Cited by 110Cardiac pacing and defibrillation studiesCardiac Arrest and ResuscitationCardiac electrophysiology and arrhythmias

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Usefulness of Baseline Electrocardiographic QRS Complex Pattern to Predict Response to Cardiac Resynchronization

Adelstein, Evan C., Saba, Samir·2009·The American Journal of Cardiology

DOI 10.1016/j.amjcard.2008.08.069

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Abstract

Cardiac resynchronization therapy (CRT) improves morbidity and mortality in patients with heart failure with QRS>120 ms, yet most patients studied in clinical trials manifested baseline left branch bundle block (LBBB). It is unclear whether benefits of CRT extend to patients with right branch bundle block (RBBB) or a paced QRS at baseline despite QRS>120 ms. Orthotopic heart transplantation- and ventricular assist device-free survival, symptomatic response, and echocardiographic response were evaluated in the 636 patients who underwent CRT at our institution from 2000 to 2007 in whom the baseline electrocardiogram showed LBBB (n=412; 65%), paced QRS (n=162; 26%), or RBBB (n=62; 10%). Mortality was assessed using the Social Security Death Index, and the medical record was analyzed for clinical data. A decrease in New York Heart Association class>or=0.5 after >or=6 months of CRT defined symptomatic response. Echocardiographic evidence of improved left ventricular function and reverse remodeling was evaluated after >or=6 months of CRT. Survival free from orthotopic heart transplantation and ventricular assist device placement was best in patients with LBBB and worst in those with RBBB, whereas patients with paced QRS had an intermediate prognosis (p=0.003). This finding remained significant after controlling for baseline differences among the 3 groups. Symptomatic response was observed most often in patients with LBBB (60%), occurred least often in patients with RBBB (14%), and was intermediate in patients with paced QRS (46%; p<0.001). Echocardiographic improvement showed a similar stepwise trend. In conclusion, patients with RBBB undergoing CRT had low rates of symptomatic and echocardiographic response, and their survival free from orthotopic heart transplantation or ventricular assist device placement was significantly worse than in patients with LBBB. Patients with conventionally paced QRS experienced an intermediate response.

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MethodResultInfluential
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Self-citation
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Niazi, 2008, Evaluation of echocardiographic screening techniques for CRT in narrow QRS patients with mechanical dyssynchrony from a multi-center study: ESTEEM-CRT, Heart Rhythm, 5, S90

