Complications and 1-year benefit of cardiac resynchronization therapy in patients over 75 years of age - Insights from the German Device Registry

Complications and Mortality Following CRT-D Versus ICD Implants in Older Medicare Beneficiaries With Heart Failure

OBJECTIVES

This study sought to assess the comparative effectiveness of cardiac resynchronization therapy with defibrillator (CRT-D) over implantable cardioverter-defibrillator (ICD) alone in older Medicare patients with heart failure with reduced ejection fraction (HFrEF).

BACKGROUND

Despite growing numbers of older patients with HFrEF, the benefits of cardiac resynchronization therapy (CRT) in this group are largely unknown.

METHODS

A cohort of fee-for-service Medicare beneficiaries ≥65 years of age with HFrEF and enrolled in Medicare Part D who underwent CRT-D or ICD implantation from January 2008 to August 2015 was identified. Beneficiaries were divided by age (65-74, 75-84, and 85+ years), and outcomes were compared between the CRT-D and ICD groups after inverse probability weighting.

RESULTS

Compared with the ICD group, the CRT-D group was older and more likely to be White, be female, and have left bundle branch block. After weighting, overall complications were high across age and device groups (14%-20%). The 1-year mortality was high across all groups. In the 2 oldest age strata, the hazard of death was lower in the CRT-D group (HR: 0.90; 95% CI: 0.86-0.95 and HR: 0.81; 95% CI: 0.72-0.90, respectively; P < 0.001); the hazard of heart failure hospitalization was lower for CRT-D vs ICD in the 85+ years age group (HR: 0.82; 95% CI: 0.74-0.92; P < 0.001).

CONCLUSIONS

In older Medicare beneficiaries undergoing ICD with or without CRT, complications and 1-year mortality were high. Compared with ICD alone, CRT-D was associated with a lower hazard of mortality in patients ≥74 years of age and lower hazard of HF hospitalization in those ≥85 years of age. These findings support the use of CRT in eligible older patients undergoing ICD implantation.

Comparative effectiveness of CRT in older patients with heart failure: Systematic review and meta-analysis

OBJECTIVE

To perform meta-analyses comparing safety and effectiveness of cardiac resynchronization therapy (CRT) in older versus younger patients with heart failure with reduced ejection fraction (HFrEF).

BACKGROUND

Pivotal CRT trials enrolled patients with HFrEF significantly younger than the typical contemporary patient with HFrEF. Thus, risks and benefits in this older population with HFrEF are largely unknown.

METHODS

PubMed, The Cochrane Library, Scopus, and Web of Science were queried for comparative effectiveness studies of CRT in older HFrEF patients. Title, abstract, and full text screening was performed to identify studies comparing at least one pre-specified endpoint between older and younger adult patients with at least 50 participants. Random effects meta-analysis in LVEF mean difference (older minus younger) and relative risk (RR) of death, improvement in New York Heart Association (NYHA) class, and complications are reported along with estimates of heterogeneity.

RESULTS

In 7 studies, there was similar LVEF improvement between groups [mean difference 1.14; 95% CI -0.04 - 2.32, p=0.06, I 2 =53%]. Older patients were equally likely as younger patients to see an improvement in NYHA class of at least 1 in 6 studies [RR 0.99; 95% CI, 0.93 - 1.06; p=0.76; I 2 =25%]. No significant differences in the incidence of hematoma, pneumothorax, lead dislodgment, cardiac perforation, or infection requiring explant was observed. RR of mortality in 11 studies demonstrated higher risk of all-cause mortality in older patients [RR 1.05; 95% CI, 1.03 - 1.08, p<0.01, I 2 =0%].

CONCLUSIONS

Compared with younger patients, older patients receiving CRT were equally likely to experience improvement in LVEF, LVEDD, and NYHA class. There was no difference in procedural complications. The higher rate of all-cause mortality in older patients likely reflects a greater underlying risk of death from competing causes.

Distribution and impact of age in patients with implantable cardioverter-defibrillators regarding early complications and 1-year clinical outcome: results from the German Device Registry

BACKGROUND

Patients receiving implantable-cardioverter-defibrillators (ICD) in clinical practice are often older or younger than in clinical trials. Whether older patients benefit from ICD-therapy in a similar way as younger patients is under debate. The objective of this study was to provide real-world data regarding outcomes with respect to age in a large cohort in the German Device Registry.

METHODS

Within the registry data from 50 German centers were collected between January 2007 and February 2014.

RESULTS

Our analysis included 3239 ICD patients representing a group of young (28%; group I: < 58 years), intermediate aged (50%; group II: 58-74 years), and elderly patients (22%; group III: 75-92 years). Intergroup comparison of all groups was performed followed by individual comparison vs. group II serving as age-reference group. Procedure-related complications did not differ between all groups. Analysis of the primary endpoint, 1-year all-cause mortality, revealed an increased mortality in the elderly and a decreased mortality in the young cohort vs. the reference group II (group I 2.1%, group II 6.2%, group III 13.2%; p < 0.001). While all-cause rehospitalizations did not differ, we observed a difference in reported device revisions showing more device revisions required in younger patients (group I 8.9%, group II 6.8%, group III 4.0%; p = 0.001).

