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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac resynchronization therapy &#40;CRT&#41;&#44; with or without defibrillation&#44; has revolutionized the treatment of heart failure&#44; leading to reverse remodeling &#40;the main prognostic factor in heart failure&#41; and improvements in quality of life&#44; functional class&#44; hospitalizations for heart failure and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> However&#44; since CRT was introduced&#44; the proportion of patients who do not respond to the therapy has remained high &#40;30-40&#37; depending on the series&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Analysis of non-response to CRT is difficult for a variety of reasons&#46; The most important are to do with the reasons for failure to respond&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> which are multifactorial and differ among patients&#46; Patients with ischemic heart disease are less likely to respond&#44; as are those with atrial fibrillation &#40;AF&#41;&#44; without left bundle branch block&#44; or with pulmonary hypertension&#44; biventricular dysfunction or other comorbidities such as respiratory or renal failure&#46; There are also factors related to the implantation procedure itself &#8211; ineffective biventricular pacing due to lead malpositioning &#40;in the anterior branch of the coronary sinus or in too apical a location&#41;&#44; or failure of the QRS interval to shorten even when the lead is correctly placed &#8211; and post-procedural factors&#44; particularly low biventricular pacing rates&#44; such as in patients with persistent AF&#44; in whom atrioventricular &#40;AV&#41; node ablation is recommended&#44; and in those with many ventricular extrasystoles&#44; for whom ablation may be required&#46; Other comorbidities&#44; significant mitral regurgitation after implantation&#44; and inadequate medical therapy may also play a part&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The study by Rio et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> sets out assess the prognostic impact of response to CRT using echocardiographic criteria&#46; The follow-up period used to define response was rather short&#44; given that there may be a late echocardiographic response in patients who do not respond initially&#44; as acknowledged by the authors in the limitations section&#46; The authors do not mention whether echocardiography was repeated over the course of the study&#44; but it is possible that some patients considered non-responders may have had a late response&#44; which could obviously affect the results&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study population is of a reasonable size &#40;178 patients&#41;&#44; and in terms of selection&#44; is typical of patients found outside the context of clinical trials&#58; all had prolonged QRS &#40;defined as &#62;120 ms&#41;&#44; most had complete left bundle branch block&#44; and 35&#37; had ischemic heart disease&#46; The retrospective nature of the registry implies some limitations&#44; including the fact that it only includes patients in whom implantation was successful&#46; It is also stated that the lead was implanted in a lateral or posterolateral position in all cases&#46; This is the optimal location for the left lead&#44; but it is not clear whether patients with leads in less favorable positions &#40;who are always to be found among patients receiving CRT devices&#41; were excluded&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The description of the methodology is somewhat vague on some points&#46; For example&#44; it is stated that the devices were programmed in DDD mode&#59; however&#44; 40&#37; of the initial population had AF&#46; It is also not clear how many of these patients had intermittent AF and how many had persistent or permanent AF&#44; nor how such a high percentage of biventricular pacing was achieved in AF patients &#40;by AV node ablation&#63; by drug therapy&#63;&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Over the eight-year study period there were significant advances in CRT systems&#44; which may have affected the results&#46; For example&#44; quadripolar left ventricular leads were introduced in 2012 and are now standard&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Nevertheless&#44; real-world studies such as this have the advantage of reflecting the types of patients seen in clinical practice&#44; rather than the study populations of clinical trials&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study by Rio et al&#46; shows a high rate of echocardiographic response &#40;61&#37;&#41; and an even higher rate of clinical response&#46; Mortality and hospitalization rates were higher in patients without echocardiographic response&#44; while clinical response was better in those with a good echocardiographic response&#46; The study&#39;s results appear to indicate that in this population&#44; clinical but not echocardiographic responders have a better prognosis than those without an echocardiographic response who do not improve clinically&#46; This finding&#44; while not wholly new&#44; having been published in other series&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> is a reminder that response to CRT&#44; as well as being multifactorial as pointed out above&#44; is also not dichotomous&#59; it represents a spectrum of possibilities&#46; Patients respond to a greater or lesser extent&#44; ranging from those whose ejection fraction normalizes to the other extreme of those who&#44; though not presenting improvement in echocardiographic parameters&#44; show improvement in functional class and in other parameters related to heart failure&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
Response to cardiac resynchronization therapy: Dichotomous or continuous variable?
Resposta à terapêutica de ressincronização cardíaca: uma variável dicotómica ou contínua?