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QRS morphology and ventricular dyssynchrony in patients with chronic right ventricular pacing
Lee, K. H., Cho, J. G., Park, H. W., Yoon, N. S., Kim, S. S., Kim, J.-H., Kim, M. C., Cho, K. H., Kim, H. K., Kim, C. H., et al. (2014) · International Journal of Cardiology · doi:10.1016/j.ijcard.2014.08.131 · Cited by 12
“QRS morphologies and width have been suggested as potential predictors of MD development in cardiac pacing [8–11], yet there has been no risk stratification developed using a QRS morphology scoring system.”
Method
Contemporary Review of Left Bundle Branch Block in the Failing Heart – Pathogenesis, Prognosis, and Therapy
Kanawati, J., & Sy, R. W. (2017) · Heart Lung and Circulation · doi:10.1016/j.hlc.2017.09.007 · Cited by 11
The relation between cardiac 123I-mIBG scintigraphy and functional response 1 year after CRT implantation
Verschure, D. O., Poel, E., Vincentis, G. D., Frantellizzi, V., Nakajima, K., Gheysens, O. S., de Groot, J. R., & Verberne, H. J. (2020) · European Heart Journal - Cardiovascular Imaging · doi:10.1093/ehjci/jeaa045 · Cited by 12
“Therefore, these results may help selecting CHF patients eligible for CRT and consequently reduce the percentage of nonresponse to CRT.”
Influential
Does Cardiac Resynchronization Therapy Benefit Patients With Right Bundle Branch Block
Bilchick, K. C. (2014) · Circulation Arrhythmia and Electrophysiology · doi:10.1161/circep.113.000747 · Cited by 11
“The change in the NYHA class was also much greater in patients with LBBB.”
MethodInfluential
Baseline delayed left ventricular activation predicts long-term clinical outcome in cardiac resynchronization therapy recipients
Eitel, C., Wilton, S. B., Switzer, N. J., Cowan, K. F., & Exner, D. V. (2011) · EP Europace · doi:10.1093/europace/eur298 · Cited by 10
“Patients chronically RV paced present with a functional LBBB, however, this does not reﬂect an underlying conduction abnormality and distinguishes these patients from those with endogenous LBBB. 24 Furthermore, notches in the QRS might be inﬂuenced by the location of the RV lead.”
Background
Global and Regional Ventricular Repolarization Study by Body Surface Potential Mapping in Patients with Left Bundle‐Branch Block and Heart Failure Undergoing Cardiac Resynchronization Therapy
Douglas, R. A., Samesima, N., Filho, M. M., Pedrosa, A., Nishioka, S., & Pastore, C. A. (2012) · Annals of Noninvasive Electrocardiology · doi:10.1111/j.1542-474x.2012.00500.x · Cited by 9
Cardiac resynchronization therapy in NYHA class IV heart failure
Khoo, M. S. C., Kelly, P. A., & Lindenfeld, J. M. (2009) · Current Cardiology Reports · doi:10.1007/s11886-009-0026-8 · Cited by 9
Left Ventricular Pacing Threshold and Outcome in MADIT‐CRT
Pires, L. A., McNitt, S. A., Solomon, S. D., Goldenberg, I., Zaręba, W., & Moss, A. J. (2014) · Journal of Cardiovascular Electrophysiology · doi:10.1111/jce.12448 · Cited by 9
Predictors of Cardiac Resynchronization Therapy Response: The Pivotal Role of Electrocardiogram
Alhebaishi, Y. S., Alshehri, H. Z., & Moghairi, A. M. A. (2013) · The Scientific World JOURNAL · doi:10.1155/2013/837086 · Cited by 8
“Less than 15% of patients in the large controlled CRT trials had RBBB on baseline ECG, and as a result most available clinical data addressing the efficacy of CRT in RBBB are derived from retrospective data analyzing a relatively small number of patients [8, 9, 12, 13, 46].”
Background
Simpler Is Better
Kalahasty, G., & Ellenbogen, K. A. (2010) · Circulation · doi:10.1161/cir.0b013e3181d2c8f0 · Cited by 8
QRS pattern and improvement in right and left ventricular function after cardiac resynchronization therapy: a radionuclide study
Domenichini, G., Burri, H., Valzania, C., Gavaruzzi, G., Fallani, F., Biffi, M., Sunthorn, H., Diemberger, I., Martignani, C., Foulkes, H., et al. (2012) · BMC Cardiovascular Disorders · doi:10.1186/1471-2261-12-27 · Cited by 7
“[12] evaluated 636 consecutive pts undergoing to CRT implantation with LBBB, RBBB, or paced QRS at baseline.”
BackgroundMethod
Targeting Left Ventricular Lead Placement to Improve Cardiac Resynchronization Therapy Outcomes
Liu, J., ADELSTEIN, E. C., & Saba, S. (2013) · Current Cardiology Reports · doi:10.1007/s11886-013-0390-2 · Cited by 6
Self-citation
QRS frequency characteristics help predict response to cardiac resynchronization in left bundle branch block less than 150 milliseconds
Niebauer, M. J., Rickard, J., Polakof, L. S., TCHOU, P. J., & Varma, N. (2014) · Heart Rhythm · doi:10.1016/j.hrthm.2014.07.034 · Cited by 6
“Although superior efficacy of CRT has been shown when the QRS width exceeds 150 ms, LBBB morphology is more predictive of CRT success compared to other causes of prolonged QRS.3,6 This is enlightening because QRS duration in LBBB is tightly linked to extent of underlying LV conduction delay.17,18 A report from our cen…”
Background
