In some patients who receive a cardiac resynchronization therapy (CRT) device, the left ventricular ejection fraction (LVEF) does not improve.

We analyzed patients enrolled in the REVERSE, MADIT-CRT, and BLOCK-HF trials, restricting the analysis to those who received CRT. Characteristics of patients with or without improved LVEF were compared using two sample t-tests and Pearson's chi-square tests. Kaplan-Meier survival curves were constructed to display time-to-event data. A log-rank test was used to compare event rates for patients with or without improved LVEF. Mixed effects Cox Proportional-Hazards models adjusting for covariates were used to analyze time to death or heart failure hospitalization (HFH) and time to death.

Of 1065 included patients, 75% (802) were men, 87% (793) were White, 11% (118) were Black, and 7% (72) were Hispanic. LVEF improved in 910 (85%) patients and did not in 155 (15%). Patients with an improved LVEF were less likely to have ischemic cardiomyopathy (ICM) (54% vs 76%; p = 0.004), more likely to have LBBB (73% vs 53%; p = < 0.001), and had longer QRS duration (159 vs 150 ms; p = < 0.001). In adjusted analyses, improved LVEF was associated with a longer time to HFH or death (HR 0.40; 95% CI 0.26-0.62; p < 0.001) or death alone (HR 0.27; 95% CI 0.15-0.48; p < 0.001).

Patients with improvement in LVEF post-CRT implantation are less likely to have ICM and more likely to have LBBB and a longer QRS interval. Improvement in LVEF was associated with better outcomes.

Ischemic heart disease (IHD) is the leading global cause of death, affecting millions and leading to significant morbidity and mortality. Ischemic cardiomyopathy (ICM), a manifestation of IHD, results in severe left ventricular dysfunction due to coronary artery disease and poses a significant challenge due to the complex pathophysiology, variable clinical presentation, and overall poor prognosis. Recent advances in medical therapy, device interventions, and revascularization techniques offer newfound hope in improving ICM patient outcomes. This article reviews the state-of-the-art management approaches for ICM, emphasizing the importance of personalized treatment plans that integrate the various contemporary therapies to address the multiple mechanisms of disease development and progression. A meticulously tailored treatment approach for each individual patient offers the hope of prolonged survival through the synergy of therapies designed to address the different and complex mechanisms that contribute to their disease process.

This review discusses the range of device therapy for ischemic cardiomyopathy (ICM). This article will review the primary data supporting guideline indications for cardiac implantable electronic devices in patients with ICM, with a focus on primary/secondary prevention transvenous implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy, and subcutaneous/extravascular ICDs. In addition, this review discusses emerging device therapy for ICM including left bundle area pacing/defibrillation, cardiac contractility modulation and baroflex activation therapy. Device therapy for ICM continues to evolve to incorporate diverse modalities across the spectrum from prevention of sudden cardiac death to modifying cardiac remodeling and recovery.

Right ventricular (RV) pacing may promote left ventricular (LV) dysfunction. Particularly in patients with preserved LV ejection fraction (LVEF), narrow QRS, and anticipated high ventricular pacing burden (HVPB), evidence is missing that biventricular (BiV) pacing can improve clinical outcome. We therefore evaluated whether implantation of a BiV pacing device (BiVPD) compared with a RV pacing device (RVPD) may improve clinical outcome in predominantly this kind of patients.

In the Biventricular Pacing for atrioventricular Block to Prevent Cardiac Desynchronization (BioPace) trial [multicentre, single-blinded (patients), randomized, parallel group], patients were equally allocated to either receive a BiVPD or a RVPD. Co-primary endpoints were (i) the composite of time to death or first heart failure hospitalization and (ii) survival time. We analysed 1810 randomized patients (median age: 73.5 years; female sex: 31.7%; mean LVEF 55.4%; mean QRS 118.4 ms), 902 to BiV and 908 to RV pacing. During mean follow-up of 68.8 months, the difference in the primary composite endpoint between both groups [346 vs. 363 events, hazard ratio (HR) 0.878; 95% confidence interval (CI) 0.756-1.020; P = 0.0882) or in mortality (305 vs. 307 deaths, HR 0.926; 95% CI 0.789-1.088; P = 0.3492) was smaller than 20%.

In patients, predominantly with preserved LVEF, narrow QRS, and HVPB, superiority of implanting BiVPDs compared with RVPDs could not be proven. Right ventricular pacing may be less harmful for this kind of patients than often suggested and primary BiV pacing does not clearly improve their clinical outcome.

Registered in ClinicalTrials.gov, number NCT00187278 (https://clinicaltrials.gov/ct2/show/study/NCT00187278).

Left bundle branch block (LBBB) causes immediate electrical and mechanical dyssynchrony of the left ventricle (LV) and gradual structural damages in the Purkinje cells and myocardium. Mechanical dyssynchrony reduces the LV ejection fraction (EF) instantly, but only to ≈55% in an otherwise normal heart. Because of the heart's in-built functional redundancy, a patient with LBBB does not always notice the heart's reduced efficiency straightaway. After a variable period of time (which could be from days to decades), the patient may become symptomatic with heart failure (HF), which classifies as HF with preserved EF ≥50% (HFpEF). The LVEF drops further because of continuous adverse remodeling and inefficient cardiac contraction. The patient transits to HF with moderately reduced EF 35%-50% (HFmrEF) and then reduced EF ≤35% (HFrEF) over 5-21 years. Cardiac resynchronization therapy (CRT) is currently only indicated in guidelines for HFrEF and LBBB. LBBB shortens the median survival of patients with HFmrEF by 5.5 years. Randomized controlled trials have shown that CRT improves echocardiographic indices for HFmrEF with LBBB. CRT in HFpEF with LBBB is a promising but underexplored/underused therapy. There have been anecdotal reports that CRT produced symptom relief in patients debilitated by HFpEF with LBBB, who constitute ≈6% of all patients with HF and an adequate pool of potential randomized controlled trial participants. Conduction system pacing in the form of left bundle branch area pacing is an emerging pacing strategy that might reverse and forestall the deleterious effects of LBBB.