Diogo Magalhães Cavaco
Serviço de Cardiologia, Hospital de Santa Cruz, CHLO, Carnaxide, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cardiac resynchronization therapy &#40;CRT&#41;&#44; with or without defibrillation&#44; has revolutionized the treatment of heart failure&#44; leading to reverse remodeling &#40;the main prognostic factor in heart failure&#41; and improvements in quality of life&#44; functional class&#44; hospitalizations for heart failure and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> However&#44; since CRT was introduced&#44; the proportion of patients who do not respond to the therapy has remained high &#40;30-40&#37; depending on the series&#41;&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Analysis of non-response to CRT is difficult for a variety of reasons&#46; The most important are to do with the reasons for failure to respond&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> which are multifactorial and differ among patients&#46; Patients with ischemic heart disease are less likely to respond&#44; as are those with atrial fibrillation &#40;AF&#41;&#44; without left bundle branch block&#44; or with pulmonary hypertension&#44; biventricular dysfunction or other comorbidities such as respiratory or renal failure&#46; There are also factors related to the implantation procedure itself &#8211; ineffective biventricular pacing due to lead malpositioning &#40;in the anterior branch of the coronary sinus or in too apical a location&#41;&#44; or failure of the QRS interval to shorten even when the lead is correctly placed &#8211; and post-procedural factors&#44; particularly low biventricular pacing rates&#44; such as in patients with persistent AF&#44; in whom atrioventricular &#40;AV&#41; node ablation is recommended&#44; and in those with many ventricular extrasystoles&#44; for whom ablation may be required&#46; Other comorbidities&#44; significant mitral regurgitation after implantation&#44; and inadequate medical therapy may also play a part&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The study by Rio et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> sets out assess the prognostic impact of response to CRT using echocardiographic criteria&#46; The follow-up period used to define response was rather short&#44; given that there may be a late echocardiographic response in patients who do not respond initially&#44; as acknowledged by the authors in the limitations section&#46; The authors do not mention whether echocardiography was repeated over the course of the study&#44; but it is possible that some patients considered non-responders may have had a late response&#44; which could obviously affect the results&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The study population is of a reasonable size &#40;178 patients&#41;&#44; and in terms of selection&#44; is typical of patients found outside the context of clinical trials&#58; all had prolonged QRS &#40;defined as &#62;120 ms&#41;&#44; most had complete left bundle branch block&#44; and 35&#37; had ischemic heart disease&#46; The retrospective nature of the registry implies some limitations&#44; including the fact that it only includes patients in whom implantation was successful&#46; It is also stated that the lead was implanted in a lateral or posterolateral position in all cases&#46; This is the optimal location for the left lead&#44; but it is not clear whether patients with leads in less favorable positions &#40;who are always to be found among patients receiving CRT devices&#41; were excluded&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The description of the methodology is somewhat vague on some points&#46; For example&#44; it is stated that the devices were programmed in DDD mode&#59; however&#44; 40&#37; of the initial population had AF&#46; It is also not clear how many of these patients had intermittent AF and how many had persistent or permanent AF&#44; nor how such a high percentage of biventricular pacing was achieved in AF patients &#40;by AV node ablation&#63; by drug therapy&#63;&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Over the eight-year study period there were significant advances in CRT systems&#44; which may have affected the results&#46; For example&#44; quadripolar left ventricular leads were introduced in 2012 and are now standard&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Nevertheless&#44; real-world studies such as this have the advantage of reflecting the types of patients seen in clinical practice&#44; rather than the study populations of clinical trials&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study by Rio et al&#46; shows a high rate of echocardiographic response &#40;61&#37;&#41; and an even higher rate of clinical response&#46; Mortality and hospitalization rates were higher in patients without echocardiographic response&#44; while clinical response was better in those with a good echocardiographic response&#46; The study&#39;s results appear to indicate that in this population&#44; clinical but not echocardiographic responders have a better prognosis than those without an echocardiographic response who do not improve clinically&#46; This finding&#44; while not wholly new&#44; having been published in other series&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> is a reminder that response to CRT&#44; as well as being multifactorial as pointed out above&#44; is also not dichotomous&#59; it represents a spectrum of possibilities&#46; Patients respond to a greater or lesser extent&#44; ranging from those whose ejection fraction normalizes to the other extreme of those who&#44; though not presenting improvement in echocardiographic parameters&#44; show improvement in functional class and in other parameters related to heart failure&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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                      "titulo" => "The effect of cardiac resynchronization on morbidity and mortality in heart failure"
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ISSN: 21742049
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Revista Portuguesa de Cardiologia (English edition)
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