Cardiac resynchronization therapy: Dire need for targeted left ventricular lead placement and optimal device programming
Pastromas, S. (2014) · World Journal of Cardiology · doi:10.4330/wjc.v6.i12.1270 · Cited by 6
Very Long-Term Outcomes of Cardiac Resynchronization Therapy in Patients With Ischemic and Nonischemic Cardiomyopathy
Gupta, A. R., Karikalan, S. A., Katukuri, N., Kumar, A., Kowlgi, G. N., DeSimone, C. V., Munoz, F. D., Ezzeddine, F. M., Lee, J. Z., Cha, Y., et al. (2025) · JACC Advances · doi:10.1016/j.jacadv.2025.101713 · Cited by 5
Electrical remodelling and response following cardiac resynchronization therapy: A novel analysis of intracardiac electrogram using a quadripolar lead
Toner, L., Flannery, D., Sugumar, H., Ord, M., Lin, T., & O’Donnell, D. (2018) · Journal of Arrhythmia · doi:10.1002/joa3.12063 · Cited by 5
“The presence of a left bundle branch block (LBBB) and a prolonged QRS duration consistently predict response to CRT.(3,5,6) A degree of electrical remodelling following CRT, defined according to surface ECG criteria, has been described and has demonstrated nonsignificant trends toward correlation with anatomical remod…”
Background
Mechanical Dyssynchrony: A Risk Factor but not a Target
Shah, A. M., & Solomon, S. D. (2015) · European Heart Journal · doi:10.1093/eurheartj/ehv458 · Cited by 5
Left Bundle Branch Block
Sze, E. Y., & Daubert, J. P. (2016) · JACC Heart Failure · doi:10.1016/j.jchf.2016.09.004 · Cited by 5
Heart failure patients selection for cardiac resynchronization therapy
Geng, J.-C., Wu, B., Zheng, L., & Zhu, J. (2010) · European Journal of Internal Medicine · doi:10.1016/j.ejim.2010.11.002 · Cited by 4
“It has been demonstrated that in failing hearts, less mechanical dyssynchrony was induced by RBBB than LBBB [78].”
BackgroundInfluential
Cardiac resynchronization therapy in patients with left ventricular systolic dysfunction and right bundle branch block: A systematic review
Cheitlin, M. D. (2012) · Yearbook of Cardiology · doi:10.1016/j.ycar.2012.01.011 · Cited by 4
Cardiac resynchronization therapy: Forget QRS duration but do not forget QRS morphology
Zaręba, W. (2013) · Journal of Electrocardiology · doi:10.1016/j.jelectrocard.2013.01.003 · Cited by 4
Useful Electrocardiographic Signs to Support the Prediction of Favorable Response to Cardiac Resynchronization Therapy
Simon, A., Pilecky, D., Kiss, L. Z., & Vámos, M. (2023) · Journal of Cardiovascular Development and Disease · doi:10.3390/jcdd10100425 · Cited by 4
“Patients with a left bundle branch block (LBBB) pattern demonstrated more beneﬁt than those with right bundle branch block (RBBB) or non-speciﬁc intraventricular conduction delay (IVCD) patterns [16–18].”
Method
Landmark Evolutions in Time and Indication for Cardiac Resynchronization Therapy: Results from a Multicenter Retrospective Registry
Bijnens, J., Trenson, S., Vörös, G., Martens, P., Ingelaere, S., Betschart, P., Voigt, J., Dupont, M., Breitenstein, A., Steffel, J., et al. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13071903 · Cited by 3
“Early retrospective studies have also indicated increased event rates [26,27] or less echocardiographic and symptomatic benefit [28] after a 3-year follow-up period among patients with a non-LBBB conduction pattern.”
Background
Underestimation of duration of ventricular activation by 12-lead ECG compared with direct measurement of activation duration derived from implanted pacemaker leads
Duncan, A., Lim, E. K. S., Mebrate, Y., Wong, T., & Gibson, D. G. (2010) · International Journal of Cardiology · doi:10.1016/j.ijcard.2010.07.001 · Cited by 3
“Our results do however confirm, as clinical trials imply, that selective LV delay is likely to be more pronounced when QRSd is N150 ms [9–13], and absent in patients with QRSd b120 ms [21] and in those with a RBBB pattern and normal axis [33].”
Result
Cardiac resynchronization therapy for the treatment of heart failure
Nayar, V., & Pugh, P. J. (2010) · Expert Review of Cardiovascular Therapy · doi:10.1586/erc.10.1 · Cited by 3
Geometrical and electrical predictors of cardiac resynchronization therapy response
Stabile, G., Iuliano, A., Rocca, V. L., Solimene, F., Fazio, R., & Simone, A. D. (2014) · Expert Review of Cardiovascular Therapy · doi:10.1586/14779072.2014.921117 · Cited by 3
“Similarly, Adelstein and Saba [22] reported that patients with RBBB undergoing CRT had low rates of symptomatic and echocardiographic response, and their survival free from orthotopic heart transplantation or ventricular assist device placement was significantly worse than in patients with LBBB (TABLE 2).”
BackgroundInfluential
Cardiac Resynchronization Therapy
Auricchio, A., & Leclercq, C. (2016) · Elsevier eBooks · doi:10.1016/b978-0-323-37804-8.00018-3 · Cited by 2
Cardiac resynchronization therapy: back to ECG?
Gianfranchi, L., & Alboni, P. (2010) · Journal of Cardiovascular Medicine · doi:10.2459/jcm.0b013e328332e84a · Cited by 2
