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Cardiac resynchronization therapy with or without defibrillation: a long-standing debate. Cardiol Rev 2021; 30:221-233. [PMID: 33758120 DOI: 10.1097/crd.0000000000000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cardiac resynchronization therapy (CRT) was shown to improve cardiac function, reduce heart failure hospitalizations, improve quality of life and prolong survival in patients with severe left ventricular dysfunction and intraventricular conduction disturbances, mainly left bundle branch block, on optimal medical therapy with ACE-inhibitors, β-blockers and mineralocorticoid receptor antagonists up-titrated to maximum tolerated evidence-based doses. CRT can be achieved by means of pacemaker systems (CRT-P) or devices with defibrillation capabilities (CRT-D). CRT-Ds offer an undoubted advantage in the prevention of arrhythmic death, but such an advantage may be of lesser degree in non-ischemic heart failure aetiologies. Moreover, the higher CRT-D hardware complexity compared to CRT-P may predispose to device/lead malfunctions and the higher current drainage may cause a shorter battery duration with consequent premature replacements and the well-known incremental complications. In a period of financial constraints, also device costs should be carefully evaluated, with recent reports suggesting that CRT-Ps may be favoured over CRT-Ds in patients with non-ischemic cardiomyopathy and no prior history of cardiac arrhythmias from a cost-effectiveness point of view. The choice between a CRT-P or a CRT-D device should be patient-tailored whenever straightforward defibrillator indications are not present. The Goldenberg score may facilitate this decision-making process in ambiguous settings. Age, comorbidities, kidney disease, atrial fibrillation, advanced functional class, inappropriate therapy risk, implantable device infections and malfunctions are factors potentially reducing the expected benefit from defibrillating capabilities. Future prospective, randomized controlled trials are warranted to directly compare the efficacy and safety of CRT-Ps and CRT-Ds.
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Long YX, Hu Y, Cui DY, Hu S, Liu ZZ. The benefits of defibrillator in heart failure patients with cardiac resynchronization therapy: A meta-analysis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 44:225-234. [PMID: 33372697 DOI: 10.1111/pace.14150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 12/01/2020] [Accepted: 12/13/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Current guidelines did not provide recommendations on indications of an additional implantable cardioverter-defibrillator (ICD) to patients receiving cardiac resynchronization therapy (CRT), and it still remains controversial due to lack of evidence from randomized controlled trials. METHOD PubMed, Embase, and Cochrane CENTRAL from the inception to May 2020 were systematically screened for studies reporting on the comparison of cardiac resynchronization therapy with defibrillator (CRT-D) and cardiac resynchronization therapy with pacemaker (CRT-P), focusing on the adjusted hazard ratio (aHR) of all-cause mortality. We pooled the effects using a random-effect model. RESULTS Twenty-one studies encompassing 69,919 patients were included in this meta-analysis. With no restriction to characteristics of including population, CRT-D was associated with a lower all-cause mortality compared with CRT-P significantly (aHR: 0.80, 95% confidence interval [CI]: 0.74-0.87, I2 = 36.8%, p < .001). This mortality benefit was also observed in patients with ischemic cardiomyopathy (aHR: 0.74, 95% CI: 0.64-0.86, I2 = 0%, p < .001). However, there is no significant difference in patients with nonischemic cardiomyopathy (NICM) (aHR: 0.91, 95% CI: 0.82-1.01, I2 = 0%, p = .087), older age (age ≥75 years, aHR: 0.96, 95% CI: 0.83-1.12, I2 = 0%, p = .610). Subgroup analysis was performed and indicated the survival benefit of CRT-D for primary prevention compared with CRT-P (aHR: 0.87, 95% CI: 0.79-0.95, I2 = 0%, p = .003). CONCLUSION After adjusted the differences in clinical characteristics, additional ICD therapy was associated with a reduced all-cause mortality in patients receiving CRT. However, our work suggested that additional ICD may not be applied to elderly (≥75 years) or patients with NICM.
