Search Results (140)

Cardiac resynchronization therapy (CRT) represents a cornerstone in the management of patients with heart failure and electrical dyssynchrony, improving symptoms, reducing hospitalizations, and prolonging survival. CRT can be delivered via a pacemaker (CRT-P) or an ICD (CRT-D). Despite its widespread use, the mortality benefit of CRT-D over CRT-P remains uncertain, as no head-to-head randomized trials have been designed to directly compare the two modalities, making device selection a frequent clinical dilemma. In practice, CRT-D accounts for 70–80% of CRT implantations in developed countries, yet solid evidence demonstrating its superiority over CRT-P is lacking. Specific patient groups, including those with non-ischemic cardiomyopathy, advanced age, multiple comorbidities, or limited life expectancy, may derive limited incremental benefit from CRT-D, which should be balanced against device costs and specific risks such as lead failure and inappropriate shocks. The present review aims to provide a comprehensive comparison between CRT-D and CRT-P, focusing on the existing body of evidence, criteria for patient selection, comparative clinical outcomes, and risk–benefit considerations for clinical decision-making. Full article

Heart failure with reduced ejection fraction (HFrEF) continues to impose a high burden of morbidity and mortality despite significant advances in pharmacologic and device-based therapy. Cardiac resynchronization therapy (CRT) and angiotensin receptor–neprilysin inhibitors (ARNIs) have independently demonstrated substantial benefits in symptoms, health-related quality of life (HRQoL), and survival. Cardiac rehabilitation (CR), incorporating structured exercise, education, and lifestyle optimization, is well established as an effective intervention in HFrEF, yet its role in the era of combined CRT and ARNI therapy remains insufficiently characterized. This literature review synthesizes current evidence on CR in HFrEF populations receiving CRT, ARNI, or both, highlighting its impact on HRQoL, exercise capacity, and functional outcomes. Across diverse study designs—including randomized trials, observational cohorts, and meta-analyses—CR consistently yielded clinically meaningful improvements in patient-reported HRQoL and objective measures such as six-minute walk distance (6MWD) and peak oxygen uptake. Data directly evaluating CR in patients concurrently receiving both CRT and ARNI are lacking; indirect evidence suggests CR is compatible with, and may add to, contemporary device and drug therapy. However, referral rates remain low, indicating an implementation gap despite strong evidence of benefit. The review underscores the importance of integrating CR into contemporary HFrEF care and identifies a pressing need for targeted prospective studies to define its role in patients receiving dual device–pharmacologic therapy. Full article

Background: The rate of long-term outcomes, including arrhythmic episodes following implantable cardioverter–defibrillator (ICD) device replacements, is often unknown. Thus, the aim of this manuscript was to evaluate the risk of ICD or cardiac resynchronization therapy–defibrillator (CRT-D) therapies in remotely monitored patients following device replacement. Methods: Data from 134 patients who underwent ICD/CRT-D replacement or upgrade were analyzed. Kaplan–Meier estimates, as well as Cox proportional hazards regression, were used to present long-term outcomes and predictors of study endpoints, these being all-cause mortality, and appropriate and inappropriate ICD/CRT-D therapies. Results: Among the cohort, 51.5% of patients received ICDs and 48.5% received CRT-Ds; the median (quartile 1–quartile 3) LVEF at replacement was 23.0% (18.0–28.0%). In 11 (8.2%) patients, the LVEF at replacement was higher than 35%. During the median (Q1–Q3) follow-up of 3.0 (1.4–5.0) years, 32.1% experienced appropriate and 6.0% experienced inappropriate therapies. The all-cause mortality rate was 38.0%, and appropriate antitachycardia pacing (ATP), a reduced baseline LVEF, and no history of myocardial infarction were independent predictors of death (odds ratios of 1.87 for appropriate ATP, 0.88 per 1% of the LVEF and 0.54 for a history of MI, respectively). The rate of appropriate device therapies was numerically lower in patients whose LVEF improved (19.8% vs. 33.3% and 0% vs. 6.5%, for appropriate and inappropriate therapies). An LVEF of >35% at replacement did not influence the analyzed outcomes. Conclusions: In patients who underwent ICD/CRT-D replacement, an improvement in LVEF was not identified as either a predictor of improved survival or of a lower risk of needing device therapies. Further stratification models are needed to evaluate the arrhythmic risk in patients after generator replacements. Full article