CONCLUSIONS

One-year mortality was doubled in elderly ICD patients probably due to non-cardiac causes. These results further underpin the need for re-evaluating the primary prevention ICD indication in octo- and nonagenarians. Young patients show lower mortality rates but seem to bear higher risk of device-related complications, which highlights the need for improved measures to reduce device-related complications in the young.

Novel two-lead cardiac resynchronization therapy system provides equivalent CRT responses with less complications than a conventional three-lead system: Results from the QP ExCELs lead registry

Introduction

The novel two‐lead cardiac resynchronization therapy (CRT)‐DX system utilizes a floating atrial dipole on the implantable cardioverter‐defibrillator lead, and when implanted with a left ventricular (LV) lead, offers a two‐lead CRT system with AV synchrony. This study compared complication rates and CRT response among subjects implanted with a two‐lead CRT‐DX system to those subjects implanted with a standard three‐lead CRT‐D system.

Methods and Results

A total of 240 subjects from the Sentus QP—Extended CRT Evaluation with Quadripolar Left Ventricular Leads postapproval study were selected to identify 120 matched pairs based on similar demographic characteristics using a Greedy algorithm. The complication‐free rate was evaluated as the primary endpoint. All‐cause mortality, heart failure hospitalizations, device diagnostic data, New York Heart Association (NYHA) class improvement, and defibrillator therapy were evaluated from clinical data, in‐office interrogations, and remote monitoring throughout the follow‐up period. Complication‐free survival favored the CRT‐DX group with 92.5% without a major complication compared to 85.0% in the CRT‐D cohort (P = .0495; 95% confidence interval: 0.1%‐14.9%) over a mean follow‐up of 1.3 and 1.4 years, respectively. Incidence of all‐cause mortality, heart failure hospitalizations, NYHA changes at 6 months postimplant, and percent of LV pacing during CRT therapy were similar in both device cohorts. Inappropriate shocks were more frequent in the CRT‐D cohort with 5.8% of subjects receiving an inappropriate shock vs 0.8% in the CRT‐DX cohort.

Conclusion

The results of this subanalysis demonstrate that the CRT‐DX system can provide similar CRT responses and significantly fewer complications when compared to a similar cohort with a conventional three‐lead CRT‐D system.

Impact of diabetes on clinical outcome of patients with heart failure undergoing ICD and CRT procedures: results from the German Device Registry

Aims

Diabetes mellitus (DM) has a negative impact on prognosis in patients with heart failure (HF). The role impact of DM in HF patients with implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT) devices might differ and remains unclear. The aim of our study was to investigate the impact of DM on periprocedural complications and clinical outcome in HF patients undergoing ICD or CRT implantation.

Methods and results

Within the German Device Registry, data from 50 German centres were collected between January 2007 and February 2014. A retrospective analysis of n = 5329 patients undergoing ICD implantation was conducted. Patients' characteristics, procedural data, periprocedural complications, and post‐procedural clinical outcome, including a composite clinical endpoint of all‐cause mortality, stroke, and myocardial infarction (MACCE), were analysed. Subgroup analysis were performed for ICD and CRT implantations. Median follow‐up was 15.7 (12.9; 20.0) and 16.2 (12.8; 21.2) months in DM and non‐DM patients. Of 5329 patients enrolled, n = 1448 (27.2%) had a diagnosis of DM. Within the cohort, 94% of DM and 90% of non‐DM patients had a diagnosis of HF. Patients with DM were older, had higher body mass index, and higher rate of cardiovascular comorbidities compared with non‐DM patients. Unadjusted and adjusted analyses revealed similar all‐over intrahospital periprocedural complication rates in both groups (4.1% vs 3.9%). Unadjusted Kaplan–Meier survival analysis showed higher all‐cause mortality after 1 year (9.0% vs 6.3%; log‐rank P = 0.001) with higher MACCE rates (10.0% vs 7.3%; P < 0.001) in the DM group versus non‐DM patients. After multivariable adjustment for relevant covariates, the association of DM to MACCE disappeared [HR 1.11 (0.89‐1.38)]. Because chronic kidney disease (CKD) was clearly associated with increased 1 year MACCE after multivariate adjustment [odds ratio (OR) 2.11 (1.68–2.64)], a subgroup analysis was performed showing a strong trend towards more perioperative complications in DM patients with CKD [OR 2.16 (0.9–5.21)], while no effect of DM was observed in patients without CKD [OR 0.73 (0.42–1.28)].

Conclusions

The overall risk of periprocedural complications and short‐term (1 year) clinical outcome in patients with DM and HF undergoing ICD or CRT defibrillator (CRT‐D) implantation was not increased. In contrast, CKD was associated with an increased risk of 1 year MACCE in HF patients undergoing ICD/CRT‐D implantation.

