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المؤلفون: Khaldoun G. Tarakji, Eoin Donnellan, Balint Laczay, Wilson Tang, Randall C. Starling, Anirudh Kumar, Divyang Patel, John Rickard, Nishant P. Shah, Oussama M. Wazni, Daniel J. Cantillon, Niraj Varma, Kevin Trulock, Laurie Ann Moennich, Zachary J. Il'Giovine, Mark Niebauer, Bruce L. Wilkoff
المصدر: Circulation: Heart Failure. 13
مصطلحات موضوعية: medicine.medical_specialty, Time Factors, medicine.medical_treatment, Cardiac resynchronization therapy, Risk Assessment, Ventricular Function, Left, Body Mass Index, Cardiac Resynchronization Therapy, Risk Factors, Internal medicine, Humans, Medicine, Obesity, Ventricular remodeling, Retrospective Studies, Heart Failure, Ejection fraction, Ventricular Remodeling, business.industry, Stroke Volume, Recovery of Function, medicine.disease, Progression-Free Survival, Heart failure, Cardiology, Cardiology and Cardiovascular Medicine, business, Body mass index
URL الوصول: https://explore.openaire.eu/search/publication?articleId=doi_dedup___::e89a367f498adfccef64af386db6edfc
https://doi.org/10.1161/circheartfailure.120.007424 -
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المؤلفون: John Barnard, Niraj Varma, Mina K. Chung, Anant Madabhushi, Eiran Z. Gorodeski, Saleem Toro, John Rickard, Kevin Trulock, Divyang Patel, Richard A. Grimm, Laurie Ann Moennich, Mark Niebauer, Albert Feeny
المصدر: Circ Arrhythm Electrophysiol
مصطلحات موضوعية: Male, medicine.medical_specialty, Time Factors, medicine.medical_treatment, Bundle-Branch Block, Cardiac resynchronization therapy, 030204 cardiovascular system & hematology, Risk Assessment, Article, Ventricular Function, Left, Cardiac Resynchronization Therapy, 03 medical and health sciences, QRS complex, Electrocardiography, 0302 clinical medicine, Predictive Value of Tests, Risk Factors, Physiology (medical), Internal medicine, medicine, Humans, 030212 general & internal medicine, cardiovascular diseases, Diagnosis, Computer-Assisted, Lead (electronics), Aged, Retrospective Studies, Heart Failure, medicine.diagnostic_test, Bundle branch block, business.industry, Signal Processing, Computer-Assisted, Stroke Volume, Recovery of Function, Middle Aged, medicine.disease, Treatment Outcome, Heart failure, Cardiology, cardiovascular system, Disease Progression, Heart Transplantation, Female, Heart-Assist Devices, Cardiology and Cardiovascular Medicine, business, circulatory and respiratory physiology, Unsupervised Machine Learning
الوصف: Background: Cardiac resynchronization therapy (CRT) improves heart failure outcomes but has significant nonresponse rates, highlighting limitations in ECG selection criteria: QRS duration (QRSd) ≥150 ms and subjective labeling of left bundle branch block (LBBB). We explored unsupervised machine learning of ECG waveforms to identify CRT subgroups that may differentiate outcomes beyond QRSd and LBBB. Methods: We retrospectively analyzed 946 CRT patients with conduction delay. Principal component analysis (PCA) dimensionality reduction obtained a 2-dimensional representation of preCRT 12-lead QRS waveforms. k -means clustering of the 2-dimensional PCA representation of 12-lead QRS waveforms identified 2 patient subgroups (QRS PCA groups). Vectorcardiographic QRS area was also calculated. We examined following 2 primary outcomes: (1) composite end point of death, left ventricular assist device, or heart transplant, and (2) degree of echocardiographic left ventricular ejection fraction (LVEF) change after CRT. Results: Compared with QRS PCA Group 2 ( n =425), Group 1 ( n =521) had lower risk for reaching the composite end point (HR, 0.44 [95% CI, 0.38–0.53]; P P P P =0.001). QRS area also stratified outcomes but had significant differences from QRS PCA groups. A stratification scheme combining QRS area and QRS PCA group identified patients with LBBB with similar outcomes to non-LBBB patients (HR, 1.32 [95% CI, 0.93–1.62]; difference in mean LVEF change: 0.8% [95% CI, −2.1% to 3.7%]). The stratification scheme also identified patients with LBBB with QRSd Conclusions: Unsupervised machine learning of ECG waveforms identified CRT subgroups with relevance beyond LBBB and QRSd. This method may assist in objective classification of bundle branch block morphology in CRT.