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Affiliation(s)
- Yu-Xiang Long
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Hu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Di-Yu Cui
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuang Hu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zeng-Zhang Liu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Barra S, Providência R, Narayanan K, Boveda S, Duehmke R, Garcia R, Leyva F, Roger V, Jouven X, Agarwal S, Levy WC, Marijon E. Time trends in sudden cardiac death risk in heart failure patients with cardiac resynchronization therapy: a systematic review. Eur Heart J 2019; 41:1976-1986. [DOI: 10.1093/eurheartj/ehz773] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/07/2019] [Accepted: 10/25/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
While data from randomized trials suggest a declining incidence of sudden cardiac death (SCD) among heart failure patients, the extent to which such a trend is present among patients with cardiac resynchronization therapy (CRT) has not been evaluated. We therefore assessed changes in SCD incidence, and associated factors, in CRT recipients over the last 20 years.
Methods and results
Literature search from inception to 30 April 2018 for observational and randomized studies involving CRT patients, with or without defibrillator, providing specific cause-of-death data. Sudden cardiac death was the primary endpoint. For each study, rate of SCD per 1000 patient-years of follow-up was calculated. Trend line graphs were subsequently constructed to assess change in SCD rates over time, which were further analysed by device type, patient characteristics, and medical therapy. Fifty-three studies, comprising 22 351 patients with 60 879 patient-years of follow-up and a total of 585 SCD, were included. There was a gradual decrease in SCD rates since the early 2000s in both randomized and observational studies, with rates falling more than four-fold. The rate of decline in SCD was steeper than that of all-cause mortality, and accordingly, the proportion of deaths which were due to SCD declined over the years. The magnitude of absolute decline in SCD was more prominent among CRT-pacemaker (CRT-P) patients compared to those receiving CRT-defibrillator (CRT-D), with the difference in SCD rates between CRT-P and CRT-D decreasing considerably over time. There was a progressive increase in age, use of beta-blockers, and left ventricular ejection fraction, and conversely, a decrease in QRS duration and antiarrhythmic drug use.
Conclusion
Sudden cardiac death rates have progressively declined in the CRT heart failure population over time, with the difference between CRT-D vs. CRT-P recipients narrowing considerably.
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Affiliation(s)
- Sérgio Barra
- Cardiology Department, Hospital da Luz Arrabida, Praceta de Henrique Moreira 150, 4400-346 V. N. Gaia, Portugal
- Cardiology Department, V. N. Gaia Hospital Center, Rua Conceição Fernandes 4434-502 V. N. Gaia, Portugal
- Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Cambridge CB2 0AY, UK
| | - Rui Providência
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, W Smithfield, London EC1A 7BE, UK
| | - Kumar Narayanan
- Cardiology Department, Medicover Hospitals, Hyderabad, India
- Paris Cardiovascular Research Center (Inserm U970), Cardiovascular Epidemiology Unit, 56 Rue Leblanc, 75015 Paris, France
| | - Serge Boveda
- Cardiology Department, Clinique Pasteur, 45 Avenue de Lombez - BP 27617 - 31076 TOULOUSE, 31300 Toulouse, France
| | - Rudolf Duehmke
- Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Cambridge CB2 0AY, UK
- Cardiology Department, James Paget University Hospital, Lowestoft Road Gorleston-on-Sea, Great Yarmouth NR31 6LA, UK
| | - Rodrigue Garcia
- Cardiology Department, Poitiers University Hospital, 2 Rue de la Milétrie, 86021 Poitiers, France
| | - Francisco Leyva
- Aston Medical Research Institute, Aston University Medical School, 295 Aston Express Way, Birmingham B4 7ET, UK
- Cardiology Department, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham B15 2TH, UK
| | - Véronique Roger
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, 200 1st St SW, Rochester, MN 55905, USA
- Department of Health Sciences Research, Mayo Clinic College of Medicine and Science, 200 1st St SW, Rochester, MN 55905, USA
| | - Xavier Jouven
