Jean Jacques Blanc

Some patients treated by cardiac resynchronization therapy (CRT) recover "normal" left ventricular (LV) function and functional status. However, whether this "normalization" persists or reverts over time remains unknown. The aim of the present study was to evaluate the long-term outcomes of LV function in patients hyper responder to CRT. Eleven consecutive patients with nonischemic dilated cardiomyopathy, sinus rhythm, left bundle branch block (LBBB), New York Heart Association (NYHA) class III or IV, and optimal pharmacological treatment were hyper responder as they fulfilled concurrently the two following criteria: functional recovery (NYHA class I or II) and normalization of LV ejection fraction (LVEF). After a mean follow-up of 65 ± 30 months between CRT implantation and last evaluation LVEF improved from 26 ± 9 to 59 ± 6% (P < 0.0001). One patient died from pulmonary embolism 31 months after implantation. Three patients exhibited LVEF ≤ 50% at their last follow-up visit (two at 40% and one at 45%). In eight patients, brief cessation of pacing was feasible (three were pacemaker-dependent). Mean QRS duration decreased from 181 ± 23 ms to 143 ± 22 ms (P = 0.006). In one patient, pacing was interrupted for 2 years and LVEF decreased markedly (from 65% to 31%) but returned to normal after a few months when pacing was resumed. In hyper responder patients, "normalization" of LV function after CRT persists as long as pacing is maintained with an excellent survival.

This editorial refers to ‘Prospective evaluation of non-pharmacological treatment in vasovagal syncope’ by J.J.C.M. Romme et al. , on page 567.

In some patients with non-ischaemic dilated cardiomyopathy (NIDCM), left bundle branch block (LBBB), and severe cardiac failure, cardiac resynchronization therapy (CRT) has been shown to reverse almost completely left ventricular (LV) function. These patients thus eligible to be qualified ‘hyper-responders’ are exclusively recruited in patients with NIDCM. Evaluate proportion of ‘hyper-responders’ among patients with NIDCM and try to determine their profile before implantation of CRT. Consecutive patients with DCM [LV ejection fraction (LVEF) 60 mm], sinus rhythm, LBBB, and New York Heart Association (NYHA) class III and IV implanted with a CRT were prospectively followed. Patients were considered ‘hyper-responders’ if they fulfilled after a minimum period of 6 months the following criteria: functional recovery (NYHA class I or II) and LVEF ≥50%. Among the 51 NIDCM patients, 11 (21.5%) were ‘hyper-responders’ following CRT (LVEF increased from 26 ± 9 to 59 ± 6%, P < 0.01). In the 40 (78.5%) remaining patients, there was no or minimal functional improvement and only a modest increase in LVEF from 21 ± 9 to 26 ± 12% ( P = 0.03). Comparison between ‘hyper-responders’ and remaining patients showed that baseline parameters of ‘hyper-responders’ were less severely deteriorated. In a significant subset of patients with CRT for NIDCM, a ‘complete’ functional recovery associated with normalization of LV function was observed. This observation suggests that LBBB could be the causative factor of DCM in this subgroup of patients. There was not a unique discriminating factor at baseline between ‘hyper-responders’ and remaining patients.

In the letter, Doctors Lam and Owen offer some very relevant comments on the recommendations for cardiac resynchronization combined with defibrillation therapy (CRT-D) in the ESC guidelines.¹ In regard to point 3.2.1, the authors provide further evidence from a network meta-analysis² grouping randomized controlled trials on device therapy in heart failure (HF) and its effects on death from any cause. This meta-analysis observed a significant reduction in deaths of any cause (Odds ratio 0.57, 95% confidence interval 0.40–0.80) conferred by CRT-D compared with medical therapy. This recent contribution was not available at the time of publication of these guidelines and it strengthens further the indication for CRT-D.

In the letter, Doctors Lam and Owen offer some very relevant comments on the recommendations for cardiac resynchronization combined with defibrillation therapy (CRT-D) in the ESC guidelines. ¹ In regard to point 3.2.1, the authors provide further evidence from a network meta-analysis ² grouping randomized controlled trials on device therapy in heart failure (HF) and its effects on death from any cause. This meta-analysis observed a significant reduction in deaths of any cause (odds ratio 0.57, 95% confidence interval 0.40–0.80) conferred by CRT-D compared with medical therapy. This recent contribution was not available at the time of publication of these guidelines and it strengthens further the indication for CRT-D.

P. Castellant, A. Perennes, M.L. Borel, C. L'Her, M. Fatemi, J-J. Blanc; 882 Adenosine triphosphate test: is it dangerous?, EP Europace, Volume 7, Issue Supple

C. L'Her, P. Castellant, M.L. Borel, M. Fatemi, J.J. Blanc; 736 Impact of an educational process on the management of patients admitted for syncope, EP Europac