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Gunten SV, Theuns DA, Kühne M, Reichlin T, Sticherling C, Schaer B. Predictors for early mortality and arrhythmic events in patients with cardiac resynchronization therapy with defibrillator: A two center cohort study. Cardiol J 2018; 26:711-716. [PMID: 30484267 DOI: 10.5603/cj.a2018.0144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 10/12/2018] [Accepted: 10/13/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Guidelines of heart failure therapy include cardiac resynchronization as standard of care in patients with severely depressed left ventricular function and wide QRS complex. It has been shown that patients benefit regarding mortality and morbidity. However, early mortality precludes longterm benefits from the device. The aim of the study was to identify predictors for early occurrence of both death and first-ever implantable cardioverter-defibrillator (ICD) therapy using a large combined database of patients with cardiac resynchronization therapy with defibrillator (CRT-D). METHODS From two registries (tertiary care centers) 904 patients were identified, no single patient was excluded. Early death was defined as death occurring within the 3 years after implantation whereas early ICD therapy as such occurring within the first year. 33 baseline parameters were compared using uni- and multivariate analysis with the Cox model and binary logistic regression. RESULTS The population was predominantly male (77%), with mean age of 63 ± 11 years and primary prevention indication in 80%. Mean follow-up was 55 ± 38 months. 256 (28%) patients had ICD therapies whereof the first-ever event occurred early in 52%. 270 (30%) patients died after 41 ± ± 31 months, mostly from advancing heart failure (41%), 141 (52%) patients of them early. Independent predictors for early ICD therapy were secondary prevention and renal failure. Independent predictors for early mortality were a history of percutaneous coronary intervention and of peripheral vascular disease. CONCLUSIONS Predictors for early mortality after CRT-D implantation were a history of percutaneous coronary intervention and peripheral vascular disease, present in only a minority of patients, thus limiting their use in clinical practice.
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Affiliation(s)
- Simon von Gunten
- Department of Cardiology, University Hospital, Basel, Switzerland
| | - Dominic A Theuns
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michael Kühne
- Department of Cardiology, University Hospital, Basel, Switzerland
| | - Tobias Reichlin
- Department of Cardiology, University Hospital, Basel, Switzerland
| | | | - Beat Schaer
- Department of Cardiology, University Hospital, Basel, Switzerland.
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Zhou FH, Jia YH, Ye SL, Lou LJ, Yang P, Li J, Zhang YJ, Qian RJ. A Chinese Compound Prescription Ding Xin Recipe Combined with Amiodarone for Treating Premature Ventricular Complexes: A Randomized, Double-Blind, Multicenter, Placebo-Controlled Trial. DIGITAL CHINESE MEDICINE 2018. [DOI: 10.1016/s2589-3777(19)30008-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Hudzik B, Zubelewicz-Szkodzinska B. Amiodarone-related thyroid dysfunction. Intern Emerg Med 2014; 9:829-39. [PMID: 25348560 DOI: 10.1007/s11739-014-1140-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 10/10/2014] [Indexed: 11/28/2022]
Abstract
Nowadays, amiodarone is the most commonly used antidysrhythmic drug in clinical practice. It is highly effective in the management of recurrent ventricular dysrhythmias, paroxysmal supraventricular dysrhythmias, including atrial fibrillation and flutter, and in the maintenance of sinus rhythm after electrical cardioversion of atrial fibrillation. Moreover, it has the added benefit of being well tolerated in patients with both normal and impaired left ventricular systolic function. Despite amiodarone's potent antidysrhythmic actions, its use is hampered by numerous adverse effects on various organs, including the thyroid. Adverse effects are becoming more prevalent given the increasing incidence of dysrhythmias and wider amiodarone use. Thus, physicians and patients should both be aware of the potential thyroid-specific sequelae. However, amiodarone is likely to remain a significant problem for endocrinologists as concerns exist over the use of the new alternative antiarrhythmic agent, dronedarone, especially in patients with heart failure and left ventricular dysfunction because of the risk of hepatic injury and increased mortality. The final diagnostic and therapeutic approaches must be discussed among the patient, the general practitioner, the cardiologist, and the endocrinologist.
