Author + information
- Received August 27, 2019
- Revision received November 14, 2019
- Accepted November 18, 2019
- Published online February 17, 2020.
- Odette A.E. Salden, MDa,∗ (, )
- Kevin Vernooy, MD, PhDb,c,d,
- Antonius M.W. van Stipdonk, MD, PhDb,c,
- Maarten J. Cramer, MD, PhDa,
- Frits W. Prinzen, PhDb,c and
- Mathias Meine, MD, PhDa
- aDepartment of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
- bDepartment of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- cDepartment of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- dDepartment of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
- ↵∗Address for correspondence:
Dr. Odette A.E. Salden, Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, P.O. Box 85500, 3584 CX Utrecht, the Netherlands.
• CRT in patients with non-LBBB is often disputed, yet, 30% to 50% of these patients benefit from the treatment.
• Current ECG selection criteria have shortcomings, which, presumably result in a suboptimal patient selection.
• The establishment of sufficient baseline dyssynchrony (both electrical and mechanical) may enhance patient selection in the non-LBBB subgroup.
• Prospective randomized trials with sufficient power are needed to validate these dyssynchrony parameters.
Cardiac resynchronization therapy (CRT) is becoming increasingly controversial in patients without typical left bundle branch block (LBBB). Yet, several recent studies displayed that a distinct subpopulation of patients with non-LBBB does benefit from CRT. Patients with non-LBBB should, therefore, not as a group be withheld from a potentially very beneficial therapy. Unfortunately, current clinical practice lacks validated selection criteria that may identify possible CRT responders in the non-LBBB subgroup. Consequently, clinical decision making in these patients is often challenging. A few studies, strongly differing in design, have proposed additive selection criteria for improved response prediction in patients with non-LBBB. There is accumulating evidence that more sophisticated echocardiographic dyssynchrony markers, taking into account the underlying electrical substrate responsive to CRT, can aid in the selection of patients with a non-LBBB who may benefit more favorably from CRT. Furthermore, it is important that cardiologists are aware of the shortcomings of current electrocardiographic selection criteria for CRT. Whereas these criteria provide an evidence-based approach for selecting patients for CRT, they do not necessarily guarantee the most optimal strategy for patient selection. Parameters obtained with vectorcardiography, such as QRS area, show potential to overcome the shortcomings of conventional electrocardiographic selection criteria and may improve response prediction regardless of QRS morphology.
- cardiac resynchronization therapy
- heart failure
- non–left bundle branch block
- patient selection
Dr. Vernooy has received research grants and speaker honoraria from Medtronic and St. Jude Medical; and has been a consultant for Medtronic and Abbott. Dr. Prinzen has received research grants from Medtronic, Abbott, Biotronik, Microport CRM, and Biosense Webster. Dr. Meine has received research grant support from Boston Scientific and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received August 27, 2019.
- Revision received November 14, 2019.
- Accepted November 18, 2019.
- 2020 American College of Cardiology Foundation
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