To optimize support by healthcare professionals to enhance physical activity, HF-related symptom monitoring, and management in patients with heart failure before and after cardiac resynchronization therapy (CRT) implantation in co-creation with patients, informal caregivers, and healthcare professionals.

A qualitative and co-design approach was used to develop support strategies collaboratively with end-users. Seventeen semi-structured interviews were conducted to explore patients' expectations and factors influencing physical activity and symptom management. The qualitatively obtained insights informed the development of support strategies using an ideas group with patients, informal caregivers, and healthcare professionals.Four themes emerged from the interviews: (1) expecting and hoping to regain energy and fitness; (2) difficulties and opportunities to become more active; (3) impact of CRT on sense of safety; and (4) dealing with continuing bothersome symptoms. Several strategies were brainstormed, prioritized, and prototyped, including optimization of CRT information, a peer contact list, expansion of the post-CRT implantation consultation to ask questions and share concerns, and a group meeting with peer patients, partners, and healthcare professionals.

Patients expected and hoped to have positive effects from CRT, but not all patients experienced improvement after CRT. To improve patients' physical activity, feelings of insecurity, symptom monitoring, and thoughtful response to symptoms, support must include providing information and support to increase their knowledge and discuss experiences and physical and mental concerns.

Left bundle branch block (LBBB) is a frequent finding in patients with heart failure (HF), particularly in those with dilated cardiomyopathy (DCM). LBBB has been commonly described as a consequence of DCM development. However, a total recovery of left ventricular (LV) function after cardiac resynchronization therapy (CRT), observed in patients with LBBB and DCM, has led to increasing acknowledgement of LBBB-induced dilated cardiomyopathy (LBBB-iDCM) as a specific pathological entity. Its recognition has important clinical implications, as LBBB-iDCM patients may benefit from an early CRT strategy rather than medical HF therapy only. At present, there are no definitive diagnostic criteria enabling the universal identification of LBBB-iDCM, and no defined therapeutic approach in this subgroup of patients. This review compiles the main findings about LBBB-iDCM pathophysiology and the current proposed diagnostic criteria and therapeutic approach.

There have been few large-scale studies on the outcomes of cardiomyopathy-associated heart failure (HF) in infants aged <1 year. This study aimed to assess longitudinal echocardiographic outcomes of infants with HF secondary to cardiomyopathy who survived for >1 year.

A prospective observational study following 327 infant patients up to 5 years in 2 large pediatric heart centers in Northern China between January 2010 and December 2018. A total of 236 (72.2%) patients had reduced left ventricular ejection fraction (LVEF) (HF with reduced ejection fraction group; LVEF <40%), 91 (27.8%) patients had midrange LVEF (HF with midrange ejection fraction group; LVEF ≥40% but <55%). LVEF improved significantly within the first year and remained stable in years 2 through 5 for both groups. The HF with midrange ejection fraction group had a higher rate of LVEF normalization (hazard ratio, 1.65; P<0.001). Baseline LVEF ≥40%, baseline left ventricular end-diastolic diameter Z score <7.8, the absence of left bundle-branch block, and the absence of β-blocker use were 4 independent favorable predictors for future LVEF normalization. A total of 62.4% of enrolled patients were diagnosed with left ventricular noncompaction. No significant difference in LVEF normalization was found among the different types of cardiomyopathy studied.

A significant number of infants with cardiomyopathy who survived >1 year were found to improve with medical therapies during the first year of diagnosis. Poorer outcomes were associated with decreased LVEF and increased heart size at diagnosis baseline, the presence of left bundle-branch block and use of β blockers. The Northern Chinese pediatric population may have a high proportion of left ventricular noncompaction.

Heart failure (HF) is associated with global changes in gene expression. Alternative mRNA splicing (AS) is a key regulatory mechanism underlying these changes. However, the whole status of molecules involved in the splicing process in human HF is unknown. Therefore, we analysed the spliceosome transcriptome in cardiac tissue (n = 36) from control subjects and HF patients (with ischaemic (ICM) and dilated (DCM) cardiomyopathies) using RNA-seq. We found greater deregulation of spliceosome machinery in ICM. Specifically, we showed widespread upregulation of the E and C complex components, highlighting an increase in SNRPD2 (FC = 1.35, p < 0.05) and DHX35 (FC = 1.34, p < 0.001) mRNA levels. In contrast, we observed generalised downregulation of the A complex and cardiac-specific AS factors, such as the multifunctional protein PCBP2 (FC = -1.29, p < 0.001) and the RNA binding proteins QKI (FC = -1.35, p < 0.01). In addition, we found a relationship between SNPRD2 (an E complex component) and the left ventricular mass index in ICM patients (r = 0.779; p < 0.01). On the other hand, we observed the specific underexpression of DDX46 (FC = -1.29), RBM17 (FC = -1.33), SDE2 (FC = -1.35) and RBFOX1 (FC = -1.33), p < 0.05, in DCM patients. Therefore, these aetiology-related alterations may indicate the differential involvement of the splicing process in the development of ICM and DCM.

Biventricular pacing is a well-established therapy for patients with heart failure (HF), left bundle branch block (LBBB) and left ventricular (LV) dysfunction. Left bundle branch pacing (LBBP) has emerged as an alternative to biventricular pacing.