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Affiliation(s)
- Bartosz Hudzik
- Third Department of Cardiology, Silesian Centre for Heart Disease, Medical University of Silesia, Curie-Sklodowska 9, 41-800, Zabrze, Poland,
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Clinical features and predictors of lethal ventricular tachyarrhythmias after cardiac resynchronization therapy for primary prevention of sudden cardiac death. J Arrhythm 2014. [DOI: 10.1016/j.joa.2013.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Haugaa KH, Marek JJ, Ahmed M, Ryo K, Adelstein EC, Schwartzman D, Saba S, Gorcsan J. Mechanical dyssynchrony after cardiac resynchronization therapy for severely symptomatic heart failure is associated with risk for ventricular arrhythmias. J Am Soc Echocardiogr 2014; 27:872-9. [PMID: 24798865 DOI: 10.1016/j.echo.2014.04.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Risk factors for ventricular arrhythmias after cardiac resynchronization defibrillator therapy (CRT-D) for severely symptomatic heart failure are of clinical importance but are not clearly defined. The objective of this study was to test the hypothesis that mechanical dyssynchrony after CRT-D is a risk factor for ventricular arrhythmias. METHODS A total of 266 consecutive CRT-D patients with class III or IV heart failure, QRS duration ≥120 msec, and ejection fractions ≤ 35% were prospectively studied. Dyssynchrony was assessed before and 6 months after CRT-D using speckle-tracking radial strain anteroseptal-to-posterior wall delay, predefined as ≥130 msec. Ventricular arrhythmias were predefined as appropriate antitachycardia pacing or shock, and the combined end point of ventricular arrhythmias, death, transplantation, or left ventricular assist device implantation was followed over 2 years. RESULTS Of the initial 266 patients, 11 died, five underwent transplantation, three received left ventricular assist devices before their 6-month echocardiographic examinations, 19 (7%) had inadequate speckle-tracking at 6-month follow-up, and 27 (10%) were lost to follow-up. Accordingly, the study group consisted of 201 patients. Dyssynchrony after CRT-D was observed in 79 (39%) and was associated with a significantly higher ventricular arrhythmic event rate: 21% (P < .001) with persistent dyssynchrony and 35% (P < .001) with new dyssynchrony, compared with 8% with no dyssynchrony after CRT-D. The combined end point of ventricular arrhythmias, death, transplantation, or left ventricular assist device implantation was significantly associated with dyssynchrony after CRT-D (hazard ratio, 2.53; 95% confidence interval, 1.49-4.28; P = .001). Dyssynchrony after CRT-D was associated with ventricular arrhythmias or death in patient subgroups by cardiomyopathy type, QRS width, and morphology (P < .05 for all). CONCLUSIONS Persistent or new radial dyssynchrony after CRT-D in severely symptomatic patients with heart failure with widened QRS complexes and reduced ejection fractions was associated with an increased rate of ventricular arrhythmias or death and appears to be a marker for a less favorable prognosis.
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Affiliation(s)
| | - Josef J Marek
- The University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Keiko Ryo
- The University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Samir Saba
- The University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John Gorcsan
- The University of Pittsburgh, Pittsburgh, Pennsylvania.
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Manfredi JA, Al-Khatib SM, Shaw LK, Thomas L, Fogel RI, Padanilam B, Rardon D, Vatthyam R, Gemma LW, Golden K, Prystowsky EN. Association Between Left Ventricular Ejection Fraction Post-Cardiac Resynchronization Treatment and Subsequent Implantable Cardioverter Defibrillator Therapy for Sustained Ventricular Tachyarrhythmias. Circ Arrhythm Electrophysiol 2013; 6:257-64. [DOI: 10.1161/circep.112.000214] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Joseph A. Manfredi
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - Sana M. Al-Khatib
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - Linda K. Shaw
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - Laine Thomas
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - Richard I. Fogel
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - Benzy Padanilam
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - David Rardon
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - Rosh Vatthyam
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - Lee W. Gemma
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - Keith Golden
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
| | - Eric N. Prystowsky
- From the AnMed Arrhythmia Specialists, Anderson, SC (J.A.M.); Duke Clinical Research Institute (L.K.S., L.T.), and Division of Cardiology (S.M.A.-K.), Duke University Medical Center, Durham, NC; and the St. Vincent Medical Group, Indianapolis, IN (R.I.F., B.P., D.R., R.V., L.W.G., K.G., E.N.P.)
