Patients that are unresponsive to cardiac resynchronization therapy (CRT) may benefit from a new device programming tool, according to the RESPOND-CRT study.
The SonR hemodynamic sensor — a sonar sensor to listen to the heart sounds as a surrogate for contractility, with an accelerometer embedded in the right atrial lead to determine whether at rest or activity — allows the device to automatically program the atrio-ventricular and inter-ventricular timings on a weekly basis without need for time-consuming echocardiographic adjustment in the office.
Freedom from lead complications up to 3 months was exhibited by 98.5% of patients, with 99.8% similarly complication-free in the period from 3 to 12 months. Patients also showed better rates of survival free of heart failure events and with an improvement in functional class or quality of life at 12 months (75.0% versus 70.4% for echo-guided patients, non-inferiority P<0.001).
By 2 years, there was a 35% risk reduction in heart failure hospitalizations (hazard ratio 0.65, 95% confidence interval 0.46-0.92), according to the prospective, double-blinded trial that included 1,039 patients from 125 sites.
“With one-third of patients not responding properly to current CRT optimization methods, we saw the need to explore alternative methods to improve patient outcomes. This new SonR technology is the first system to automatically optimize for patients every week. Importantly, it works while the patient is active and therefore provides patients with a better way of life,” Josep Brugada, MD, PhD, of Hospital Clínic de Barcelona, said in a press release. “This is a very promising technology for patients managing their heart failure and has the potential to become the new gold standard for CRT optimization.”
But was echo optimization ever the gold standard?
The problem with applying the data to clinical practice is that the trial assumes that it is, commented Vivek Reddy, MD, of New York’s Mount Sinai Hospital. “The pessimists could argue that it’s as good as putting a regular pacemaker in and programming it at the standard default setting.”
On the flip side, an optimistic way to look at this is as encouraging data, he told MedPage Today. “This is not something that’s going to change practice right now, but it’s very interesting.”
The findings were presented at the Heart Rhythm Society (HRS) annual meeting held in San Francisco. Other research of note at the conference follows.
The MPP IDE study showed data for yet another device programming strategy, suggesting that multi-point pacing (MPP) for CRT-defibrillators is non-inferior to standard quadripolar biventricular pacing.
“MPP was shown to be safe and effective and the study met the pre-specified hypothesis that the response to MPP is non-inferior to Quadripolar Bi-V pacing,” the authors reported. When MPP was programmed with the two pair of cathodes spaced more than 30 mm apart and a 5-millisecond left ventricular delay, the CRT responder rate shot up to 87%. What’s more, “all non-responders were converted to responders.”
Ablation Versus Meds for VT
The VANISH trial showed that if ischemic cardiomyopathy (ICM) patients with an implantable cardioverter defibrillator (ICD) have persistent ventricular tachycardia despite being on antiarrhythmic medications, then it’s time to resort to ablation.
Ablation was associated with a lower risk for combined death, excessive ventricular tachycardia, and appropriate ICD shock than was a strategy of escalating to more antiarrhythmia medication (59.1% versus 68.5%, P=0.04), according to data that were simultaneously published in the New England Journal of Medicine.
“This does move therapy towards the use of ablation, and one more step away from drug therapy,” Bruce Wilkoff, MD, of the Cleveland Clinic, told MedPage Today.
Same-Day Discharge After ICD
Leaving the hospital on the same day as ICD implantation can be safe for low-risk patients, a small trial found.
There was no benefit to next-day discharge when it came to the rate of 30-day procedural complications (1.81% versus 4.38% for same-day discharge, P=0.37), according to the investigators. For same-day discharge patients, those complications included three hematomas not requiring intervention and one cardiac perforation. Their next-day discharge counterparts had one lead dislodgement and one case of infection.
“Even with the dodgy math of hospital accounting, we can say probably this saves the country money,” co-author Ranjit Suri, MD, of Mount Sinai Hospital in New York, concluded at an HRS press conference.
First Randomized Rotor Ablation trial
Rotor mapping may be a hindrance to the success of radiofrequency ablation for persistent atrial fibrillation (afib), according to a presentation from the OASIS investigators. That said, such electrical “rotors” of the heart may not even exist.
Conventional pulmonary vein isolation with nonpulmonary vein trigger ablation emerged as the winning strategy for the reduction of afib. Rotor mapping, instead, just added time to the procedure; alone it had dismal outcomes.
“Unless there is a new version of rotor mapping that is significantly different, in my lab this will be the end of rotor ablation with this system,” said co-author Andrea Natale, MD, of the Texas Cardiac Arrhythmia Institute in Austin. Still, given that this was the first trial of its kind, he argued for more randomized trials of rotor ablation.