The aim of this study was to assess the retrograde conduction properties of the left bundle branch in patients with nonischemic cardiomyopathy and LBBB during LBBP and its clinical implications.

Patients undergoing successful LBBP for nonischemic cardiomyopathy with LV ejection fraction (LVEF) ≤35% and LBBB were included. Continuous recording of His potential was performed using a quadripolar catheter. Unidirectional block was defined as retrograde His bundle activation during LBBP with stimulus to His potential (SH) duration less than or equal to antegrade HV interval and bidirectional block as VH dissociation or SH duration greater than HV interval. HF hospitalization, ventricular arrhythmias, and mortality were documented.

A total of 165 patients were included. The mean follow-up duration was 21.8 ± 13.1 months. Bidirectional block (group I) was observed in 82% (n = 136), and these patients were noted to have advanced HF stage and prolonged baseline QRS duration. Unidirectional block (group II) with intact retrograde conduction was observed in 18% (n = 29) and was associated with narrow paced QRS duration and higher LVEF during follow-up. Super-response (LVEF ≥50%) was observed in 54.4% (n = 74) in group I compared with 73.3% (n = 22) in group II (P = 0.03). The OR for LVEF normalization was 4.1 (95% CI: 1.26-13.97; P = 0.02), with unidirectional block compared with bidirectional block in patients with LBBB and LV dysfunction. Adverse clinical outcomes as measured by a composite of HF hospitalization, ventricular arrhythmias, and mortality were significantly higher in group I compared with group II (12.5% vs 0%; P = 0.04).

Bidirectional block in LBBB was characterized by advanced HF symptoms, while unidirectional block was associated with better clinical outcomes after cardiac resynchronization therapy by LBBP.

Although sex-related differences in the epidemiology, risk factors, clinical characteristics and outcomes of heart failure are well known, investigations in the past decade have shed light on an often overlooked aspect of heart failure: the influence of sex on treatment response. Sex-related differences in anatomy, physiology, pharmacokinetics, pharmacodynamics and psychosocial factors might influence the response to pharmacological agents, device therapy and cardiac rehabilitation in patients with heart failure. In this Review, we discuss the similarities between men and women in their response to heart failure therapies, as well as the sex-related differences in treatment benefits, dose-response relationships, and tolerability and safety of guideline-directed medical therapy, device therapy and cardiac rehabilitation. We provide insights into the unique challenges faced by men and women with heart failure, highlight potential avenues for tailored therapeutic approaches and call for sex-specific evaluation of treatment efficacy and safety in future research.

Heart failure (HF) is a complex medical condition characterized by both electrical and mechanical dyssynchrony. Both dyssynchrony mechanisms are intricately linked together, but the current guidelines for cardiac resynchronization therapy (CRT) rely only on the electrical dyssynchrony criteria, such as the QRS complex duration. This possible inconsistency may result in undertreating eligible individuals who could benefit from CRT due to their mechanical dyssynchrony, even if they fail to fulfill the electrical criteria. The main objective of this literature review is to provide a comprehensive analysis of the practical value of echocardiography for the assessment of left ventricular (LV) dyssynchrony using parameters such as septal flash and apical rocking, which have proven their relevance in patient selection for CRT. The secondary objectives aim to offer an overview of the relationship between septal flash and apical rocking, to emphasize the primary drawbacks and benefits of using echocardiography for evaluation of septal flash and apical rocking, and to offer insights into potential clinical applications and future research directions in this area. Conclusion: there is an opportunity to render resynchronization therapy more effective for every individual; septal flash and apical rocking could be a very useful and straightforward echocardiography resource.

The existing ECG criteria for diagnosing left bundle branch block (LBBB) are insufficient to distinguish between true and false blocks accurately.

We hypothesized that the notch width of the QRS complex in the lateral leads (I, avL, V5, V6) on the LBBB-like ECG could further confirm the diagnosis of true complete left bundle branch block (t-LBBB). We conducted high-density, three-dimensional electroanatomical mapping in the cardiac chambers of 37 patients scheduled to undergo CRT. These patients' preoperative electrocardiograms met the ACC/AHA/HRS guidelines for the diagnosis of complete LBBB. If the left bundle branch potential could be mapped from the base of the heart to the apex on the left ventricular septum, it was defined as a false complete left bundle branch block (f-LBBB). Otherwise, it was categorized as a t-LBBB. We conducted a comparative analysis between the two groups, considering the clinical characteristics, real-time correspondence between the spread of ventricular electrical excitation and the QRS wave, QRS notch width of the lateral leads (I, avL, V5, V6), and the notch width/left ventricular end-diastolic diameter (Nw/LVd) ratio. We performed the ROC correlation analysis of Nw/LVd and t-LBBB to determine the sensitivity and specificity for diagnostic authenticity.

Twenty-five patients were included in the t-LBBB group, while 12 patients were assigned to the f-LBBB group. Within the t-LBBB group, the first peak of the QRS notch correlated with the depolarization of the right ventricle and septum, the trough corresponded to the depolarization of the left ventricle across the left ventricle, and the second peak aligned with the depolarization of the left ventricular free wall. In contrast, within the f-LBBB group, the first peak coincided with the depolarization of the right ventricle and a majority of the left ventricle, the second peak occurred due to the depolarization of the latest, locally-activated myocardium in the left ventricle, and the trough was a result of delayed activation of the left ventricle that did not align with the usual peak timing. The QRS notch width (45.2 ± 12.3 ms vs. 52.5 ± 9.2 ms, P < 0.05) and the Nw/LVd ratio (0.65 ± 0.19 ms/mm vs. 0.81 ± 0.17 ms/mm, P < 0.05) were compared between the two groups. After conducting the ROC correlation analysis, a sensitivity of 56% and a specificity of 91.7% for diagnosing t-LBBB using Nw/LVd were obtained.

