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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article provides an overview of cardiac resynchronization therapy (CRT) in patients with atrial fibrillation (AF), including the effect of AF on CRT outcomes and strategies for CRT pacing in AF patients.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eheart failure\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Einterventional techniques \u0026amp; devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Earrhythmias\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ECRT in AF\u003C\/h2\u003E\n         \u003Cp id=\u0022p-2\u0022\u003EMichael R. Gold, MD, Medical University of South Carolina, Charleston, SC, provided an overview of cardiac resynchronization therapy (CRT) in patients with atrial fibrillation (AF), including the effect of AF on CRT outcomes and strategies for CRT pacing in AF patients.\u003C\/p\u003E\n         \u003Cp id=\u0022p-3\u0022\u003EAF is frequent in patients with congestive heart failure (CHF) and reduces the efficacy of CRT in several ways. Biventricular pacing is less frequent in the presence of AF, irregularities of the ventricular response adversely affect the filling and emptying of the left ventricle, and the presence of AF leads to the inability to optimize atrioventricular timing to maximize contractility and preload.\u003C\/p\u003E\n         \u003Cp id=\u0022p-4\u0022\u003EAF is the most common arrhythmic cause of hospitalization for patients on CRT. Data from a prospectively collected registry of patients from February 1999 to October 2005 who had CRT devices implanted showed that hospital stays for patients with AF were twice as long as those for patients without AF. In addition, ICU admissions were 3 times as frequent (41% vs 14%), and the use of ionotropic therapy increased by about 50% [Kahn et al. \u003Cem\u003EHRS\u003C\/em\u003E 2006].\u003C\/p\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EDespite these effects, data from the CARE-HF study have shown that CRT reduces mortality regardless of whether patients developed AF [Hoppe UC et al. \u003Cem\u003ECirculation\u003C\/em\u003E 2006]. Pacing strategies for patients with AF include aggressive rhythm and rate control with antiarrhythmic therapy and increasing the lower rate of pacing to maintain a higher biventricular pacing rate. Other features and devices that can be used to maintain the percentage of ventricular pacing include ventricular r ate regulation, triggered pacing modes, and AV node ablation.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EMechanisms Associated with CRT Benefit\u003C\/h2\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EWe know that 20\u201330% of patients respond to CRT [Bax J et al. \u003Cem\u003EJ Am Col Cardiol\u003C\/em\u003E 2005]. Jeroen J. Bax, MD, University Hospital Leiden, Leiden, The Netherlands, provided some insight into why this might be so and whether QRS is an appropriate predictor of CRT response.\u003C\/p\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EAlthough it is not clear what exactly drives the benefit of CRT, most studies indicate that it is LV dyssynchrony [Bax J et al. \u003Cem\u003EJ Am Col Cardiol\u003C\/em\u003E 2005]. However, when Bleeker and colleagues studied 90 patients with end-stage heart failure (HF) and QRS ranging from 80 to 240, they found no correlation between QRS duration and left ventricular (LV) dyssynchrony (r=0.26; p=NS) [Bleeker GB. \u003Cem\u003EJ Cardiovasc Electrophysiol\u003C\/em\u003E 2004].\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EFurther, when patients were stratified by duration of QRS interval, 30% to 40% of HF patients with QRS \u0026gt;120 ms did not exhibit LV dyssynchrony, which may explain the lack of response of some patients to CRT.\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EAlternatively, 27% of patients with HF and a narrow QRS complex show significant LV dyssynchrony and may be candidates for CRT. Thus, if response to CRT is related to LV dyssynchrony, then QRS duration may not be all that important in determining the response to CRT. In Prof. Bax\u0027s view, larger studies are needed to help answer these questions.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EDuration of Benefit Associated with CRT\u003C\/h2\u003E\n         \u003Cp id=\u0022p-10\u0022\u003EWilliam T. Abraham, MD, Ohio State University, Columbus, OH, discussed the benefits that are seen with CRT and whether these results can be sustained.\u003C\/p\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EMore than 4000 NYHA Class III or IV patients on CRT have been evaluated in randomized controlled trials. The short term results of these trials (usual duration, 6 months) have demonstrated consistent improvement in quality of life (QOL) (significant improvement on the Minnesota Living with Heart Failure Score), functional status improvement (\u22651 improvement in NYHA class), and exercise capacity (improvements in 6 minute walk distance or peak VO\u003Csub\u003E2\u003C\/sub\u003E). The trials also have provided strong evidence for reverse remodeling\u2014eg, lower LV volumes and dimensions, higher LVEF, and lower mitral regurgitation, as well as a reduction in HF and trends toward reductions in all-cause morbidity and mortality [Abraham WT \u0026amp; Hayes DL. \u003Cem\u003ECirculation\u003C\/em\u003E 2003].\u003C\/p\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EOne of the questions that must be answered, however, is \u201cAre these results sustained?\u201d According to data from the MIRACLE trial, the improvement in QOL scores, 6 minute walk distance, and NYHA Functional class appear to be sustained out to at least 24 months (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E) [Abraham WT. AHA 2003]. In terms of outcomes and remodeling, the CARE-HF Extension study demonstrated a 40% reduction in all-cause mortality associated with CRT after a mean follow-up of 36.4 months (p\u0026lt;0.0001). Significant improvements were also seen in time to death from worsening HF (45%; p=0.003) and time to sudden cardiac death (46%; p=0.006).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/22\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022CRT Benefits Sustained Through 2 (Years Paired Data Displayed).\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2096116781\u0022 data-figure-caption=\u0022CRT Benefits Sustained Through 2 (Years Paired Data Displayed).\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/22\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/22\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/22\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11091\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-13\u0022 class=\u0022first-child\u0022\u003ECRT Benefits Sustained Through 2 (Years Paired Data Displayed).\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EAccording to Dr. Abraham, remodeling is probably our best surrogate for the efficacy of HF therapy. The initial improvements in both LV end systolic volume (LVESV) and LVEF observed with CRT in the CARE HF trial were sustained through 29 months (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). What is most interesting about reverse remodeling observed to date with CRT is that it appears to be progressive over a long period of time, implying that the improvements with CRT are sustainable.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/22\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022CARE-HF: Changes in LVESV and LVEF.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2096116781\u0022 data-figure-caption=\u0022CARE-HF: Changes in LVESV and LVEF.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/22\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/22\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/8\/2\/22\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/11093\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-15\u0022 class=\u0022first-child\u0022\u003ECARE-HF: Changes in LVESV and LVEF.\u003C\/p\u003E\n            \u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2008 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/8\/2\/22.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmghd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmghd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}