- Paris Cardiovascular Research Center (Inserm U970), Cardiovascular Epidemiology Unit, 56 Rue Leblanc, 75015 Paris, France
- Cardiology Department, European Georges Pompidou Hospital, 20 Rue Leblanc, 75015 Paris, France
- Paris Descartes University, 12 Rue de l'École de Médecine, 75006 Paris, France
| | - Sharad Agarwal
- Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Cambridge CB2 0AY, UK
| | - Wayne C Levy
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Eloi Marijon
- Paris Cardiovascular Research Center (Inserm U970), Cardiovascular Epidemiology Unit, 56 Rue Leblanc, 75015 Paris, France
- Cardiology Department, European Georges Pompidou Hospital, 20 Rue Leblanc, 75015 Paris, France
- Paris Descartes University, 12 Rue de l'École de Médecine, 75006 Paris, France
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Barra S, Providência R, Duehmke R, Boveda S, Begley D, Grace A, Narayanan K, Tang A, Marijon E, Agarwal S. Cause-of-death analysis in patients with cardiac resynchronization therapy with or without a defibrillator: a systematic review and proportional meta-analysis. Europace 2017; 20:481-491. [DOI: 10.1093/europace/eux094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/15/2017] [Indexed: 02/05/2023] Open
Affiliation(s)
- Sérgio Barra
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
| | - Rui Providência
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Rudolf Duehmke
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
| | - Serge Boveda
- Cardiology Department, Clinique Pasteur, Toulouse, France
| | - David Begley
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
| | - Andrew Grace
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
| | | | - Anthony Tang
- Cardiology Department, University of Western Ontario, London, Ontario, Canada
| | - Eloi Marijon
- Paris Cardiovascular Research Center, Cardiovascular Epidemiology Unit, Paris, France
- Cardiology Department, European Georges Pompidou Hospital, Paris, France
- Paris Descartes University, Paris, France
| | - Sharad Agarwal
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
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Barra S, Providência R, Tang A, Heck P, Virdee M, Agarwal S. Importance of Implantable Cardioverter-Defibrillator Back-Up in Cardiac Resynchronization Therapy Recipients: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2015; 4:e002539. [PMID: 26546574 PMCID: PMC4845241 DOI: 10.1161/jaha.115.002539] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 09/28/2015] [Indexed: 01/18/2023]
Abstract
BACKGROUND It remains to be determined whether patients receiving cardiac resynchronization therapy (CRT) benefit from the addition of an implantable cardioverter-defibrillator (ICD). METHODS AND RESULTS We performed a literature search looking for studies of patients implanted with CRTs. Comparisons were performed between patients receiving CRT-defibrillator (CRT-D) versus CRT-pacemaker (CRT-P). The primary outcome was all-cause mortality. Data were pooled using a random-effects model. The relative risk (RR) and hazard ratio (HR, when available) were used as measurements of treatment effect. Nineteen entries were entitled for inclusion, comprising 12 378 patients (7030 receiving CRT-D and 5348 receiving CRT-P) and 29 799 patient-years of follow-up. Those receiving CRT-D were younger, were more often males, had lower NYHA class, lower prevalence of atrial fibrillation, higher prevalence of ischemic heart disease, and were more often on beta-blockers. Ten studies showed significantly lower mortality rates with the CRT-D device, while the remaining 9 were neutral. The pooled data of studies revealed that CRT-D patients had significantly lower mortality rates compared with CRT-P patients (mortality rates: CRT-D 16.6% versus CRT-P 27.1%; RR=0.69, 95% CI 0.62-0.76; P<0.00001). The number needed to treat to prevent one death was 10. The observed I(2) values showed moderate heterogeneity among studies (I(2)=48%). The benefit of CRT-D was more pronounced in ischemic cardiomyopathy (HR=0.70, 95% CI 0.59-0.83, P<0.001, I(2)=0%), but a trend for benefit, albeit of lower magnitude, could also be seen in non-ischemic dilated cardiomyopathy (HR=0.79, 95% CI 0.61-1.02, P=0.07, I(2)=36%). CONCLUSIONS The addition of the ICD associates with a reduction in the risk of all-cause mortality in CRT patients. This seems to be more pronounced in patients with ischemic cardiomyopathy.