By utilizing the current diagnostic criteria for LBBB, an increased Nw/LVd value can enhance the effectiveness of diagnosing LBBB.

Left bundle branch block (LBBB) and atrial fibrillation (AF) are commonly coexisting conditions. The impact of LBBB on catheter ablation of AF has not been well determined. This study aims to explore the long-term outcomes of patients with AF and LBBB after catheter ablation.

Forty-two patients with LBBB of 11,752 patients who underwent catheter ablation of AF from 2011 to 2020 were enrolled as LBBB group. After propensity score matching in a 1:4 ratio, 168 AF patients without LBBB were enrolled as non-LBBB group. Late recurrence and a composite endpoint of stroke, all-cause mortality, and cardiovascular hospitalization were compared between the two groups.

Late recurrence rate was significantly higher in the LBBB group than that in the non-LBBB group (54.8% vs. 31.5%, p = .034). Multivariate analysis showed that LBBB was an independent risk factor for late recurrence after catheter ablation of AF (hazard ratio [HR] 2.19, 95% confidence interval [CI] 1.09-4.40, p = .031). LBBB group was also associated with a significantly higher incidence of the composite endpoint (21.4% vs. 6.5%, HR 3.98, 95% CI 1.64-9.64, p = .002).

LBBB was associated with a higher risk for late recurrence and a higher incidence of composite endpoint in the patients underwent catheter ablation.

Accurate assessment of left ventricular (LV) function is essential for managing patients with left bundle branch block (LBBB). This study aimed to evaluate the relationship between LV systolic function, left ventricular diastolic filling time (LVFT), QRS duration, and heart failure symptoms in patients with LBBB.

This study was conducted between June 2021 and June 2022. Patients with LBBB and sinus rhythm who were referred to the echocardiography department were included in the study. All the patients underwent electrocardiogram-gated echocardiography using the same machine. In this study, the LVFT value was measured in absolute terms and as a ratio to the R-R interval (LVFT/RR).

A total of sixty-five patients were included, forty-two (64.6%) were women, and the mean age was 60.71 ± 8.72. We performed three one-way ANOVA tests that showed that LV filling time/RR ratio, QRS duration, and ejection fraction were significantly different between heart failure classes (p = 0.008, p = 0.001, and p < 0.001, respectively). A weak correlation was observed between LVEF and LVFT/RR (r = 0.349, p = 0.004). Additionally, QRS duration was negatively correlated with LVEF (r =  - 0.395, p = 0.004) and LVFT/RR (r =  - 0.350, p = 0.004), although these correlations were weak.

We showed that LVFT/RR ratio differed significantly between HF functional classes and was lower in patients with more severe HF symptoms. Additionally, QRS duration was negatively correlated with LVEF and LVFT/RR, and patients with more severe HF symptoms had longer QRS durations.

The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria. The classical paradigm postulates that the increased left ventricular mass generates a stronger electrical field, increasing the leftward and posterior QRS forces, reflected in the augmented QRS amplitude. However, the low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm. The theoretical background for voltage measured at the body surface is defined by the solid angle theorem, which relates the measured voltage to spatial and non-spatial determinants. The spatial determinants are represented by the extent of the activation front and the distance of the recording electrodes. The non-spatial determinants comprise electrical characteristics of the myocardium, which are comparatively neglected in the interpretation of the QRS patterns. Various clinical conditions are associated with LVH. These conditions produce considerable diversity of electrical properties alterations thereby modifying the resultant QRS patterns. The spectrum of QRS patterns observed in LVH patients is quite broad, including also left axis deviation, left anterior fascicular block, incomplete and complete left bundle branch blocks, Q waves, and fragmented QRS. Importantly, the QRS complex can be within normal limits. The new paradigm stresses the electrophysiological background in interpreting QRS changes, i.e., the effect of the non-spatial determinants. This postulates that the role of ECG is not to estimate LV size in LVH, but to understand and decode the underlying electrical processes, which are crucial in relation to cardiovascular risk assessment.

Cardiac resynchronisation therapy (CRT) is an established treatment for patients with symptomatic heart failure with reduced left ventricular ejection fraction (LVEF ≤ 35%; HFrEF) and conduction disturbances (QRS duration ≥ 130 ms). The presence of mechanical dyssynchrony (MD) on echocardiography has been hypothesised to be of predictive value in determining indication for CRT. This study investigated the impact of MD (apical rocking [AR] and septal flash [SF]) on long-term survival in CRT recipients. HFrEF patients (n = 425; mean age 63.0 ± 10.6 years, 72.3% male, 60.7% non-ischaemic aetiology) with a guideline-derived indication for CRT underwent device implantation. MD markers were determined at baseline and after a mean follow-up of 11.5 ± 8.0 months; long-term survival was also determined. AR and/or SF were present in 307 (72.2%) participants at baseline. During post-CRT follow-up, AR and/or SF disappeared in 256 (83.4%) patients. Overall mean survival was 95.9 ± 52.9 months, longer in women than in men (109.1 ± 52.4 vs. 90.9 ± 52.4 months; p < 0.001) and in younger (< 60 years) versus older patients (110.6 ± 53.7 vs. 88.6 ± 51.1 months; p < 0.001). Patients with versus without MD markers at baseline generally survived for longer (106.2 ± 52.0 vs. 68.9 ± 45.4 months; p < 0.001), and survival was best in patients with resolved versus persisting MD (111.6 ± 51.2 vs. 79.7 ± 47.6 months p < 0.001). Age and MD at baseline were strong predictors of long-term survival in HFrEF patients undergoing CRT on multivariate analysis. Novel echocardiography MD parameters in HFrEF CRT recipients predicted long-term mediated better outcome, and survival improved further when AR and/or SF disappear after CRT implantation.