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Eickholt C, Siekiera M, Kirmanoglou K, Rodenbeck A, Heussen N, Schauerte P, Lichtenberg A, Balzer J, Rassaf T, Perings S, Kelm M, Shin DI, Meyer C. Improvement of left ventricular function under cardiac resynchronization therapy goes along with a reduced incidence of ventricular arrhythmia. PLoS One 2012; 7:e48926. [PMID: 23152822 PMCID: PMC3495960 DOI: 10.1371/journal.pone.0048926] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Accepted: 10/02/2012] [Indexed: 12/13/2022] Open
Abstract
Objectives The beneficial effects of cardiac resynchronization therapy (CRT) are thought to result from favorable left ventricular (LV) reverse remodeling, however CRT is only successful in about 70% of patients. Whether response to CRT is associated with a decrease in ventricular arrhythmias (VA) is still discussed controversially. Therefore, we investigated the incidence of VA in CRT responders in comparison with non-responders. Methods In this nonrandomized, two-center, observational study patients with moderate-to-severe heart failure, LV ejection fraction (LVEF) ≤35%, and QRS duration >120 ms undergoing CRT were included. After 6 months patients were classified as CRT responders or non-responders. Incidence of VA was compared between both groups by Kaplan-Meier analysis and Cox regression analysis. ROC analysis was performed to determine the aptitude of LVEF cut-off values to predict VA. Results In total 126 consecutive patients (64±11years; 67%male) were included, 74 were classified as responders and 52 as non-responders. While the mean LVEF at baseline was comparable in both groups (25±7% vs. 24±8%; P = 0.4583) only the responder group showed an improvement of LVEF (36±6% vs. 24±7; p<0.0001) under CRT. In total in 56 patients VA were observed during a mean follow-up of 28±14 months, with CRT responders experiencing fewer VA than non-responders (35% vs. 58%, p<0.0061). Secondary preventive CRT implantation was associated with a higher likelihood of VA. As determined by ROC analysis an increase of LVEF by >7% was found to be a predictor of a significantly lower incidence of VA (AUC = 0.606). Conclusions Improvement of left ventricular function under cardiac resynchronization therapy goes along with a reduced incidence of ventricular arrhythmia.
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Affiliation(s)
- Christian Eickholt
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmology and Angiology, Dusseldorf, Germany
| | - Marcus Siekiera
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmology and Angiology, Dusseldorf, Germany
| | - Kiriakos Kirmanoglou
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmology and Angiology, Dusseldorf, Germany
| | - Astrid Rodenbeck
- Division of Cardiology, Pulmology and Angiology, University Hospital RWTH-Aachen, Aachen, Germany
| | - Nicole Heussen
- Department of Medical Statistics, University Hospital RWTH-Aachen, Aachen, Germany
| | - Patrick Schauerte
- Division of Cardiology, Pulmology and Angiology, University Hospital RWTH-Aachen, Aachen, Germany
| | - Artur Lichtenberg
- Heinrich-Heine-University Duesseldorf, Department of Cardiovascular Surgery, Dusseldorf, Germany
| | - Jan Balzer
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmology and Angiology, Dusseldorf, Germany
| | - Tienush Rassaf
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmology and Angiology, Dusseldorf, Germany
| | - Stefan Perings
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmology and Angiology, Dusseldorf, Germany
| | - Malte Kelm
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmology and Angiology, Dusseldorf, Germany
| | - Dong-In Shin
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmology and Angiology, Dusseldorf, Germany
| | - Christian Meyer
- Heinrich-Heine-University Duesseldorf, Medical Faculty, Department of Cardiology, Pulmology and Angiology, Dusseldorf, Germany
- * E-mail:
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8
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The impact of cardiac resynchronization therapy on the incidence of ventricular arrhythmias in mild heart failure. Heart Rhythm 2011; 8:679-84. [DOI: 10.1016/j.hrthm.2010.12.031] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Accepted: 12/16/2010] [Indexed: 11/16/2022]