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Affiliation(s)
- Sérgio Barra
- Cardiology DepartmentPapworth Hospital NHS Foundation TrustCambridgeUK
| | | | - Anthony Tang
- University of Western OntarioLondonOntarioCanada
| | - Patrick Heck
- Cardiology DepartmentPapworth Hospital NHS Foundation TrustCambridgeUK
| | - Munmohan Virdee
- Cardiology DepartmentPapworth Hospital NHS Foundation TrustCambridgeUK
| | - Sharad Agarwal
- Cardiology DepartmentPapworth Hospital NHS Foundation TrustCambridgeUK
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Kunz LM, Normand SLT, Sedrakyan A. Meta-analysis of rate ratios with differential follow-up by treatment arm: inferring comparative effectiveness of medical devices. Stat Med 2015; 34:2913-25. [PMID: 26011521 DOI: 10.1002/sim.6530] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 04/13/2015] [Accepted: 04/26/2015] [Indexed: 11/09/2022]
Abstract
Modeling events requires accounting for differential follow-up duration, especially when combining randomized and observational studies. Although events occur at any point over a follow-up period and censoring occurs throughout, most applied researchers use odds ratios as association measures, assuming follow-up duration is similar across treatment groups. We derive the bias of the rate ratio when incorrectly assuming equal follow-up duration in the single study binary treatment setting. Simulations illustrate bias, efficiency, and coverage and demonstrate that bias and coverage worsen rapidly as the ratio of follow-up duration between arms moves away from one. Combining study rate ratios with hierarchical Poisson regression models, we examine bias and coverage for the overall rate ratio via simulation in three cases: when average arm-specific follow-up duration is available for all studies, some studies, and no study. In the null case, bias and coverage are poor when the study average follow-up is used and improve even if some arm-specific follow-up information is available. As the rate ratio gets further from the null, bias and coverage remain poor. We investigate the effectiveness of cardiac resynchronization therapy devices compared with those with cardioverter-defibrillator capacity where three of eight studies report arm-specific follow-up duration.
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Affiliation(s)
- Lauren M Kunz
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, 20892, MD, U.S.A.,Department of Biostatistics, Harvard School of Public Health, Boston, 02115, MA, U.S.A
| | - Sharon-Lise T Normand
- Department of Biostatistics, Harvard School of Public Health, Boston, 02115, MA, U.S.A.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts, 02115, U.S.A
| | - Art Sedrakyan
- Weill Cornell Medical College of Cornell University and New York Presbyterian Hospital, New York, 10065, NY, U.S.A
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Bortnik M, Degiovanni A, Dell’Era G, Cavallino C, Occhetta E, Marino P. Prevalence of ventricular arrhythmias in patients with cardiac resynchronization therapy without back-up ICD. J Cardiovasc Med (Hagerstown) 2014; 15:301-6. [DOI: 10.2459/jcm.0b013e3283638148] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Morani G, Gasparini M, Zanon F, Casali E, Spotti A, Reggiani A, Bertaglia E, Solimene F, Molon G, Accogli M, Tommasi C, Paoletti Perini A, Ciardiello C, Padeletti L. Cardiac resynchronization therapy-defibrillator improves long-term survival compared with cardiac resynchronization therapy-pacemaker in patients with a class IA indication for cardiac resynchronization therapy: data from the Contak Italian Registry. Europace 2013; 15:1273-9. [PMID: 23439866 DOI: 10.1093/europace/eut032] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS In candidates for cardiac resynchronization therapy (CRT), the choice between pacemaker (CRT-P) and defibrillator (CRT-D) implantation is still debated. We compared the long-term prognosis of patients who received CRT-D or CRT-P according to class IA recommendations of the European Society of Cardiology (ESC) and who were enrolled in a multicentre prospective registry. METHODS AND RESULTS A total of 620 heart failure patients underwent successful implantation of a CRT device and were enrolled in the Contak Italian Registry. This analysis included 266 patients who received a CRT-D and 108 who received a CRT-P according to class IA ESC indications. Their survival status was verified after a median follow-up of 55 months. During follow-up, 73 CRT-D and 44 CRT-P patients died (rate 6.6 vs. 10.4%/year; log-rank test, P = 0.020). Patients receiving CRT-P were predominantly older, female, had no history of life-threatening ventricular arrhythmias, and more frequently presented non-ischaemic aetiology of heart failure, longer QRS durations, and worse renal function. However, the only independent predictor of death from any cause was the use of CRT-P (hazard ratio, 1.97; 95% confidence interval, 1.21-3.16; P = 0.007). CONCLUSION The implantation of CRT-D, rather than CRT-P, may be preferable in patients presenting with current class IA ESC indications for CRT. Indeed, CRT-D resulted in greater long-term survival and was independently associated with a better prognosis.