URL الوصول: https://explore.openaire.eu/search/publication?articleId=doi_dedup___::2a7d792336867db3d1c4a76d3feb18e2
https://europepmc.org/articles/PMC7901121/ -
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المؤلفون: Ayman A. Hussein, Thomas Dresing, Niraj Varma, Walid Saliba, Jad A. Ballout, Bruce D. Lindsay, Mohamed Diab, David O. Martin, Mohamed Kanj, Patrick J. Tchou, Oussama M. Wazni, John Rickard, Mark Niebauer, Mandeep Bhargava, Bryan Baranowski, Mina K. Chung, Khaldoun G. Tarakji, Thomas Callahan, Daniel J. Cantillon
المصدر: Circ Arrhythm Electrophysiol
مصطلحات موضوعية: Male, medicine.medical_specialty, Time Factors, Radiofrequency ablation, medicine.medical_treatment, Drug Resistance, Shock, Cardiogenic, Catheter ablation, Ventricular tachycardia, Article, Ventricular Function, Left, law.invention, Extracorporeal Membrane Oxygenation, Refractory, Heart Rate, Recurrence, Risk Factors, law, Physiology (medical), Internal medicine, medicine, Humans, Assisted Circulation, Hospital Mortality, Registries, Aged, Retrospective Studies, business.industry, Cardiogenic shock, Stroke Volume, Recovery of Function, Middle Aged, Ablation, medicine.disease, Treatment Outcome, Concomitant, Heart failure, Ventricular Fibrillation, Catheter Ablation, Tachycardia, Ventricular, Cardiology, Female, Cardiology and Cardiovascular Medicine, business, Anti-Arrhythmia Agents
الوصف: Background: There is paucity of data regarding radiofrequency ablation for ventricular tachycardia (VT) in patients with cardiogenic shock and concomitant VT refractory to antiarrhythmic drugs on mechanical support. Methods: Patients undergoing VT ablation at our center were enrolled in a prospectively maintained registry and screened for the current study (2010–2017). Results: All 21 consecutive patients with cardiogenic shock and concomitant refractory ventricular arrhythmia undergoing bailout ablation due to inability to wean off mechanical support were included. Median age was 61 years, 86% were men, median left ventricular ejection fraction was 20%, 81% had ischemic cardiomyopathy, and PAINESD score was 18±5. The type of mechanical support in place before the procedure was intra-aortic balloon pump in 14 patients (67%), Impella CP in 2, extracorporeal membrane oxygenation in 2, extracorporeal membrane oxygenation and intra-aortic balloon pump in 2, and extracorporeal membrane oxygenation and Impella CP in 1. Endocardial voltage maps showed myocardial scar in 19 patients (90%). The clinical VTs were inducible in 13 patients (62%), whereas 6 patients had premature ventricular contraction–induced ventricular fibrillation/VT (29%), and VT could not be induced in 2 patients (9%). Activation mapping was possible in all 13 with inducible clinical VTs. Substrate modification was performed in 15 patients with scar (79%). After ablation and scar modification, the arrhythmia was noninducible in 19 patients (91%). Seventeen (81%) were eventually weaned off mechanical support successfully, but 6 (29%) died during the index admission from persistent cardiogenic shock. Patients who had ventricular arrhythmia and cardiogenic shock on presentation had a trend toward lower in-hospital mortality compared with those who presented with cardiogenic shock and later developed ventricular arrhythmia. Conclusions: Bailout ablation for refractory ventricular arrhythmia in cardiogenic shock allowed successful weaning from mechanical support in a large proportion of patients. Mortality remains high, but the majority of patients were discharged home and survived beyond 1 year.