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Sohns C, Zabel M. [Current role of amiodarone in antiarrhythmic therapy]. Herzschrittmacherther Elektrophysiol 2010; 21:239-243. [PMID: 21104260 DOI: 10.1007/s00399-010-0091-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Decades after its registration, amiodarone is still regarded as the most effective antiarrhythmic drug available for the treatment of tachyarrhythmias. Amiodarone is classified as a class III antiarrhythmic drug. In addition to the prolongation of cardiac repolarization, its leading pharmacologic features are sodium and calcium channel block, nonselective β-adrenergic inhibition as well as high lipophilicity and a very long plasma half-life. In patients with paroxysmal atrial fibrillation, amiodarone is the most effective antiarrhythmic drug in maintaining sinus rhythm. Furthermore, it prevents ventricular arrhythmias, such as frequent ventricular extrasystoles or nonsustained runs of ventricular tachycardia, as well as sustained ventricular tachycardia and ventricular fibrillation. In patients with increased risk for sudden cardiac death, e.g., with severely depressed left ventricular function, amiodarone is a highly effective and safe antiarrhythmic drug. In addition, amiodarone has been shown to reduce the number of appropriate and inappropriate shocks in patients with an implantable cardioverter-defibrillator. During long-term amiodarone treatment, typical side effects including corneal microdeposits, blue-gray skin discoloration, photosensitivity, hypothyroidism, hyperthyroidism, peripheral neuropathy, optical neuritis and hepatotoxicity accrue. Upon cessation of medication, these are almost always reversible. Irreversible, severe adverse effects, such as pulmonary toxicity, are very rare under the currently used maintenance dose of 200 mg/day. With regard to its side effect profile, an adequate follow-up of patients including laboratory values, lung function tests, and visual acuity is necessary.
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Affiliation(s)
- C Sohns
- Abteilung für Kardiologie und Pneumologie/Herzzentrum, Schwerpunkt Klinische Elektrophysiologie, Georg-August-Universität Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland
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Prediction of appropriate defibrillator therapy in heart failure patients treated with cardiac resynchronization therapy. Am J Cardiol 2010; 105:105-11. [PMID: 20102900 DOI: 10.1016/j.amjcard.2009.08.659] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Revised: 08/07/2009] [Accepted: 08/07/2009] [Indexed: 11/23/2022]
Abstract
The necessity of implantable cardioverter-defibrillator (ICD) implantation in patients with systolic heart failure (HF) who undergo cardiac resynchronization therapy (CRT) may be questioned. The aim of this study was to identify patients at low risk for sustained ventricular arrhythmia. One hundred sixty-nine consecutive patients with HF (mean age 60 +/- 12 years, 125 men, 73% in New York Heart Association class III) referred for CRT and prophylactic, primary prevention ICD implantation underwent baseline clinical and echocardiographic assessment and regular device follow-up. The primary study end point was appropriate ICD therapy. During a mean follow-up period of 654 +/- 394 days, 35 patients (21%) had sustained ventricular arrhythmias requiring appropriate ICD therapy. Of the 3 patients who experienced sudden cardiac death, 2 had been treated with appropriate ICD therapy before sudden cardiac death. In a multivariate model, only history of nonsustained ventricular tachycardia (p = 0.001), a severely (<20%) decreased left ventricular ejection fraction (p = 0.001), and digitalis therapy (p = 0.08) independently predicted appropriate ICD therapy. Patients with 0 (n = 46), 1 (n = 36), 2 (n = 73), and 3 (n = 14) risk factors for appropriate ICD therapy had a 7%, 14%, 27%, and 64% and 0%, 6%, 10%, and 43% incidence of appropriate ICD therapy for ventricular arrhythmias and for rapid ventricular tachycardia or ventricular fibrillation, respectively. In conclusion, apart from commonsense considerations (age and significant co-morbidities), ICD addition seems ineffective in CRT patients without nonsustained ventricular tachycardia, digoxin therapy, and severely reduced left ventricular systolic function.
