Niels Risum1, Bhupendar Tayal2, Thomas F Hansen3, Niels E Bruun4, Magnus T Jensen5, Trine K Lauridsen3, Samir Saba6, Joseph Kisslo7, John Gorcsan6, Peter Sogaard8. 1. Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark. Electronic address: nielsrisum@gmail.com. 2. Division of Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Cardiology and Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark. 3. Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark. 4. Division of Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark. 5. Department of Cardiology, Holbæk Hospital, Holbæk, Denmark. 6. Division of Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania. 7. Division of Cardiovascular Medicine, Duke University Medical Center, Durham, North Carolina. 8. Department of Cardiology and Clinical Medicine, Aalborg University Hospital, Aalborg, Denmark.
Abstract
BACKGROUND: Current guidelines suggest that patients with left bundle branch block (LBBB) be treated with cardiac resynchronization therapy (CRT); however, one-third do not have a significant activation delay, which can result in nonresponse. By identifying characteristic opposing wall contraction, 2-dimensional strain echocardiography (2DSE) may detect true LBBB activation. OBJECTIVES: This study sought to investigate whether the absence of a typical LBBB mechanical activation pattern by 2DSE was associated with unfavorable long-term outcome and if this is additive to electrocardiographic (ECG) morphology and duration. METHODS: From 2 centers, 208 CRT candidates (New York Heart Association classes II to IV, ejection fraction ≤35%, QRS duration ≥120 ms) with LBBB by ECG were prospectively included. Before CRT implantation, longitudinal strain in the apical 4-chamber view determined whether typical LBBB contraction was present. The pre-defined outcome was freedom from death, left ventricular assist device, or heart transplantation over 4 years. RESULTS: Two-thirds of patients (63%) had a typical LBBB contraction pattern. During 4 years, 48 patients (23%) reached the primary endpoint. Absence of a typical LBBB contraction was independently associated with increased risk of adverse outcome after adjustment for ischemic heart disease and QRS width (hazard ratio [HR]: 3.1; 95% CI: 1.64 to 5.88; p < 0.005). Adding pattern assessment to a risk prediction model including QRS duration and ischemic heart disease significantly improved the net reclassification index to 0.14 (p = 0.04) and improved the C-statistics (0.63 [95% CI: 0.54 to 0.72] vs. 0.71 [95% CI: 0.63 to 0.80]; p = 0.02). Use of strict LBBB ECG criteria was not independently associated with outcome in the multivariate model (HR: 1.72; 95% CI: 0.89 to 3.33; p = 0.11. Assessment of LBBB contraction pattern was superior to time-to-peak indexes of dyssynchrony (p < 0.01 for all). CONCLUSIONS: Contraction pattern assessment to identify true LBBB activation provided important prognostic information in CRT candidates.
BACKGROUND: Current guidelines suggest that patients with left bundle branch block (LBBB) be treated with cardiac resynchronization therapy (CRT); however, one-third do not have a significant activation delay, which can result in nonresponse. By identifying characteristic opposing wall contraction, 2-dimensional strain echocardiography (2DSE) may detect true LBBB activation. OBJECTIVES: This study sought to investigate whether the absence of a typical LBBB mechanical activation pattern by 2DSE was associated with unfavorable long-term outcome and if this is additive to electrocardiographic (ECG) morphology and duration. METHODS: From 2 centers, 208 CRT candidates (New York Heart Association classes II to IV, ejection fraction ≤35%, QRS duration ≥120 ms) with LBBB by ECG were prospectively included. Before CRT implantation, longitudinal strain in the apical 4-chamber view determined whether typical LBBB contraction was present. The pre-defined outcome was freedom from death, left ventricular assist device, or heart transplantation over 4 years. RESULTS: Two-thirds of patients (63%) had a typical LBBB contraction pattern. During 4 years, 48 patients (23%) reached the primary endpoint. Absence of a typical LBBB contraction was independently associated with increased risk of adverse outcome after adjustment for ischemic heart disease and QRS width (hazard ratio [HR]: 3.1; 95% CI: 1.64 to 5.88; p < 0.005). Adding pattern assessment to a risk prediction model including QRS duration and ischemic heart disease significantly improved the net reclassification index to 0.14 (p = 0.04) and improved the C-statistics (0.63 [95% CI: 0.54 to 0.72] vs. 0.71 [95% CI: 0.63 to 0.80]; p = 0.02). Use of strict LBBB ECG criteria was not independently associated with outcome in the multivariate model (HR: 1.72; 95% CI: 0.89 to 3.33; p = 0.11. Assessment of LBBB contraction pattern was superior to time-to-peak indexes of dyssynchrony (p < 0.01 for all). CONCLUSIONS: Contraction pattern assessment to identify true LBBB activation provided important prognostic information in CRT candidates.
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