Population aging is a global public health issue involving increased prevalence of age-related diseases, and concomitant burden on medical resources and the economy. Ninety-two diseases have been identified as age-related, accounting for 51.3% of the global adult disease burden. The economic cost per capita for older people over 60 years is 10 times that of the younger population. From the aspects of predictive, preventive, and personalized medicine (PPPM), developing a risk-prediction model can help identify individuals at high risk for all-cause mortality and provide an opportunity for targeted prevention through personalized intervention at an early stage. However, there is still a lack of predictive models to help community-dwelling older adults do well in healthcare.

This study aims to develop an accurate 1-, 3-, 5-, and 8-year all-cause mortality risk-prediction model by using clinical multidimensional variables, and investigate risk factors for 1-, 3-, 5-, and 8-year all-cause mortality in community-dwelling older adults to guide primary prevention.

This is a two-center cohort study. Inclusion criteria: (1) community-dwelling adult, (2) resided in the districts of Chaonan or Haojiang for more than 6 months in the past 12 months, and (3) completed a health examination. Exclusion criteria: (1) age less than 60 years, (2) more than 30 incomplete variables, (3) no signed informed consent. The primary outcome of the study was all-cause mortality obtained from face-to-face interviews, telephone interviews, and the medical death database from 2012 to 2021. Finally, we enrolled 5085 community-dwelling adults, 60 years and older, who underwent routine health screening in the Chaonan and Haojiang districts, southern China, from 2012 to 2021. Of them, 3091 participants from Chaonan were recruited as the primary training and internal validation study cohort, while 1994 participants from Haojiang were recruited as the external validation cohort. A total of 95 clinical multidimensional variables, including demographics, lifestyle behaviors, symptoms, medical history, family history, physical examination, laboratory tests, and electrocardiogram (ECG) data were collected to identify candidate risk factors and characteristics. Risk factors were identified using least absolute shrinkage and selection operator (LASSO) models and multivariable Cox proportional hazards regression analysis. A nomogram predictive model for 1-, 3-, 5- and 8-year all-cause mortality was constructed. The accuracy and calibration of the nomogram prediction model were assessed using the concordance index (C-index), integrated Brier score (IBS), receiver operating characteristic (ROC), and calibration curves. The clinical validity of the model was assessed using decision curve analysis (DCA).

Nine independent risk factors for 1-, 3-, 5-, and 8-year all-cause mortality were identified, including increased age, male, alcohol status, higher daily liquor consumption, history of cancer, elevated fasting glucose, lower hemoglobin, higher heart rate, and the occurrence of heart block. The acquisition of risk factor criteria is low cost, easily obtained, convenient for clinical application, and provides new insights and targets for the development of personalized prevention and interventions for high-risk individuals. The areas under the curve (AUC) of the nomogram model were 0.767, 0.776, and 0.806, and the C-indexes were 0.765, 0.775, and 0.797, in the training, internal validation, and external validation sets, respectively. The IBS was less than 0.25, which indicates good calibration. Calibration and decision curves showed that the predicted probabilities were in good agreement with the actual probabilities and had good clinical predictive value for PPPM.

The personalized risk prediction model can identify individuals at high risk of all-cause mortality, help offer primary care to prevent all-cause mortality, and provide personalized medical treatment for these high-risk individuals from the PPPM perspective. Strict control of daily liquor consumption, lowering fasting glucose, raising hemoglobin, controlling heart rate, and treatment of heart block could be beneficial for improving survival in elderly populations.

The online version contains supplementary material available at 10.1007/s13167-023-00342-4.

The ECG diagnosis of LVH is predominantly based on the QRS voltage criteria, i.e. the increased QRS complex amplitude in defined leads. The classical ECG diagnostic paradigm postulates that the increased left ventricular mass generates a stronger electrical field, increasing the leftward and posterior QRS forces. These increased forces are reflected in the augmented QRS amplitude in the corresponding leads. However, the clinical observations document increased QRS amplitude only in the minority of patients with LVH. The low sensitivity of voltage criteria has been repeatedly documented. We discuss possible reasons for this shortcoming and proposal of a new paradigm.

Cardiac resynchronization therapy (CRT) via biventricular pacing (BiVP-CRT) is considered a mainstay treatment for symptomatic heart failure patients with reduced ejection fraction and wide QRS. However, up to one-third of patients receiving BiVP-CRT are considered non-responders to the therapy. Multiple strategies have been proposed to maximize the percentage of CRT responders including two new physiological pacing modalities that have emerged in recent years: His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Both pacing techniques aim at restoring the normal electrical activation of the ventricles through the native conduction system in opposition to the cell-to-cell activation of conventional right ventricular myocardial pacing. Conduction system pacing (CSP), including both HBP and LBBAP, appears to be a promising pacing modality for delivering CRT and has proven to be safe and feasible in this particular setting. This article will review the current state of the art of CSP-based CRT, its limitations, and future directions.

Cardiac resynchronisation therapy (CRT) has become the cornerstone of heart failure (HF) treatment. Despite the obvious benefit from this therapy, an estimated 30% of CRT patients do not respond ("non-responders"). The cause of "non-response" is multi-factorial and includes suboptimal device settings. To optimise CRT settings, echocardiography has been considered the gold standard but has limitations: it is user dependent and consumes time and resources. CRT proprietary algorithms have been developed to perform device optimisation efficiently and with limited resources. In this review, we discuss CRT optimisation including the various adopted proprietary algorithms and conduction system pacing.