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11
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Not too late, not too fast!! Eur Heart J 2009; 30:2689-92. [DOI: 10.1093/eurheartj/ehp446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Echocardiography and noninvasive imaging in cardiac resynchronization therapy: results of the PROSPECT (Predictors of Response to Cardiac Resynchronization Therapy) study in perspective. J Am Coll Cardiol 2009; 53:1933-43. [PMID: 19460606 DOI: 10.1016/j.jacc.2008.11.061] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 10/14/2008] [Accepted: 11/02/2008] [Indexed: 11/23/2022]
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YPENBURG CLAUDIA, WESTENBERG JOSJ, BLEEKER GABEB, VAN de VEIRE NICO, MARSAN NINAA, HENNEMAN MAUREENM, van der WALL ERNSTE, SCHALIJ MARTINJ, ABRAHAM THEODOREP, BAROLD SSERGE, BAX JEROENJ. Noninvasive Imaging in Cardiac Resynchronization Therapy-Part 1: Selection of Patients. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:1475-99. [DOI: 10.1111/j.1540-8159.2008.01212.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Field ME, Sweeney MO. Socio-economic analysis of cardiac resynchronization therapy. J Interv Card Electrophysiol 2007; 17:225-36. [PMID: 17372813 DOI: 10.1007/s10840-006-9079-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 12/29/2006] [Indexed: 10/23/2022]
Abstract
The field of electrical device therapy has benefited from two basically independent lines of investigation demonstrating mortal benefit from either cardiac resynchronization therapy (CRT) or implantable cardioverter-defibrillator (ICD) therapy in patients with heart failure. Current clinical evidence data is insufficient to conclude that CRT-defibrillation (CRTD) offers an advantage over CRT-pacing (CRTP) alone. The cost of adding a defibrillator to the CRTP device is substantial and will act as a barrier to wide scale penetration. Annualized sudden death rates are very low in certain primary prevention populations. Consequently, the potential for overtreatment is very large and the negative costs of ICD therapy are distributed equally among those patients who will have a life saving benefit and those who were "destined" never to require the therapy. The perception that these costs are acceptable if lives are saved is commonly cited as justification for expensive therapy on a population scale, but there is an important and practical difference between costs per unit life saved and costs among patients who really never needed the device. Until the a priori predictors of volumetric response to CRT are better understood, the use of CRTD in class IV patients should be discouraged since ICD therapy is unlikely to extend life in volumetric non-responders. Similarly, the use of CRTD in patients who are "destined" for significant volumetric response is probably unwise since their risk of sudden death is minimized due to favorable substrate modification. Clinical trials comparing conventional ICDs, CRTP and CRTD are necessary to rationalize use of expensive hardware resources among different patient populations. Additionally, the importance of patient preference regarding end of life care should receive greater emphasis. While CRTP may be considered palliative in terminal heart failure, the decision to offer CRTD must include a discussion with the patient regarding mode of death and the potential for the defibrillator to replace a sudden and peaceful death with a prolonged death from progressive pump failure.
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Affiliation(s)
- Michael E Field
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Boston, MA, 02115, USA
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Gradaus R, Breithardt G. Should all patients with heart failure and left ventricular dysfunction receive combined CRT–ICD therapy? ACTA ACUST UNITED AC 2007; 4:68-9. [PMID: 17228290 DOI: 10.1038/ncpcardio0739] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Accepted: 10/20/2006] [Indexed: 11/09/2022]
Affiliation(s)
- Rainer Gradaus
- Department of Cardiology and Angiology at the Hospital of the University of Münster, Germany
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17
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DeMaria AN, Ben-Yehuda O, Feld GK, Ginsburg GS, Greenberg BH, Lew WYW, Lima JAC, Maisel AS, Narula J, Sahn DJ, Tsimikas S. Highlights of the Year in JACC2006. J Am Coll Cardiol 2007; 49:509-27. [PMID: 17258099 DOI: 10.1016/j.jacc.2006.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2006] [Accepted: 12/05/2006] [Indexed: 12/15/2022]
Affiliation(s)
- Anthony N DeMaria
- Cardiology Division, University of California-San Diego, 92103-9000, USA.
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