Background: Left bundle branch area pacing (LBBAP) has emerged as a physiological alternative to conventional pacing, offering improved ventricular synchrony and clinical outcomes. However, extraction of deeply implanted LBBAP leads remains challenging, particularly in the context of device-related infections. Case Summary: We report two cases of successful extraction of chronically implanted LBBAP leads using a novel technique based on femoral countertraction with pigtail catheters. In the first case, a deep septal implanted 3830 lead was extracted in a patient with persistent bacteremia and suspected device-related endocarditis. Continuous traction was applied to the mid-portion of the lead using a pigtail catheter introduced via femoral access, facilitating safe removal without the use of powered sheaths proximal to the distal tip of the lead. In the second case, three leads (RA, RV, LBBAP) from a cardiac resynchronization therapy with deffibrilation support (CRT-D) system were completely removed in a patient with device extrusion and pocket erosion, using a dual pigtail approach anchored to the atrial and septal leads. Results: In both cases, the technique enabled successful extraction without complications. Procedural times were approximately 70 and 65 min, respectively. In vitro testing suggested that the pigtail catheter applied a sustained moderate traction force (~0.06 kgf), translating to an estimated pressure of 0.85–1.91 kgf/cm² at the septal lead interface. Conclusions: This case series demonstrates that LBBAP lead extraction is feasible using a novel femoral countertraction technique with pigtail catheters. Steady, moderate traction over time may provide a safer alternative to forceful subclavicular extraction, especially in chronically implanted deep septal leads. Further studies are warranted to evaluate the reproducibility, safety, and clinical applicability of this approach. Full article

Background: Sacubitril/valsartan (S/V) improves left ventricular (LV) function and clinical outcome in heart failure (HF) with reduced ejection fraction (HFrEF). Data on its clinical value in the specific cohort of HFrEF patients demonstrating no adequate response to cardiac resynchronization therapy (CRT nonresponders; CRT-NRs) are limited. Herein, we investigated the impact of S/V initiated as a replacement for ACEi/ARB therapy in CRT nonresponder (CRT-NR) patients. Methods: Our HF database was searched to identify CRT-NRs who received S/V treatment for at least 6 months as a replacement for ACEi/ARB (Group I; 70 patients) and CRT-NRs who remained on ACEi/ARB (Group II, 70). In addition, HFrEF patients without CRT indication who received S/V therapy for at least 6 months (Group III; 135) were also included in this analysis. The primary endpoint was the composite of all-cause mortality including heart transplantation (HTx) or left ventricular assist device implantation (LVAD) and HF hospitalization (HFH). Secondary endpoints were (i) all-cause mortality+HTx+LVAD and (ii) HFH analyzed separately. Results: Over a median follow-up of 22 months, the primary composite endpoint occurred in 27 out of 70 patients (38.57%) in Group I, 43 out of 70 patients (61.42%) in Group II, and 60 out of 135 patients (44.42%) in Group III. The differences were significant between Groups I and II (p: 0.005), as well as between Group II and III (p: 0.012), while the two groups on S/V (Group I and III) demonstrated similar outcomes (p = 0.465). HFH analyzed separately as a secondary endpoint occurred in 19 out of 70 patients (27.14%) in Group I, 38 out of 70 patients (54.28%) in Group II, and 36 out of 135 patients (26.66%) in Group III (Group I vs. II p: 0.001; Groups II vs. III p: 0.001, Group I vs. III, p: 0.896). All-cause mortality+HTx+LVAD analyzed separately as the other secondary endpoint demonstrated no significant differences among the three groups. Conclusions: S/V therapy improved HFH but not mortality in CRT-NR patients. Comparable improvement was demonstrated after SV in the CRT-NR and in the general HFrEF cohort with no CRT indication. Full article