Algorithms to automatically adjust atrioventricular (AV) and interventricular (VV) intervals in cardiac resynchronization therapy (CRT) devices are common, but their clinical efficacy is unknown.

The purpose of this study was to evaluate automatic CRT algorithms in patients with heart failure for the reduction of mortality, heart failure hospitalizations, and clinical improvement.

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) in patients with CRT using automatic algorithms that change AV and VV intervals dynamically without manual input, on a beat-to-beat basis. We performed a subgroup analysis including intracardiac electrogram-based (EGM) algorithms and contractility-based algorithms.

Nine RCTs with 8531 participants were included, of whom 4275 (50.1%) were randomized to automatic algorithm. Seven of the 9 trials used EGM-based algorithms, and 2 used contractility sensors. There was no difference in all-cause mortality (10.3% vs 11.3%; odds ratio [OR] 0.90; 95% confidence interval [CI] 0.71-1.03; P = .13; I2 = 0%) or heart failure hospitalizations (15.0% vs 16.1%; OR 0.924; 95% CI 0.81-1.04; P = .194; I2 = 0%) between the automatic algorithm group and the control group. Study-defined clinical improvement was also not significantly different between groups (66.6% vs 63.3%; risk ratio 1.01; 95% CI 0.95-1.06; P = .82; I2 = 50%). In the contractility-based subgroup, there was a trend toward greater clinical improvement with the use of the automatic algorithm (75% vs 68.3%; OR 1.45; 95% CI 0.97-2.18; P = .07; I2 = 40%), which did not reach statistical significance. The overall risk of bias was low.

Automatic algorithms that change AV or VV intervals did not improve mortality, heart failure hospitalizations, or cardiovascular symptoms in patients with heart failure and CRT.

Left bundle branch block (LBBB) has been confirmed to be independently associated with adverse outcomes in dilated cardiomyopathy (DCM). However, prognostic data on nonspecific intraventricular conduction delay (NSIVCD) are still limited and conflicting. We aimed to evaluate the prognosis of DCM with NSIVCD.

A total of 548 DCM patients who underwent cardiovascular magnetic resonance imaging (CMR) from January 2016 to December 2017 were consecutively enrolled. The cohort was divided into four groups: 87 with LBBB, 27 with RBBB, 61 with NSIVCD, and 373 without intraventricular conduction delay (IVCD). After a median follow-up of 58 months (interquartile range: 47-65), 123 patients reached the composite endpoints, which included cardiovascular death, heart transplantation, and malignant arrhythmias. The associations between different patterns of IVCD and the outcomes of DCM were analysed by Kaplan‒Meier analysis and Cox proportional hazards regression analysis.

Of 548 DCM patients, there were 398 males (72.6%), and the average age was 46 ± 15 years, ranging from 18 to 76 years. In Kaplan‒Meier analysis, patients with NSIVCD and LBBB showed higher event rates than patients without IVCD, while RBBB patients did not. By multivariate Cox regression analysis, LBBB, NSIVCD, NYHA class, left ventricular ejection fraction (LVEF), indexed left ventricular end-diastolic diameter (LVEDDI), percentage of late gadolinium enhancement mass (LGE%), and global longitudinal strain (GLS) were found to be independently associated with the outcomes of DCM.

In addition to LBBB, NSIVCD was an unfavourable prognostic marker in patients with DCM, independent of LVEDDI, NYHA class, LVEF, LGE%, and GLS.

Despite substantial progress in medical and device-based heart failure (HF) therapy, ventricular arrhythmias (VA) and sudden cardiac death (SCD) remain a major challenge. Here we review contemporary management of VA in the context of HF with one particular focus on recent advances in imaging and catheter ablation.

Besides limited efficacy of antiarrhythmic drugs (AADs), their potentially life-threatening side effects are increasingly acknowledged. On the other hand, with tremendous advances in catheter technology, electroanatomical mapping, imaging, and understanding of arrhythmia mechanisms, catheter ablation has evolved into a safe, efficacious therapy. In fact, recent randomized trials support early catheter ablation, demonstrating superiority over AAD. Importantly, CMR imaging with gadolinium contrast has emerged as a central tool for the management of VA complicating HF: CMR is not only essential for an accurate diagnosis of the underlying entity and subsequent treatment decisions, but also improves risk stratification for SCD prevention and patient selection for ICD therapy. Finally, 3-dimensional characterization of arrhythmogenic substrate by CMR and imaging-guided ablation approaches substantially enhance procedural safety and efficacy. VA management in HF patients is highly complex and should be addressed in a multidisciplinary approach, preferably at specialized centers. While recent evidence supports early catheter ablation of VA, an impact on mortality remains to be demonstrated. Moreover, risk stratification for ICD therapy may have to be reconsidered, taking into account imaging, genetic testing, and other parameters beyond left ventricular function.

Our main objective was to present a multidisciplinary review on the epidemiology of sudden cardiac death (SCD) and the tools that could be used to identify malignant ventricular arrhythmias (VAs) and to perform risk stratification. In addition, indications and contraindications for the use of implantable cardioverter defibrillator (ICD) in general and in special populations including the elderly and patients with chronic kidney disease (CKD) are also given.

An expert group from the Inter American Society of Cardiology (IASC), through their HF Council (CIFACAH) and Electrocardiology Council (ElectroSIAC), together with the Latin American Heart Rhythm Society (LAHRS), reviewed and discussed the literature regarding the appropriate use of an ICD in people with heart failure (HF) with reduced ejection fraction (HFpEF). Indications and contraindications for the use of ICD are presented in this multidisciplinary review.

