The utility of 12-lead Holter monitoring in patients with permanent atrial fibrillation for the identification of nonresponders after cardiac resynchronization therapy
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Objectives This study sought to determine the incidence of ineffective capture using 12-lead Holter monitoring and to assess whether this affects response to cardiac resynchronization therapy (CRT).Background Cardiac resynchronization therapy is used in patients with atrial fibrillation (AF), prolonged QRS duration, and heart failure in the setting of ventricular dysfunction. The percentage of ventricular pacing is used as an indicator of adequate biventricular (BiV) pacing. Although device counters show a high pacing percentage, there may be ineffective capture because of underlying fusion and pseudo-fusion beats.Methods We identified 19 patients (age 72 +/- 8 years, ejection fraction 18 +/- 5%), with permanent AF who underwent CRT. All patients received digoxin, beta-blockers, and amiodarone for rate control; device interrogation showed >90% BiV pacing. Patients had a 12-lead Holter monitor to assess the presence of effective (>90% fully paced beats/24 h) pacing. At 12 months post-CRT, the New York Heart Association functional class was reassessed and an echocardiogram was obtained and compared with pre-CRT.Results Only 9 (47%) patients had effective pacing. The other 10 (53%) patients had 16.4 +/- 4.6% fusion and 23.5 +/- 8.7% pseudo-fusion beats. Long-term responders (> or =1 New York Heart Association functional class improvement) to CRT had a significantly higher percentage of fully paced beats (86.4 +/- 17.1% vs. 66.8 +/- 19.1%; p = 0.03) than nonresponders.Conclusions Pacing counters overestimate the degree of effective BiV pacing in patients with permanent AF undergoing CRT therapy. Only patients with complete capture responded clinically to CRT. These findings have important implications for the application of CRT to patients with permanent AF and heart failure.
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In a small sample of CRT patients with AF and over 90% biventricular pacing by device interrogation, 12-lead Holter monitoring revealed a high prevalence (53%) of fusion and pseudofusion beats and lesser CRT response.
“Kamath et al. (2009) documented that in a small sample of CRT patients with AF and over 90% biventricular pacing as shown by a device interrogation, analysis of 12-lead Holter monitoring revealed high prevalence (53%) of patients with fusion and pseudofusion beats and lesser CRT response.”
From 2017 ISHNE-HRS expert consensus statement on ambulatory ECG and external cardiac monitoring/telemetry (2017) · cites this paper as Kamath et al., 2009
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- Authors
- Kamath, G. S., Cotiga, D., Koneru, J. N., Arshad, A., Pierce, W., Aziz, E. F., Mandava, A., Mittal, S., & Steinberg, J. S.
- Affiliations
- St. Luke's-Roosevelt Hospital Center (US)
- Corresponding author
- Steinberg, Jonathan S.
- ORCID
- Venue
- Journal of the American College of Cardiology
- Publisher
- Elsevier BV
- Published
- 2009-03
- Volume
- 53
- Issue
- 12
- Pages
- 1050-1055
- ISSN
- 0735-1097 (ISSN-L)
- OpenAlex
- W2024384121
- Cited by
- 171
- References
- 25
- Citations by year
- 2026: 2 · 2025: 3 · 2024: 7 · 2023: 5 · 2022: 11 · 2021: 11 · 2020: 8 · 2019: 6 · 2018: 9 · 2017: 13 · 2016: 11 · 2015: 8 · 2014: 15 · 2013: 18 · 2012: 20
- FWCI
- 9.49
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Journal of the American College of Cardiology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Boston Scientific Corporation
- Biotronik
- Medtronic
- St. Jude Medical
- 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, permanent atrial fibrillation, fusion beats, heart failure, CRT response, ventricular dysfunction
- MeSH terms
- Aged, Aged, 80 and over, Atrial Fibrillation, Cardiac Pacing, Artificial, Echocardiography, Female, Humans, Male, Middle Aged, Electrocardiography, Ambulatory, Treatment Outcome
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