The Year of 2008 in Electrocardiology
Stern, S. (2010) · Annals of Noninvasive Electrocardiology · doi:10.1111/j.1542-474x.2009.00347.x · Cited by 1
Should a Patient with Severe Left Ventricular Dysfunction, Congestive Heart Failure, and Right Bundle Branch Block QRS Receive Cardiac Resynchronization Therapy?
TOMPKINS, C. M., & Zaręba, W. (2012) · Cardiac Electrophysiology Clinics · doi:10.1016/j.ccep.2012.02.012 · Cited by 1
Defibrillators and Cardiac Resynchronization Therapy as a Bridge to Cardiac Transplantation
Hasan, A., & Sun, B. (2011) · Heart Failure Clinics · doi:10.1016/j.hfc.2011.01.001 · Cited by 1
ACCF/AHA Practice Guideline
Yancy, C. W., Jessup, M. L., Bozkurt, B., Butler, J., Drazner, M. H., Fonarow, G. C., Geraci, S. A., Horwich, T. B., Januzzi, J. L., Johnson, M. R., et al. (2013) · Cited by 1
Use of Cardiac Resynchronisation Therapy – Change of Clinical Settings
Looi, K., TANG, A. S. L., & Agarwal, S. (2011) · Arrhythmia & Electrophysiology Review · doi:10.15420/aer.2011.3.1.20 · Cited by 1
“004).(40) The highest symptomatic NYHA response rate was observed in those with LBBB, whereas few patients with RBBB responded (p<0.”
Background
Potential Underestimation of Left Ventricular Mechanical Dyssynchrony in Dyssynchrony and Outcomes Assessment
Zhou, Z., Ma, F., Zhu, J., Wang, J., Zhang, J., & Zhao, D. (2024) · Journal of Multidisciplinary Healthcare · doi:10.2147/jmdh.s450264 · Cited by 1
Cardiac resynchronization therapy: evaluation of ventricular dysynchrony and patient selection.
Baquero, G. A., Banchs, J. E., Davidson, W. R., Penny-Peterson, E., Samii, S. M., Wolbrette, D. L., Naccarelli, G. V., & Gonzalez, M. D. (2010) · PubMed · Cited by 1
Cardiac resynchronisation therapy in 2015: keeping up with the pace
Voskoboinik, A., McGavigan, A. D., & Mariani, J. A. (2015) · Internal Medicine Journal · doi:10.1111/imj.12774 · Cited by 1
His-optimized cardiac resynchronization therapy in a patient with heart failure and right bundle branch block: a case report
Volkov, D., Lopin, D. A., Rybchynskyi, S. V., & Skoryi, D. (2021) · European Heart Journal - Case Reports · doi:10.1093/ehjcr/ytab277 · Cited by 1
“• The retrograde aortic approach can be considered as an initial one in patients with RBBB undergoing atrioventricular nodal radiofrequency ablation for rate control after HOT-CRT.”
ResultInfluential
The QRS Interval in Patients Treated with Resynchronization Therapy: Which Value?
Boriani, G., Bertini, M., Diemberger, I., Biffi, M., & Martignani, C. (2009) · European Journal of Heart Failure · doi:10.1093/eurjhf/hfp079 · Cited by 1
“patients with an LBBB.(10) In the study by Gervais et al.”
Background
Mechanical Dyssynchrony with Gated Myocardial Perfusion SPECT: Reproducibility is the Key
Vigdor, A., & Bravo, P. E. (2021) · Journal of Nuclear Cardiology · doi:10.1007/s12350-020-02463-z · Cited by 1
Estudo da repolarização ventricular em pacientes submetidos à terapia de ressincronização cardíaca, portadores de bloqueio de ramo esquerdo e insuficiência cardíaca, através do mapeamento eletrocardiográfico de superfície
Douglas, R. A. (2011) · doi:10.11606/t.5.2011.tde-17062011-164713
Kardiale Resynchronisationstherapie: Präoperatives Screening
Kindermann, M., Mahfoud, F., Ukena, C., & Fröhlig, G. (2009) · Herzschrittmachertherapie + Elektrophysiologie · doi:10.1007/s00399-009-0053-6
“Linksschenkelblock.”
Influential
Caracterização do padrão da ativação elétrica ventricular de indivíduos portadores de ressincronizador cardíaco através do mapeamento eletrocardiográfico de superfície
Samesima, N. (2011) · doi:10.11606/t.5.2011.tde-24052011-121744
The influence of mental load and physical load on the interventricular synchronous depolarization
Li, Y., Xu, Z. F., Wei, M., Zhang, L., Yang, X., & Yao, Y. (2013) · ICME International Conference on Complex Medical Engineering (CME) · doi:10.1109/iccme.2013.6548247
Periprocedural Management of Cardiac Resynchronization Therapy
Rickard, J., & Varma, N. (2014) · Current Treatment Options in Cardiovascular Medicine · doi:10.1007/s11936-014-0298-1
Predictive Power of the Baseline QRS Complex Duration for Clinical Response to Cardiac Resynchronisation Therapy CARDIAC RESYNCHRONISATION THERAPY | ORIGINAL ARTICLE
Kazemisaeid, A., Bozorgi, A., Sharif, A. Y., Davoodi, G., Sadeghian, S., Sadeghian, H., & Sheikhvatan, M. (2011)
PREDICTIVE POWER OF THE BASELINE QRS COMPLEX DURATION FOR CLINICAL RESPONSE TO CARDIAC RESYNCHRONISATION THERAPY
Kazemisaeid, A., Bozorgi, A., Sharif, A. Y., Sadeghian, S., Sheikhvatan, M., Davoodi, G., Sadeghian, H., & Dogmehchi, E. (2011) · European Journal of Cardiovascular Medicine · doi:10.5083/ejcm.20424884.36
Predictive Power of the Baseline QRS Complex Duration for Clinical Response to Cardiac Resynchronisation Therapy CARDIAC MARKERS | ORIGINAL RESEARCH
Bozorgi, A., Sharif, A. Y., Davoodi, G., Sadeghian, S., Sadeghian, H., Sheikhvatan, M., Kazemisaeid, A., & Dogmehchi, E. (2011)