Numerous clinical studies have demonstrated the usefulness of ICD in both primary and secondary prevention of SCD in HFpEF. There are currently precise indications and contraindications for the use of these devices.

In some Latin American countries, a low rate of implantation is correlated with low incomes, but this is not the case for all Latin America. Determinants of the low rates of ICD implantation in many Latin American countries are still a matter of research. VA remains one of the most common causes of cardiovascular death associated with HFrEF and different tools are available for stratifying the risk of SCD in this population.

Left bundle branch block (LBBB) might be the first finding of cardiovascular diseases but also the prerequisite for cardiac resynchronization therapy (CRT) in heart failure (HF) with reduced ejection fraction (HFrEF). The prognosis for patients with LBBB and the implications of CRT in an unselected real-world setting are the focus of our study.

A central electrocardiogram (ECG) database and national registers have been screened to identify patients with LBBB. Predictors of HF and the use of CRT were identified with Cox models. The hazard ratios (HRs) of death, cardiovascular death (CVD), and HF hospitalization (HFH) were estimated according to CRT use. Of 5359 patients with LBBB and QRS > 150 ms, median age 76 years, 36% were female. At the time of index ECG, 41% had a previous history of HF and 27% developed HF. Among 1053 patients with a class I indication for CRT, only 60% received CRT with a median delay of 137 days, and it was associated with a lower risk of death [HR: 0.45, 95% confidence interval (CI): 0.36-0.57], CVD (HR: 0.47, 95% CI: 0.35-0.63), and HFH (HR: 0.56, 95% CI: 0.48-0.66). The age of over 75 years and the diagnosis of dementia and chronic obstructive pulmonary disease were predictors of CRT non-use, while having a pacing/defibrillator device independently predicted CRT use.

In an unselected LBBB population, CRT is underused but of great value for HF patients. Therefore, it is crucial to find ways of better implementing and understanding CRT utilization and characteristics that influence the management of our patients.

Nonischemic cardiomyopathies are a frequent occurrence. The understanding of the mechanism(s) and triggers of these cardiomyopathies have led to improvement and even recovery of left ventricular function. Although chronic right ventricular pacing-induced cardiomyopathy has been recognized for many years, left bundle branch block and pre-excitation have been recently identified as potential reversible causes of cardiomyopathy. These cardiomyopathies share a similar abnormal ventricular propagation that can be recognized by a wide QRS duration with left bundle branch block pattern; thus, we coined the term abnormal conduction-induced cardiomyopathies. Such abnormal propagation results in an abnormal contractility that can only be recognized by cardiac imaging as ventricular dyssynchrony. Appropriate diagnosis and treatment will not only lead to improved left ventricular ejection fraction and functional class, but may also reduce morbidity and mortality. This review presents an update of the mechanisms, prevalence, incidence, and risk factors, as well as their diagnosis and management, while highlighting current gaps of knowledge.

d-loop transposition of the great arteries (d-TGA) and congenitally corrected transposition of the great arteries (cc-TGA) feature a right ventricle attempting to sustain the systemic circulation. A systemic right ventricle (sRV) cannot support cardiac output in the long run, eventually decompensating and causing heart failure. The burden of d-TGA patients with previous atrial switch repair and cc-TGA patients with heart failure will only increase in the coming years due to the aging adult congenital heart disease population and improvements in the management of advanced heart failure. Clinical data still lags behind in developing evidence-based guidelines for risk stratification and management of sRV patients, and clinical trials for heart failure in these patients are underrepresented. Recent studies have provided foundational data for the commencement of robust clinical trials in d-TGA and cc-TGA patients. Further insights into the multifactorial nature of sRV failure can only be provided by the results of such studies. This review discusses the mechanisms of heart failure in sRV patients with biventricular circulation and how these mediators may be targeted clinically to alleviate sRV failure.

Heart failure (HF) is a complex, multifactorial, progressive clinical condition affecting 64.3 million people worldwide, with a strong impact in terms of morbidity, mortality and public health costs. In the last 50 years, along with a better understanding of HF physiopathology and in agreement with the four main models of HF, many therapeutic options have been developed. Recently, the European Society of Cardiology (ESC) HF guidelines enthusiastically introduced inhibitors of the sodium-glucose cotransporter (SGLT2i) as first line therapy for HF with reduced ejection fraction (HFrEF) in order to reduce hospitalizations and mortality. Despite drugs developed as hypoglycemic agents, data from the EMPA-REG OUTCOME trial encouraged the evaluation of the possible cardiovascular effects, showing SGLT2i beneficial effects on loading conditions, neurohormonal axes, heart cells' biochemistry and vascular stiffness, determining an improvement of each HF model. We want to give a boost to their use by increasing the knowledge of SGLT2-I and understanding the probable mechanisms of this new class of drugs, highlighting strengths and weaknesses, and providing a brief comment on major trials that made Gliflozins a cornerstone in HF therapy. Finally, aspects that may hinder SGLT2-i widespread utilization among different types of specialists, despite the guidelines' indications, will be discussed.