Contemporary Management of Heart Failure in the Elderly

The foundation of the treatment of heart failure with reduced ejection fraction is a number of pharmacotherapies shown to reduce morbidity and mortality in large randomised multinational clinical trials. These include angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists, and more recently, a combined angiotensin receptor blocker neprilysin inhibitor, sacubitril/valsartan. In select cases, digoxin, ivabradine and hydralazine with isosorbide dinitrate have a role to play in the treatment of heart failure with reduced ejection fraction. On this foundation, other more advanced treatments such as implantable cardioverter defibrillators and cardiac resynchronisation therapy are recommended in guidelines for the treatment of heart failure with reduced ejection fraction (i.e. an ejection fraction of ≤ 40%) and for a select few there remains the option of mechanical circulatory support and cardiac transplantation. The efficacy of pharmacotherapy does not vary by age and each of these therapies should be considered in all patients, irrespective of age. Other factors such as co-morbidities like renal dysfunction may limit the use of some of these drugs in the elderly. Decision making with regard to device therapy is more complex; the likelihood of competing non-cardiovascular causes of death and life expectancy need to be considered. Despite multiple treatment options for heart failure with reduced ejection fraction, the options for heart failure with preserved ejection fraction are limited. In the absence of robust outcomes data from a large randomised trial, a mineralocorticoid receptor antagonist is a reasonable therapy to reduce the risk of hospitalisation for heart failure in patients with heart failure with preserved ejection fraction.

Can we rely on Danish? Real-world data on patients with nonischemic cardiomyopathy from the German Device Registry

According to current guidelines prophylactic implantable cardioverter-defibrillator (ICD) therapy is recommended in patients with significantly impaired left ventricular systolic function. However, the recently published DANISH trial did not find a significantly lower long-term rate of death from any cause compared with usual clinical care in patients with non-ischemic cardiomyopathy. We investigated whether registry data from a multi-center 'real-life' registry on patients with non-ischemic cardiomyopathy are similar to this trial. The German Device Registry (DEVICE) is a nationwide, prospective registry with one-year follow-up investigating 5451 patients receiving device implantations in 50 German centers. The present analysis of DEVICE focused on patients with non-ischemic cardiomyopathy and a left ventricular ejection fraction ≤35% who received a prophylactic ICD. Out of 779 patients with symptomatic heart failure and nonischemic cardiomyopathy, 33.1% received a single chamber ICD (VVI), while 11.0% were implanted with a dual-chamber ICD (DDD), and 55.8% received a defibrillator system for cardiac resynchronization therapy. Median follow-up was 16.1 months. 90.7% were alive at follow-up, 9.3% had died during this period. Overall mortality after one year was 5.4%. Overall mortality one year after implantation was significantly increased in patients 68 years and older(7.9%) as compared to younger patients (59-68 years: 2.5%; < 59 years: 3.8%; p < 0.015). Data from the present registry support the recently published results of the DANISH trial. In particular the influence of an increased age as proven in the DANISH trial might also play a role in the present collective. This limits the potential beneficial effect of ICD therapy in particular in the elderly population.

Frequency of in-hospital adverse outcomes and cost utilization associated with cardiac resynchronization therapy defibrillator implantation in the United States

BACKGROUND

The utilization of cardiac resynchronization therapy defibrillator (CRT-D) has increased significantly, since its initial approval for use in selected patients with heart failure. Limited data exist as for current trends in implant-related in-hospital complications and cost utilization. The aim of our study was to examine in-hospital complication rates associated with CRT-D and their trends over the last decade.

METHODS AND RESULTS

Using the Nationwide Inpatient Sample, we estimated 378 248 CRT-D procedures from 2003 to 2012. We investigated common complications, including mechanical, cardiovascular, pericardial complications (hemopericardium, cardiac tamponade, or pericardiocentesis), pneumothorax, stroke, vascular complications (consisting of hemorrhage/hematoma, incidents requiring surgical repair, and accidental arterial puncture), and in-hospital deaths described with CRT-D, defining them by the validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code. Mechanical complications (5.9%) were the commonest, followed by cardiovascular (3.6%), respiratory failure (2.4%), and pneumothorax (1.5%). Age (≥65 years), female gender (OR, 95% CI; P value) (1.08, 1.03-1.13; 0.001), and the Charlson score ≥3 (1.52, 1.45-1.60; <0.001) were significantly associated with increased mortality/complications.

CONCLUSIONS

The overall complication rate in patients undergoing CRT-D has been increasing in the last decade. Age (≥65), female sex, and the Charlson score ≥3 were associated with higher complications. In patients who underwent CRT-D implantation, postoperative complications were associated with significant increases in cost.

[Chronic heart failure in older patients : Updated national healthcare guidelines on chronic heart failure from a geriatric perspective]

The incidence and prevalence of chronic heart failure (CHF) increase with age. In the second edition of the National Disease Management Guidelines (NVL) on CHF, published in August 2017, geriatric aspects are specifically addressed. The paper provides an overview of the recommendations by the guidelines on drug therapy, device therapy and operative therapy as well on the coordination of care focusing on older and multimorbid patients.