Authors: Adelstein, E. C., & Saba, S.
Affiliations: University of Pittsburgh (US)
Corresponding author: Adelstein, Evan C.
ORCID: Adelstein, Evan C.
Saba, Samir
Venue: The American Journal of Cardiology
Publisher: Elsevier BV
Published: 2009-01
Volume: 103
Issue: 2
Pages: 238-242
ISSN: 0002-9149 (ISSN-L)
DOI: 10.1016/j.amjcard.2008.08.069
OpenAlex: W2063717496
Cited by: 110
References: 13
Citations by year: 2026: 1 · 2025: 2 · 2024: 5 · 2023: 3 · 2021: 2 · 2020: 1 · 2018: 1 · 2017: 4 · 2016: 5 · 2015: 7 · 2014: 11 · 2013: 13 · 2012: 19
FWCI: 8.73
Type: journal article
Language: en
Open access: closed
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: The American Journal of Cardiology (publishedVersion)
PubMed (publishedVersion)
Topics: Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac pacing and defibrillation studies
Health Sciences › Medicine › Emergency Medicine › Cardiac Arrest and Resuscitation
Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiac electrophysiology and arrhythmias
Keywords: cardiac resynchronization therapy, right bundle branch block, left bundle branch block, QRS morphology, heart failure, symptom response, left ventricular function, reverse remodeling, ventricular assist devices
MeSH terms: Aged, Bundle-Branch Block, Cardiac Pacing, Artificial, Echocardiography, Electrocardiography, Female, Heart Failure, Humans, Male, Predictive Value of Tests, Logistic Models, Proportional Hazards Models, Survival Analysis, Treatment Outcome

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Usefulness of Baseline Electrocardiographic QRS Complex Pattern to Predict Response to Cardiac Resynchronization

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