URL الوصول: https://explore.openaire.eu/search/publication?articleId=doi_dedup___::f22fb2268fcc13288857f3c52106224c
https://doi.org/10.1161/circep.119.007669 -
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المؤلفون: Divyang Patel, Eoin Donnellan, Oussama M. Wazni, Anirudh Kumar, Adam Grimaldi, Bryan Baranowski, Niraj Varma, Kevin Trulock, Erich L. Kiehl, Bruce L. Wilkoff, Saleem Toro, Laurie Ann Moennich, Daniel J. Cantillon, Mark Niebauer, Ayman A. Hussein, John Rickard, Khaldoun G. Tarakji
المصدر: Journal of cardiovascular electrophysiologyREFERENCES. 31(5)
مصطلحات موضوعية: Male, medicine.medical_specialty, Time Factors, medicine.medical_treatment, Cardiac resynchronization therapy, Diastole, 030204 cardiovascular system & hematology, Risk Assessment, Cardiac Resynchronization Therapy, 03 medical and health sciences, QRS complex, 0302 clinical medicine, Risk Factors, Physiology (medical), Internal medicine, medicine, Humans, cardiovascular diseases, 030212 general & internal medicine, Cardiac Resynchronization Therapy Devices, Survivors, Aged, Retrospective Studies, Heart Failure, Ischemic cardiomyopathy, Ejection fraction, business.industry, Atrial fibrillation, Odds ratio, Recovery of Function, Middle Aged, medicine.disease, Treatment Outcome, cardiovascular system, Cardiology, Female, Cardiology and Cardiovascular Medicine, business, circulatory and respiratory physiology, Social Security Death Index
الوصف: BACKGROUND Cardiac resynchronization therapy (CRT) is indicated in patients with medically refractory heart failure and wide QRS duration. While much is known about predictors of left ventricular (LV) remodeling after CRT implantation and short-term mortality, limited data exist on long-term outcomes after CRT placement. METHODS We retrospectively reviewed all patients undergoing CRT implantation at our center between 2003 and 2008 and examined mortality using institutional electronic records, social security death index, and online obituary search. We included only patients with preimplant echoes with LV ejection fraction (LVEF) 35% or below. Variable selection was performed using stepwise regression and models were compared using goodness-of-fit criteria. A final model was validated with the bootstrap regression method. RESULTS Out of the 877 CRT patients undergoing implantation during this time, 287 (32.7%) survived longer than 10 years. Significant (P
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المؤلفون: David D. Spragg, Eiran Z. Gorodeski, John Barnard, Divyang Patel, Richard A. Grimm, Mina K. Chung, Niraj Varma, Carolyn J. Park, Mark Niebauer, Anant Madabhushi, Saleem Toro, Michael LaBarbera, Albert Feeny, Sunil Sinha, Xinge Ji, Kevin Trulock, John Rickard
المصدر: Circ Arrhythm Electrophysiol
مصطلحات موضوعية: Male, Time Factors, medicine.medical_treatment, Clinical Decision-Making, Cardiac resynchronization therapy, Machine learning, computer.software_genre, Risk Assessment, Ventricular Function, Left, Article, Decision Support Techniques, Cardiac Resynchronization Therapy, Machine Learning, Predictive Value of Tests, Risk Factors, Physiology (medical), Medicine, Humans, Aged, Ohio, Retrospective Studies, Heart Failure, business.industry, Patient Selection, Stroke Volume, Recovery of Function, Middle Aged, medicine.disease, Progression-Free Survival, Echocardiography, Heart failure, Baltimore, Practice Guidelines as Topic, Disease Progression, Heart Transplantation, Female, Artificial intelligence, Heart-Assist Devices, Current (fluid), Cardiology and Cardiovascular Medicine, business, computer
