2015


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2015/№4

Decreased microvolt T-wave alternation as an index for effectiveness of resynchronization therapy in patients with CHF

Vaykhanskaya T. G., Koptyukh T. M., Kurushko T. V., Sidorenko I. V., Ryabov A. A.
State Institution Republican Science and Practice Center "Cardiology", R. Luxemburg 110, Minsk, Republic of Belarus

Keywords: cardiac resynchronization therapy, dilated cardiomyopathy, microvolt T-wave alteration, ventricular tachyarrhythmias

DOI: 10.18087/rhfj.2015.4.2100

Background. Cardiac resynchronization therapy (CRT) using biventricular stimulation is an effective treatment for patients with cardiac systolic dysfunction and electromechanical ventricular asynchrony. Aim. To study the effect of reverse LV remodeling on the time course of microvolt T-wave alternation (mTWA) and ventricular tachyarrhythmic ectopic activity in patients with CRT for HF induced by dilated cardiomyopathy (DCMP). Materials and methods. The study included 69 patients with DCMP (males, 75.4 %; 48.7±11.4; NYHA FC, 3.03±0.29; sinus rhythm; complete left bundle branch block with QRS duration of 144±23.3 msec; LV EF, 27.2±7.5 %) with implanted CRT-D (n=37) and CRT-P (n=32). Multimodal examination (EchoCG, ECG HM, and 7‑min ECG using the “Intecard-7” software for analysis of ventricular ectopic beats and mTWA) was performed for all patients prior to the device implantation and after 12.9±1.3 months of follow-up. MTWA was evaluated in CRT patients at the native ventricular conduction (VVI-40 or 0V0 mode). Serial 24‑h ECG monitoring and dynamic telemetry of implanted devices were performed for detection of ventricular tachyarrhythmic (VTA) events. Results. In the general group (49 / 71 % of patients with positive clinical and hemodynamic response to CRT and 20 / 29 % of CRT non-responders), mTWA was decreased (from 53.2±14.9 to 36.6±15.7 mcV; p<0.001) 12 months after the CRT implantation. In patients with positive (reverse) LV remodeling, mTWA significantly decreased (from 51.3±13.4 to 20.6±6.32 mcV; р<0.0001), VTA episodes were absent, and changes in mTWA significantly positively correlated with the decrease in LV cavity (for ESV, r=0.52, р<0.005; for EDV, r=0.51, р<0.005) and negatively correlated with changes in LV EF (r= –0.56, р<0.005). Multifactorial and ROC analyses showed a high predictive value of the 21 mcV decrease in mTWA (∆mTWA ≥21 mcV: sensitivity, 79 %; specificity, 75 %; S=0.826; CI, 95 %: 0.749–0.902; р<0.001) as an independent predictor for low risk of VTA episodes in patients with DCMP and as an anti-arrhythmic marker for effective CRT. Conclusion. In patients with DCMP after 12 months of CRT, decreased mTWA was associated with reverse LV remodeling and low arrhythmogenic risk. The decrease in mTWA by >21 mcV can be rationally used as a non-invasive anti-arrhythmic predictor and a marker for prevention of VTA in effective CRT.
  1. Cazeau S, Leclercq C, Lavergne T, Walker S, Varma C, Linde C et al. Effects of multisite biventricular pacing in patients with heart fai­lure and intraventricular conduction delay. New Engl J Med. 2001 Mar 22;344 (12):873–80.
  2. Garrigue S, Bordachar P, Reuter S, Jaris P, Kobeissi A, Gaggini G et al. Comparison of permanent left ventricular and biventricular pacing in patients with heart failure and chronic atrial fibrillation: prospective haemodynamic study. Heart. 2002 Jun;87 (6):529–34.
  3. Young JB, Abraham WT, Smith AL, Leon AR, Lieberman R, Wilkoff B et al. Combined cardiac resynchronization and implan­table cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD Trial. JAMA. 2003 May 28;289 (20):2685–94.
  4. Higgins SL, Hummel JD, Niazi IK, Giudici MC, Worley SJ, Saxon LA et al. Cardiac resynchronization therapy for the treatment of heart failure in patients with intraventricular conduction delay and malignant ventricular tachyarrhythmias. J Am Coll Cardiol. 2003 Oct 15;42 (8):1454–9.
  5. Ревишвили А. Ш., Неминущий Н. М. Сердечная ресинхронизирующая терапия в лечении хронической сердечной недостаточности. Вестник аритмологии. 2007;48:47–57.
  6. Bradley DJ, Bradley EA, Baughman KL, Berger RD, Calkins H, Goodman SN et al. Cardiac resynchronization and death from progressive heart failure: a meta-analysis of randomized controlled trials. JAMA. 2003 Feb 12;289 (6):730–40.