Background and Clinical Significance: Heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF) frequently coexist, creating a complex clinical interplay that exacerbates morbidity and mortality. AF can directly precipitate or worsen HFrEF through mechanisms such as tachycardia-induced cardiomyopathy, loss of atrial contribution to ventricular filling, and irregular ventricular response. The use of evidence-based therapies improves clinical outcomes in patients with HFrEF. Case Presentation: We present a clinical case of a 58-year-old man with left bundle branch block (LBBB), tachysystolic AF, and the aforementioned induced HFrEF. The patient’s medical treatment was optimized according to recent guidelines. Subsequent to the improvements in HF treatment, the patient’s echocardiographic data showed a higher left ventricle ejection fraction (LVEF); however, it remained below 35%. Moreover, tachysystolia persisted and was not sufficiently controlled with medications. Therefore, an upgrade of the pacemaker to cardiac resynchronization therapy (CRT) following the destruction of the AV node was performed to control tachysystolic AF and worsening of HF. After the treatment adjustments, the patient’s symptoms regressed, and echocardiography showed improved LVEF up to 41%. Conclusions: This case highlights the successful identification and timely application of intensive heart rate control management and heart failure induced by AF treatment. Full article

Anodal capture, characterized by a different QRS morphology compared to cathodal capture, is a well-known issue in cardiac resynchronization therapy (CRT). Left bundle branch area pacing (LBBAP), a novel physiological pacing technique, is also used as a bailout strategy following failed conventional CRT implantation. In LBBAP, QRS transition, defined by a change in paced QRS morphology, serves as a key marker of successful lead placement. This case report is the first to document both high-output anodal capture and LBBAP-induced QRS transition in a single individual receiving LBBAP with an implantable cardioverter–defibrillator (ICD) as a bailout strategy for failed cardiac resynchronization therapy with defibrillator (CRT-D) implantation. Their coexistence underscores unique device optimization challenges in this emerging approach. Full article

Cardiac devices have transformed the management of heart failure, ventricular arrhythmias, ischemic cardiomyopathy, and valvular heart disease. Technologies such as cardiac resynchronization therapy (CRT), conduction system pacing, left ventricular assist devices (LVADs), and implantable cardioverter-defibrillators have contributed to abated global cardiovascular risk through action onto pathophysiological processes such as mechanical unloading, electrical resynchronization, or hemodynamic optimization, respectively. While their clinical benefits are well established, their long-term molecular and structural effects on the myocardium remain under investigation. Cardiac devices dynamically interact with myocardial and vascular biology, inducing molecular and extracellular matrix adaptations that vary by pathology. CRT enhances calcium cycling and reduces fibrosis, but chronic pacing may lead to pacing-induced cardiomyopathy. LVADs and Impella relieve ventricular workload yet alter sarcomeric integrity and mitochondrial function. Transcatheter valve therapies influence ventricular remodeling, conduction, and coronary flow. Understanding these remodeling processes is crucial for optimizing patient selection, device programming, and therapeutic strategies. This narrative review integrates the current knowledge on the molecular and structural effects of cardiac devices, highlighting their impact across different disease settings. Full article