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Jiang M, He B, Zhang Q. Comparison of CRT and CRT-D in heart failure: Systematic review of controlled trials. Int J Cardiol 2012; 158:39-45. [DOI: 10.1016/j.ijcard.2010.12.091] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 11/10/2010] [Accepted: 12/24/2010] [Indexed: 10/18/2022]
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BAI RONG, BIASE LUIGIDI, ELAYI CLAUDE, CHING CHIKEONG, BARRETT CONOR, PHILIPPS KAREN, LIM PASCAL, PATEL DIMPI, CALLAHAN TOM, MARTIN DAVIDO, ARRUDA MAURICIO, SCHWEIKERT ROBERTA, SALIBA WALIDI, WILKOFF BRUCE, NATALE ANDREA. Mortality of Heart Failure Patients After Cardiac Resynchronization Therapy: Identification of Predictors. J Cardiovasc Electrophysiol 2008; 19:1259-65. [DOI: 10.1111/j.1540-8167.2008.01234.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Rosanio S, Schwarz ER, Vitarelli A, Zarraga IGE, Kunapuli S, Ware DL, Birnbaum Y, Tuero E, Uretsky BF. Sudden death prophylaxis in heart failure. Int J Cardiol 2007; 119:291-6. [PMID: 17208319 DOI: 10.1016/j.ijcard.2006.11.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Revised: 10/03/2006] [Accepted: 11/09/2006] [Indexed: 11/19/2022]
Abstract
Sudden cardiac death (SCD) is the leading cause of mortality in heart failure (HF). Today the implantable cardioverter-defibrillator (ICD) has become a commonplace therapy around the world for patients with both ischemic and non-ischemic cardiomyopathy and an ejection fraction (EF) < or = 35%. However, EF alone does not discriminate between the modes of death from HF (sudden arrhythmic death vs. non-sudden death). Other risk statifiers, such as electrophysiologic study and microvolt T-wave alternans testing, should therefore be used in the appropriate settings to minimize the number of unnecessary device implants. In addition, left ventricular mechanical dyssynchrony has now become recognized as an additional major marker of cardiac mortality. Its assessment should entail echocardiography rather than measurement of the QRS duration. This will allow us to better integrate the ability of cardiac resynchronization therapy (CRT) in enhancing cardiac function with the ability of an ICD in preventing SCD. This review aims to: 1) give a synthesis of the published evidence regarding the value of implantable ICDs and CRT in the primary prophylaxis of SCD in HF; 2) discuss controversial clinical issues in this area; and 3) recommend practical device-based management strategies.
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Affiliation(s)
- Salvatore Rosanio
- The Department of Internal Medicine, Division of Cardiology, The University of Texas Medical Branch, Galveston, Texas 77555-0553, United States.