  7. McAlister FA, Ezekowitz JA, Wiebe N, Rowe B, Spooner C, Crumley E et al. Systematic review: cardiac resynchronization in patients with symptomatic heart failure. Ann Intern Med. 2004 Sep 7;141 (5):381–90.
  8. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. New Engl J Med. 2005 Apr 14;352 (15):1539–49.
  9. Gervais R, Leclercq C, Shankar A, Jacobs S, Eiskjaer H, Johannessen A et al. Surface electrocardiogram to predict outcome in candidates for cardiac resynchronization therapy: a sub-analysis of the CARE-HF trial. Eur J Heart Fail. 2009 Jul;11 (7):699–705.
  10. Шнейдер Ю. А., Красноперов П. В., Рогачева Н. М. Сердечная ресин­хро­низирующая терапия: от истоков до наших дней. Вестник аритмологии. 2010;60:75–80.
  11. Daubert JC, Saxon L, Adamson PB, Auricchio A, Berger RD, Beshai JF et al. 2012 EHRA / HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Europace. 2012 Sep;14 (9):1236–86.
  12. Costantini O, Hohnloser SH, Kirk MM, Lerman BB, Baker JH 2nd, Sethuraman B et al. The ABCD (Alternans Before Cardioverter Defibrillator) trial: strategies using T-wave alternans to improve efficiency of sudden cardiac death prevention. J Am Coll Cardiol. 2009 Feb 10;53 (6):471–9.
  13. Russo AM, Marchinski FE. Should microvolt t-wave alternans be utilized routinely in selecting patients for prophylactic implan­table cardioverter-defibrilator insertion of ischemic heart disease? J Am Coll Cardiol. 2007 Jan 2;49 (1):59–61.
  14. Вайханская Т. Г., Курушко Т. В., Cидоренко И. В., Коптюх Т. М., Гуль Л. М., Мельникова О. П. и др. Электрокардиографические предикторы ответа на ресинхронизирующую терапию сердечной недостаточности у пациентов с дилатационной кардиомиопатией. Кардиология. 2013;53 (3):48–54.
  15. Zizek D, Cvijic M, Tazic J, Jan M, Frljak S, Zupan I. Effect of cardiac resynchronization therapy on beat-to-beat T-wave amplitude varia­bility. Europace. 2012 Nov;14 (11):1646–52.
  16. Hohnloser SH, Klingenheben T, Bloomfield D, Dabbous O, Cohen RJ. Usefulness of microvolt T-wave alternans for prediction of ventricular tachyarrhythmic events in patients with dilated cardiomyo­pathy: results from a prospective observational study. J Am Coll Cardiol. 2003 Jun 18;41 (12):2220–4.
  17. Rashba EJ, Osman AF, MacMurdy K, Kirk MM, Sarang SE, Peters RW et al. Enhanced detection of arrhythmia vulnerability using T-wave alternans, left ventricular ejection fraction, and programmed ventricular stimulation: a prospective study in subjects with chronic ischemic heart disease. J Cardiovasc Electrophysiol. 2004 Feb;15 (2):170–6.
  18. Chow T, Kereiakes DJ, Onufer J, Woelfel A, Gursoy S, Peterson BJ et al. Does microvolt T-wave alternans testing predict ventricular tachyarrhythmias in patients with ischemic cardiomyopathy and prophylactic defibrillators? The MASTER (Microvolt T-wave Alternans Testing for Risk Stratification of Post-Myocardial Infarction Patients) trial. J Am Coll Cardiol. 2008 Nov 11;52 (20):1607–15.
  19. Salerno-Uriarte JA, De Ferrari GM, Klersy C, Pedretti RF, Tritto M, Sallusti L et al. Prognostic value of T-wave alternans in patients with heart failure due to nonischemic cardiomyopathy: results of the ALPHA study. J Am Coll Cardiol. 2007 Nov 6;50 (19):1896–904.
  20. Minkkinen M, Kähönen M, Viik J, Nikus K, Lehtinen R, Koobi T et al. Enhanced predictive power of quantitative TWA during routine exercise testing in the Finnish Cardiovascular (FINCAVAS) Study. J Cardiovasc Electrophysiol. 2009 Apr;20 (4):408–15.
  21. Verrier RL, Nieminen T. T-wave alternans as a therapeutic marker for antiarrhythmic agents. J Cardiovasc Pharmacol. 2010 Jun;55 (6):544–54.
  22. Вайханская Т. Г., Коптюх Т. М., Курушко Т. В., Сидоренко И. В., Геворкян Т. Т. Снижение микровольтной альтернации Т-волны как дополнительный предиктор успешной ресинхронизирующей терапии. Кардиология в Беларуси. 2014;3 (34):49–60.
  23. Лебедев Д. И., Минин С. М., Криволапов С. Н. Влияние кардиоресинхронизирующей терапии на динамику течения желудочковых тахикардий у пациентов с дилатационной кардиомиопатией и тяжелой сердечной недостаточностью. Журнал Сердечная Недостаточность. 2014;15 (1):39–44.
Vaykhanskaya T. G., Koptyukh T. M., Kurushko T. V., Sidorenko I. V., Ryabov A. A. Decreased microvolt T-wave alternation as an index for effectiveness of resynchronization therapy in patients with CHF. Russian Heart Failure Journal. 2015;16 (4):195–203

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