Background/Objectives: This study aimed to evaluate myocardial scar burden and distribution, as well as other nuclear imaging parameters, in predicting cardiac resynchronization therapy (CRT) responses and long-term outcomes in patients selected for CRT with ischemic HF etiology. Methods: Seventy-one patients were prospectively included. They all had NYHA class II/III despite optimal medical therapy, LVEF ≤ 35%, wide QRS complexes, and ischemic HF etiology. All were indicated for de novo CRT implantation and underwent a SPECT MPI viability test prior to CRT implantation. Two-dimensional echocardiography was performed one day before CRT implantation and 6 months after the intervention. The follow-up examination was conducted six months after the CRT implantation and, after 5 years, patients underwent a telephone follow-up to assess survival. Results: Most patients (85%) were male, with an average age of 66.26 ± 9.25 yrs. SPECT MPI revealed large myocardial scars (44.53 ± 20.94%) with high summed rest scores (SRSs) of 25.02 ± 11.29 and low EFs of 26.67 ± 7.71%. At the 6-month follow-up, after the CRT implantation, the NYHA class significantly changed and 35% of the patients were classified as CRT responders. The only difference between responders and non-responders was in the SRS and myocardial scar size (p < 0.001). A scar size of 19.5% was an optimal cutoff for the prediction of CRT response (AUC 0.853, Sn 85% and 1-sp 94%). Conclusions: SPECT MPI parameters are valuable in predicting responses and long-term survival in patients with CRT. Patients with myocardial scars of less than 19.5% may be suited to CRT and experience better cardiovascular survival. Full article

This review investigates recent developments in cardiac mechano-electrical-fluid interaction (MEFI) modeling, with a focus on multiphysics simulation platforms and digital twin frameworks developed between 2015 and 2025. The purpose of the study is to assess how computational modeling methods—particularly finite element and immersed boundary techniques, monolithic and partitioned coupling schemes, and artificial intelligence (AI)-enhanced surrogate modeling—capture the integrated dynamics of cardiac electrophysiology, tissue mechanics, and hemodynamics. The goal is to evaluate the translational potential of MEFI models in clinical applications such as cardiac resynchronization therapy (CRT), arrhythmia classification, atrial fibrillation ablation, and surgical planning. Quantitative results from the literature demonstrate <5% error in pressure–volume loop predictions, >0.90 F1 scores in machine-learning-based arrhythmia detection, and <10% deviation in myocardial strain relative to MRI-based ground truth. These findings highlight both the promise and limitations of current MEFI approaches. While recent advances improve physiological fidelity and predictive accuracy, key challenges remain in achieving multiscale integration, model validation across diverse populations, and real-time clinical applicability. The review concludes by identifying future milestones for clinical translation, including regulatory model certification, standardization of validation protocols, and integration of patient-specific digital twins into electronic health record (EHR) systems. Full article

Background/Objectives: We aimed to identify the factors associated with clinically important changes in quality of life (QoL) of real-world heart failure (HF) patients. Methods: This is a single-centre, prospective cohort study including 419 patients at an HF clinic between January 2013 and February 2020. QoL was assessed regularly using Minnesota Living with Heart Failure Questionnaire (MLHFQ). We used five nested linear mixed-effects models to account for QoL measurements between patients and within-patient. Models were adjusted for time, sociodemographic factors, comorbidities, self-care adherence, and HF severity factors. Results: Median age was 78 years, 54.4% of patients were female, and 49.6% had left ventricle ejection fraction ≥ 50%. At baseline, 62.5% of patients were New York Heart Association (NYHA) class II. Median N-terminal-pro-B type natriuretic peptide level was 1454 pg/mL. Mean MLHFQ total score at baseline was 25 points (95%CI: 22.97–27.60). Having an implanted cardiac resynchronization therapy-pacemaker (CRT-P) was associated with moderate to large improvement in QoL (−13.55 points, 95%CI: −22.45–−4.65). NYHA class II and estimated glomerular filtration rate < 30 mL/min/1.73 m² were associated with small to moderate QoL deterioration (9.74 points, 95%CI: 6.74–12.75 and 5.82 points, 95%CI: 1.17–10.47, respectively). NYHA classes III or IV and a recent HF hospitalization were associated with large to very large QoL deterioration (28.39 points, 95%CI: 23.82–32.96; 60.59 points, 95%CI: 34.46–86.72; and 26.91 points, 95%CI: 21.80–32.03, respectively). Conclusions: CRT-P implantation, NYHA class and HF hospitalization are associated with the most clinically important QoL changes. Full article

