs) is often equated with normal systolic function. However, midwall mechanics reveal systolic dysfunction in hypertensive heart disease accompanied by hypertrophic remodeling. Midwall mechanics are unstudied in patients with acute diastolic heart failure (HF). This study analyzed left ventricular (LV) midwall stress-shortening relations in 61 patients aged >60 years with hypertensive heart disease, HF, and normal EF. Sixty-one hypertensive patients (mean age 78 +/- 10 years) who presented with HF, each with an EF >50%, underwent echocardiography. Midwall mechanics were compared with those of 79 controls (mean age 75 +/- 8 years) without structural heart disease. Relative wall thickness (0.63 +/- 0.11 vs 0.46 +/- 0.10 mm) and LV mass (237 +/- 67 vs 177 +/- 57 g) were significantly greater in patients with HF compared with controls. Mean EFs were similar in patients with HF and controls (64 +/- 9% vs 67 +/- 9%). Although mean endocardial fractional shortening (35 +/- 7% vs 37 +/- 7%) was not significantly different, midwall shortening in patients with HF was significantly less compared with controls (16 +/- 2% vs 19 +/- 3%, p <0.05). Eighteen of the 61 patients with HF (30%) had midwall shortening that was <95% confidence intervals of the normal midwall stress-shortening relations. By this criterion, these patients had systolic dysfunction despite normal EF; they had smaller LV chambers (in dimension and volume), greater relative wall thickness, and smaller stroke volumes. In conclusion, almost 1/3 of patients hospitalized with diastolic HF had systolic dysfunction, characterized by abnormal midwall stress-shortening relations.