Background Previous studies have demonstrated that 2-dimensional (2D) global longitudinal strain (GLS) is associated with cardiovascular outcomes in patients with left bundle-branch block. However, the predictive value of 3-dimensional (3D) speckle-tracking echocardiography has not yet been investigated in these patients. Methods and Results The authors retrospectively identified 290 patients with left bundle-branch block who underwent echocardiography more than twice. Using speckle-tracking echocardiography, 2D-GLS, 3D-GLS, 3D-global circumferential strain, 3D global radial strain, and 3D global area strain were acquired. The association between 2D and 3D strains and the follow-up left ventricular (LV) ejection fraction (LVEF) was analyzed. The study population was divided into 2 sets: a group with preserved LVEF (baseline LVEF ≥40%) and a group with reduced LVEF (baseline LVEF <40%). After a median follow-up of 29.1 months (interquartile range, 13.1-53.0 months), 14.9% of patients progressed to LV dysfunction in the group with preserved LVEF, and 51.0% of patients showed improved LV function in the group with reduced LVEF. Multivariable analysis of 2D and 3D strains revealed that higher 2D-GLS (odds ratio [OR], 0.65 [95% CI, 0.54-0.78], P<0.001) was highly associated with maintaining LVEF in patients with preserved LVEF. However, a lower 3D-global circumferential strain (OR, 0.61 [95% CI, 0.47-0.78], P<0.001) showed a strong association with persistently reduced LVEF in patients with reduced LVEF. Conclusions Although 2D-GLS showed a powerful predictive value for the deterioration of LV function in the preserved LVEF group, 3D strain, especially 3D-global circumferential strain, can be helpful to predict consistent LV dysfunction in patients with left bundle-branch block who have reduced LVEF.

The treatment of dilated cardiomyopathy (DCM) has recently been greatly improved, especially with the widespread use of sacubitril/valsartan (ARNI) combination therapy. We know that ARNI-like drugs can significantly improve the symptoms of heart failure with reducing ejection fraction. However, clinical studies evaluating the safety and efficacy of ARNI in DCM-associated arrhythmia are limited, and whether individuals with arrhythmia would benefit from ARNI remains controversial. In this case, we report a patient with complete left bundle branch block (CLBBB) associated with DCM whose CLBBB returned to normal after treatment with ARNI.

A 38-year-old man was admitted to the hospital for 20 days for idiopathic paroxysmal dyspnea. He presented with exacerbated dyspnea symptoms at night, accompanied by cough and sputum.

Physical examination revealed a grade 4/6 systolic murmur could be heard in the apical area of the heart and mild edema was present in both lower limbs. Laboratory examination found that the B-type natriuretic peptide was significantly increased. Echocardiography indicated left atrial internal diameter, right ventricular internal diameter, and left ventricular diastolic diameter were enlarged and ejection fraction was significantly decreased. Besides, the pulsation of the wall was diffusely attenuated. Electrocardiogram was suggestive of tachycardia and CLBBB. A diagnosis of DCM with CLBBB was considered based on a comprehensive evaluation of the physical examination, laboratory examination, echocardiography and electrocardiogram.

The patient was treated with ARNI at a dose of 50 mg (twice a day) at first, gradually increasing to the target dose (200 mg, twice a day) in the following 9 months as shown in Table 1, along with metoprolol 25 mg (once a day [qd]), diuretics 20 mg (qd), and aldosterone 20 mg (qd).

After treatment with ARNI during the 9-month follow-up, the patient's symptoms improved, and CLBBB returned to normal.

Clinical studies evaluating the safety and efficacy of ARNI in DCM-associated arrhythmia are limited, and whether individuals with arrhythmia would benefit from ARNI remains controversial. This report will help to instruct the clinical treatment of DCM patients with CLBBB and the potential application of ARNI.

Cardiac resynchronization therapy (CRT) is an effective therapy for patients who suffer from heart failure and ventricular dyssynchrony such as left bundle branch block (LBBB). When it works, it reverses adverse left ventricular (LV) remodeling and the progression of heart failure. However, CRT response rate is currently as low as 50-65%. In theory, CRT outcome could be improved by allowing clinicians to tailor the therapy through patient-specific lead locations, timing, and/or pacing protocol. However, this also presents a dilemma: there are far too many possible strategies to test during the implantation surgery. Computational models could address this dilemma by predicting remodeling outcomes for each patient before the surgery takes place. Therefore, the goal of this study was to develop a rapid computational model to predict reverse LV remodeling following CRT. We adapted our recently developed computational model of LV remodeling to simulate the mechanics of ventricular dyssynchrony and added a rapid electrical model to predict electrical activation timing. The model was calibrated to quantitatively match changes in hemodynamics and global and local LV wall mass from a canine study of LBBB and CRT. The calibrated model was used to investigate the influence of LV lead location and ischemia on CRT remodeling outcome. Our model results suggest that remodeling outcome varies with both lead location and ischemia location, and does not always correlate with short-term improvement in QRS duration. The results and time frame required to customize and run this model suggest promise for this approach in a clinical setting.

Heart failure (HF) is a clinical condition distinguished by structural and functional defects in the myocardium, which genetic and environmental factors can induce. HF is caused by various genetic factors that are both heterogeneous and complex. The incidence of HF varies depending on the definition and area, but it is calculated to be between 1 and 2% in developed countries. There are several factors associated with the progression of HF, ranging from coronary artery disease to hypertension, of which observed the most common genetic cause to be cardiomyopathy. The main objective of this study is to investigate heart failure and its association with cardiomyopathy with their genetic variants. The selected novel genes that have been linked to human inherited cardiomyopathy play a critical role in the pathogenesis and progression of HF. Research sources collected from the human gene mutation and several databases revealed that numerous genes are linked to cardiomyopathy and thus explained the hereditary influence of such a condition. Our findings support the understanding of the genetics aspect of HF and will provide more accurate evidence of the role of changing disease accuracy. Furthermore, a better knowledge of the molecular pathophysiology of genetically caused HF could contribute to the emergence of personalized therapeutics in future.