Background/Objectives: Patients with normal sinus rhythms undergoing cardiac resynchronization therapy defibrillator (CRT-D) implantation may benefit from a novel two-lead CRT-D system (CRT-DX), which features an atrial sensing dipole integrated into the right ventricular lead. This single-arm, international, non-controlled investigation focused on the safety and clinical efficacy of CRT-DX devices in CRT-D candidates who do not require atrial pacing. Methods: Patients indicated for CRT-D implantation (resting heart rates > 40 bpm and ≥100 bpm during exercise, no second or higher-degree AV block, and no history of persistent or permanent atrial fibrillation) were enrolled across 21 sites in four European countries. The primary endpoint was the need for an additional RA lead implantation within 12 months. Secondary endpoints comprised any invasive re-intervention to the CRT-DX system or infection. Results: Among the 110 patients (mean age 62 years, 70% male), 60% had an underlying non-ischemic cardiac disease. During 12 months of follow-up, RA lead implantation was required in two patients for atrial undersensing or chronotropic incompetence (RA lead implantation-free rate: 98.2% (95% CI: 92.7–99.5%)). Atrial sensing amplitudes were stable (mean: 4.7 ± 1.7 mV), AV-synchrony was maintained at >99%, and the median percentage of biventricular pacing exceeded 98%. The left ventricular ejection fraction improved by an absolute 14.7%. Conclusions: Using simple, clinically applicable inclusion criteria, the two-lead CRT-DX system demonstrated a low rate of subsequent RA lead implantations (1.8%) and maintained adequate RA sensing amplitudes throughout the observation period. The two-lead CRT-DX concept appears to be a feasible alternative for patients with preserved chronotropic competence. Full article

Background/Objectives: Impaired kidney function significantly increases mortality in recipients of implantable cardioverter defibrillators (ICDs). However, in the landmark studies evaluating ICDs and cardiac resynchronization therapy with a defibrillator (CRT-D) for the treatment of heart failure (HF) with a reduced ejection fraction (HFrEF), patients with Chagas cardiomyopathy (CC) have been underrepresented. This study aimed to determine whether kidney dysfunction has the same negative impacts on patients with ICDs or CRT-Ds and CC. Methods: We prospectively followed patients with CC and left ventricular ejection fractions (LVEFs) of ≤40% who underwent ICD or CRT-D implantation and had at least one prior creatinine measurement. The primary outcome was the survival rate during follow-up. Variables with a p of <0.10 from the univariate analysis were selected for inclusion in the Cox regression model. Results: A total of 343 patients were enrolled, with a median follow-up duration of 777 days. The mean age was 60.2 (±11.2) years. Fifty percent of patients were observed to have a New York Heart Association (NYHA) functional class of III, and the median left ventricular ejection fraction (LVEF) was 27% (22–32). Overall mortality events occurred in 113 (32.9%) participants during follow-up. Although the estimated glomerular filtration rate (eGFR) was significantly associated with survival in the univariate analysis [HR 0.98 (CI 95% 0.98–0.99), p = 0.007], it did not retain significance in the multivariate model [HR 0.99 (0.98–1.00), p = 0.138], which was adjusted for age, gender, atrial fibrillation (AF), body mass index (BMI), and the use of digoxin, furosemide, anticoagulants, and LVEF. Conclusions: Unlike other cardiomyopathies, impaired eGFR was not an independent predictor of mortality in this cohort of CC patients undergoing ICD or CRT-D implantation, possibly due to the distinctive pathophysiological mechanisms of the disease. These findings suggest that clinicians should not be discouraged from recommending CIEDs in patients with CC and moderately impaired kidney function, although further studies are warranted to assess outcomes in those with advanced CKD. Full article