الوصف: Background: Cardiac resynchronization therapy (CRT) has significant nonresponse rates. We assessed whether machine learning (ML) could predict CRT response beyond current guidelines. Methods: We analyzed CRT patients from Cleveland Clinic and Johns Hopkins. A training cohort was created from all Johns Hopkins patients and an equal number of randomly sampled Cleveland Clinic patients. All remaining patients comprised the testing cohort. Response was defined as ≥10% increase in left ventricular ejection fraction. ML models were developed to predict CRT response using different combinations of classification algorithms and clinical variable sets on the training cohort. The model with the highest area under the curve was evaluated on the testing cohort. Probability of response was used to predict survival free from a composite end point of death, heart transplant, or placement of left ventricular assist device. Predictions were compared with current guidelines. Results: Nine hundred twenty-five patients were included. On the training cohort (n=470: 235, Johns Hopkins; 235, Cleveland Clinic), the best ML model was a naive Bayes classifier including 9 variables (QRS morphology, QRS duration, New York Heart Association classification, left ventricular ejection fraction and end-diastolic diameter, sex, ischemic cardiomyopathy, atrial fibrillation, and epicardial left ventricular lead). On the testing cohort (n=455, Cleveland Clinic), ML demonstrated better response prediction than guidelines (area under the curve, 0.70 versus 0.65; P =0.012) and greater discrimination of event-free survival (concordance index, 0.61 versus 0.56; P P Conclusions: ML with 9 variables incrementally improved prediction of echocardiographic CRT response and survival beyond guidelines. Performance was not improved by incorporating more variables. The model offers potential for improved shared decision-making in CRT (online calculator: http://riskcalc.org:3838/CRTResponseScore ). Significant remaining limitations confirm the need to identify better variables to predict CRT response.
URL الوصول: https://explore.openaire.eu/search/publication?articleId=doi_dedup___::79d522fea8ee897ed670c8579b0a8b84
https://pubmed.ncbi.nlm.nih.gov/31216884 -
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المؤلفون: John, Rickard, Bryan, Baranowski, Richard A, Grimm, Mark, Niebauer, Niraj, Varma, W H Wilson, Tang, Bruce L, Wilkoff
المصدر: Pacing and clinical electrophysiology : PACE. 40(5)
مصطلحات موضوعية: Heart Failure, Male, Incidence, Reproducibility of Results, Organ Size, Prognosis, Sensitivity and Specificity, Cardiac Resynchronization Therapy, Survival Rate, Electrocardiography, Treatment Outcome, Risk Factors, Outcome Assessment, Health Care, Humans, Female, Hypertrophy, Left Ventricular, Diagnosis, Computer-Assisted, Aged, Ohio, Retrospective Studies
الوصف: QRS duration (QRSd) may be impacted by both left ventricular (LV) dilatation and conduction delay. It is possible therefore that the same QRSd may portend significantly different amounts of LV activation delay in patients with small versus large left ventricles. We hypothesized that LV size modifies the effect of QRSd on predicting outcomes in patients undergoing CRT implant.We extracted data on consecutive patients presenting for initial CRT implant. In patients with a follow-up echocardiogram, response was defined as an absolute improvement in LV ejection fraction ≥5%. Multivariate models were created to determine if left ventricular end-diastolic diameter (LVEDD) modified the effect of QRSd on its association with both long-term survival free of left ventricular assist device (LVAD) and heart transplant and echocardiographic response.464 patients met inclusion criteria. At a mean follow-up of 4.9 ± 2.6 years, there were 210 deaths, 13 heart transplants, and 12 LVAD placements. There was a weak but significant correlation between baseline QRSd and LVEDD (Spearman's Rho 0.106, P0.001). In a multivariate analysis, there was no evidence of effect modification of LVEDD on QRSd (LVEDDi*QRS interaction term HR 1.0 [0.995-1.006], P = 0.94). Note that 305 patients had a follow-up echocardiogram, of whom 193 met the criteria for response. In a multivariate analysis, there was no evidence of effect modification of LVEDD on QRSd (LVEDDi*QRS interaction term odds ratio 0.998 (0.988-1.008), P = 0.65).LV size does not modify the effect of QRSd and its association with outcomes following CRT. The correlation between LV size and QRSd in patients with a QRSd ≥ 120 ms is weak.
