Closed loop stimulation in patients with chronic heart failure and severe chronotropic incompetence: Responders versus non-responders. (1st January 2023)

• Record Type: Journal Article
• Authors: Proff, Joachim; Merkely, Béla; Papp, Roland; Lenz, Corinna; Nordbeck, Peter; Butter, Christian; Meyhoefer, Juergen; Doering, Michael; MacCarter, Dean; Ingel, Katharina; Wolfarth, Bernd; Thouet, Thomas; Landmesser, Ulf; Roser, Mattias
• Is Part Of: International journal of cardiology. Volume 370(2023)
• Page Start: 222
• Page End: 228
• Publication Date: 2023-01-01
• Subjects: Cardiac resynchronization therapy -- Severe chronotropic incompetence -- Rate-adaptive pacing -- Closed loop stimulation -- Cardiopulmonary exercise testing -- Left ventricular ejection fraction; APMHR age-predicted maximum heart rate -- CI chronotropic incompetence -- CLS Closed Loop Stimulation -- CPX cardiopulmonary exercise -- CRT cardiac resynchronization therapy -- DDD-40 DDD biventricular pacing at 40 pulses/min -- FFR force-frequency relationship -- HF heart failure -- HFimpEF HF with improved LVEF -- HFrEF HF with reduced LVEF -- HRPEAK peak heart rate -- HRRECOVERY heart rate decrease at 60 s after the end of exercise -- HRREST resting heart rate before exercise -- %HRR percentage of heart rate reserve utilized at end-exercise -- LV left ventricular -- LVEF LV ejection fraction -- LVEDV LV end-diastolic volume -- LVESV LV end-systolic volume -- MLHFQ Minnesota Living with Heart Failure Questionnaire -- NT-proBNP N-terminal prohormone of brain natriuretic peptide -- OUES oxygen uptake efficiency slope -- O2P oxygen uptake divided by heart rate -- QoL quality of life -- VCO2 CO2 production -- VE minute ventilation -- VE/VCO2 ventilatory efficiency slope -- VO2max maximum oxygen uptake -- ∆ difference between DDD-CLS and DDD-40 -- %∆ relative change DDD-CLS vs. DDD-40; Cardiology -- Periodicals; Electronic journals; 616.12
• DOI: 10.1016/j.ijcard.2022.10.019
• Languages: English
• ISSNs: 0167-5273

Abstract

Abstract: Background: Clinical effects of rate-adaptive pacing (RAP) are unpredictable and highly variable among cardiac resynchronization therapy (CRT) patients with chronotropic incompetence. Physiologic sensors such as Closed Loop Stimulation (CLS), measuring intracardiac impedance changes (surrogate for ventricular contractility), may add clinical benefit and help identify predictors of response to RAP. The objective of the present BIOlCREATE study subanalysis was to identify criteria for selection of CRT patients who are likely to respond positively to CLS-based RAP. Methods: In the randomized, crossover BIO|CREATE study, CRT patients with severe chronotropic incompetence and NYHA class II/III were randomized to CLS with conventional upper sensor rate programming or to no RAP for 1 month, followed by crossover for another month. At 1-month and 2-month follow-ups, patients underwent treadmill-based cardiopulmonary exercise test. Positive CLS response was defined as a ≥ 5% reduction in ventilatory efficiency slope. Eight of 17 patients (47%) were CLS responders. In this subanalysis, we compared responders and non-responders to explore outcomes, mechanisms, and predictors. Results: All cardiopulmonary variables, health-related quality of life, patient activity status, and NT-proBNP concentration showed favorable trend in CLS responders and unfavorable trend in non-responders, underlining the need to find predictors. Following all analyses, we recommend CLS in heart failure patients with improved left ventricular ejection fraction (LVEF >40%, after a ≥ 10-point increase from a CRT-pre-implant value of ≤40%), corresponding to 'HFimpEF' in the universal classification system. Conclusion: HFimpEF patients are likely to benefit from CLS-based RAP, in contrast to 'HFrEF' (heart failure with reduced LVEF [≤40%]). Highlights: Rate adaptive pacing (RAP) in CRT patients with severe chronotropic incompetence Physiologic Closed Loop Stimulation (CLS) sensor might increase benefits from RAP. How to predict which CRT patients will respond positively to CLS-based RAP. Heart failure patients with improved LVEF (HFimpEF) are best responders to CLS. HFimpEF: LVEF>40% and a ≥10-point increase from a CRT-pre-implant value of ≤40%.