Objectives: This review aims to systematically evaluate the clinical outcomes of left ventricle-only fusion pacing (LV-only fCRTp) and identify evidence-based selection criteria that may optimize patient response and long-term therapeutic benefit. Background: Cardiac resynchronization therapy (CRT) is traditionally associated with biventricular pacing (BiVp). However, approximately 20–40% of patients seem to remain non-responders to this therapy. LV-only fCRTp offers a more physiological alternative by combining left ventricular epicardial pacing with the intrinsic ventricular activation wavefront. Beyond optimization strategies, the observed variability in response highlights the need for better patient selection in order to fully unlock its therapeutic potential. Methods: A systematic literature search was conducted in PubMed and Cochrane Library for original articles published up to April 2025, following PRISMA 2020 guidelines. The search focused on LV-only fCRTp performed either through standard RA/LV/RV biventricular devices or RA/LV dual-chamber systems. Results: Twenty-seven studies met the inclusion criteria. Among these, 17 studies obtained LV-only fCRTp using biventricular devices, and 10 were considered true LV-only fCRTp using RA/LV dual-chamber devices. Standard and specific selection criteria were used to qualify patients for LV-only fCRTp. Preserved atrioventricular conduction, ischemic cardiomyopathy, arrhythmic risk stratification, and the management of supraventricular arrhythmias were common overlapping parameters among studies with high variability, highlighting their potential role in response. RA/LV devices yielded consistent clinical benefits and low complication rates, particularly in nonischemic patients with stable AV conduction and low arrhythmic risk, while having a lower financial burden. Conclusions: Beyond guideline recommendations for CRT, this review identifies supplementary selection criteria that could further influence the effectiveness and stability of fusion pacing. Full article

Background: Dilated Cardiomyopathy (DCM) is one of the leading causes of non-ischemic cardiomyopathy in the United States (US). The aim of our study is to analyze the general trends in DCM admissions between 2016 and 2021, and analyze social and healthcare disparities in terms of treatments and outcomes. Methods: National Inpatient Sample (NIS) data for the years 2016 to 2021 were used for the analysis. General population trends were analyzed. Normality of data distribution was tested using the Kolmogorov–Smirnov test and homogeneity was assessed using Levine’s test. One-way ANOVA was used after confirmation of normality of distribution to analyze social and healthcare disparities. Subgroup analysis was conducted, with the paired t-test for continuous variables and Fischer’s exact t-test for categorical variables to analyze statistical differences. Multivariate regression analysis was conducted to analyze the association of factors that were significant in the one-way ANOVA and paired t/chi square tests. A two-tailed p-value < 0.05 was used to determine statistical significance. Results: A total of 5262 admissions for DCM were observed between 2016 and 2021. A general declining trend was observed in the total number of DCM admissions, with a 33.51% decrease in total admissions in 2021 compared to 2016. All-cause in-hospital mortality remained stable across the years (between 3.5% and 4.5%). A total of 15.3% of admissions had CRT/ICD devices in place. A total of 425 patients (8.07%) for DCM underwent HT, and 214 admissions for DCM (4.06%) underwent LVAD placements between 2016 and 2021 In terms of interventions for DCM, namely Cardiac Resynchronization Therapy (CRT), Left Ventricular Assist Devices (LVADs) and Heart Transplantations (HTs), significant variance was observed in the mean age of the admissions with admissions over the mean age of 55 had lower number of interventions. Significant variance in terms of sex was observed for DCM admissions receiving HT, with lower rates observed for females. In terms of quarterly income, patients belonging to the lowest fourth quartile had higher rates of LVAD and HT compared to general DCM admissions. In the multivariate regression analysis, age at admission had significant association with lower chances of receiving LVADs and HT among DCM admissions, and significant association with higher chances of all-cause mortality during the hospital stay. Conclusions: A general declining trend in the total number of DCM admissions was observed between 2016 and 2021. Significant gender disparities were seen with lower rates of females with DCM receiving LVADs and HT. DCM admissions with mean age of 55 and above were found to have significantly lower rates of receiving LVADs and HT, and higher chances of all-cause mortality during the admission. Full article