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المؤلفون: John, Rickard, Alan, Cheng, David, Spragg, Daniel, Cantillon, Bryan, Baranowski, Niraj, Varma, Bruce L, Wilkoff, W H Wilson, Tang
المصدر: Journal of cardiovascular electrophysiology. 25(3)
مصطلحات موضوعية: Heart Failure, Male, Time Factors, Middle Aged, Cardiac Resynchronization Therapy, Cohort Studies, Ventricular Dysfunction, Left, Treatment Outcome, Predictive Value of Tests, Risk Factors, Humans, Female, Kidney Diseases, Aged, Retrospective Studies
الوصف: In patients with advanced heart failure, the decision of whether to pursue cardiac resynchronization therapy (CRT) or to proceed directly to advanced heart failure therapies can be challenging. We sought to create a prediction rule to identify patients with advanced systolic heart failure at heightened risk of rapid deterioration despite receiving CRT.Clinical data were collected on consecutive patients with advanced heart failure presenting for a new CRT device at the Cleveland Clinic between February 12, 2002 and July 8, 2008. Early demise was defined as death, left ventricular assist device, or heart transplant within 6 months following CRT implant. Using a multivariate model, variables associated with early demise were identified and a prediction rule created.A total of 879 patients were included of whom 47 met criteria for early demise. Using forward stepwise regression followed by a bootstrapping analysis, the final model included: left ventricular end-diastolic diameter ≥6.5 cm (OR 3.23 [1.72-6.06 g], P0.001), the presence of a non-left bundle branch block (non-LBBB) morphology (OR 2.18 [1.18-4.04, P = 0.013]), creatinine ≥1.5 mg/dL (OR 2.98 [1.52-5.49], P0.001), and lack of or intolerance to β-blocker use (OR 2.80 [1.46-5.39], P = 0.002). The specificity for ≥2 and ≥3 risk factors was 72.6% and 94.6%, respectively.Left ventricular dilatation, the presence of a non-LBBB morphology, renal dysfunction, and lack of or intolerance to β-blockers are associated with early demise following CRT. In patients with at least 3 of these factors, bypassing CRT with early adoption of advanced heart failure therapies may be considered given the high specificity for rapid decline.
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المؤلفون: Mahesh, Manne, John, Rickard, Niraj, Varma, Mina K, Chung, Patrick, Tchou
المصدر: Pacing and clinical electrophysiology : PACE. 36(8)
مصطلحات موضوعية: Heart Failure, Male, Stroke Volume, Comorbidity, Cardiac Resynchronization Therapy, Survival Rate, Ventricular Dysfunction, Left, Age Distribution, Treatment Outcome, Risk Factors, Prevalence, Humans, Female, Sex Distribution, Aged, Ohio, Retrospective Studies
الوصف: Earlier studies in patients with reduced left ventricular ejection fraction (LVEF) ≤35% and prolonged QRS showed better survival outcomes with cardiac resynchronization therapy (CRT). Some patients respond dramatically to CRT by improving their LVEF to the normal range and are considered "super-responders." Our aim was to determine whether super-responders survival increases to levels comparable to the general population. We compared the survival of super-responders to the general population matched for age and sex.Of 909 patients with CRT device implantation between September 1998 and July 2008, 814 patients had pre- and post-CRT echocardiogram. A total of 95 patients with LVEF ≥ 50% following CRT were classified as super-responders. For 92 super-responders, who had U.S. Social Security numbers, an age- and sex-matched example was selected from the Social Security Life Tables. An expected survival plot of the matched population was then compared to the actual survival of super-responders.Super-responders had comparable survival to the age-sex matched general population (P = 0.53), and Kaplan-Meier survival analysis in 92 patients showed that super-responders with CRT pacemakers had similar survival to those with CRT implantable cardioverter defibrillators (P = 0.77). Super-responders were more likely to be females (54% vs 25%, P0.001) and less likely to have significant coronary artery disease (62% vs 42%, P0.001).Normalization of LVEF by CRT improves survival to levels comparable to the general population. This observation favors the concept that some CRT candidates have a cardiomyopathy likely generated by the conduction abnormality that is reversible through biventricular pacing.
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