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Gasparini M, Lunati M, Santini M, Tritto M, Curnis A, Bocchiardo M, Vincenti A, Pistis G, Valsecchi S, Denaro A. Long-term survival in patients treated with cardiac resynchronization therapy: a 3-year follow-up study from the InSync/InSync ICD Italian Registry. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 29 Suppl 2:S2-10. [PMID: 17169128 DOI: 10.1111/j.1540-8159.2006.00485.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Studies reporting the long-term survival of patients treated with cardiac resynchronization therapy (CRT) outside the realm of randomized controlled trials are still lacking. The aim of this study was to quantify the survival of patients treated with CRT in clinical practice and to investigate the long-term effects of CRT on clinical status and echocardiographic parameters. METHODS The study population consisted of 317 consecutive patients with implanted CRT devices from eight Italian University/Teaching Hospitals. The patients were enrolled in a national observational registry and had a minimum follow-up of 2 years. A visit was performed in surviving patients and mortality data were obtained by hospital file review or direct telephone contact. RESULTS During the study period, 83 (26%) patients died. The rate of all-cause mortality was significantly higher in ischemic than nonischemic patients (14% vs 8%, P = 0.002). Multivariate analysis showed that ischemic etiology (HR 1.72, CI 1.06-2.79; P = 0.028) and New York Heart Association (NYHA) class IV (HR 2.87, CI 1.24-6.64; P = 0.014) were the strongest predictors of all-cause mortality. The effects of CRT persisted at long-term follow-up (for at least 2 years) in terms of NYHA class improvement, increase of left ventricular ejection fraction, decrease of QRS duration (all P = 0.0001), and reduction of left ventricular end-diastolic and end-systolic diameters (P = 0.024 and P = 0.011, respectively). CONCLUSIONS During long-term (3 years) follow-up after CRT, total mortality rate was 10%/year. The outcome of ischemic patients was worse mainly due to a higher rate of death from progressive heart failure. Ischemic etiology along with NYHA class IV was identified as predictors of death. Benefits of CRT in terms of clinical function and echocardiographic parameters persisted at the time of long-term follow-up.
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Vitarelli A, Franciosa P, Conde Y, Cimino E, Nguyen BL, Ciccaglione A, Morichetti MC, Chachques JC, Rosanio S. Echocardiographic Assessment of Ventricular Asynchrony in Dilated Cardiomyopathy and Congenital Heart Disease: Tools and Hopes. J Am Soc Echocardiogr 2005; 18:1424-39. [PMID: 16376781 DOI: 10.1016/j.echo.2005.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2005] [Indexed: 11/29/2022]
Abstract
Ventricular dyssynchrony is a relatively common problem in patients with heart failure, in particular those with wide QRS complex, and appears to have a deleterious effect on the natural history of heart failure, as it has been associated with increased mortality. Mechanistic studies, observational evaluations, and randomized trials have consistently demonstrated the beneficial effects of cardiac resynchronization therapy (CRT) in patients with moderate-to-severe chronic systolic heart failure and ventricular dyssynchrony who have failed optimal medical treatment. However, despite the promising results, it is estimated that in approximately 30% of patients undergoing CRT, the symptoms of heart failure do not improve or become even worse. One of the most important reasons for this failure is probably the lack of distinct mechanical dyssynchrony before implantation. A number of echocardiographic tools have been developed during the past 3 years for quantitative measurement of the severity of dyssynchrony before and after CRT. This review discusses the actual and potential role of different echocardiographic techniques in selection of patients and optimization of CRT and the value of some new clinical applications such as in congenital heart disease.
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Rosanio S, Schwarz ER, Ahmad M, Jammula P, Vitarelli A, Uretsky BF, Birnbaum Y, Ware DL, Atar S, Saeed M. Benefits, unresolved questions, and technical issues of cardiac resynchronization therapy for heart failure. Am J Cardiol 2005; 96:710-7. [PMID: 16125501 DOI: 10.1016/j.amjcard.2005.04.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2005] [Revised: 04/20/2005] [Accepted: 04/20/2005] [Indexed: 11/29/2022]
Abstract
This review aims to provide a synthesis of the published evidence regarding the rationale and clinical benefits of cardiac resynchronization therapy (CRT) with implantable atrial-synchronized biventricular pacing (BVP) devices in patients with moderate to advanced heart failure and intra- and interventricular conduction delays. In addition, it addresses clinical and technical issues that have yet to be resolved, such as the selection of the most suitable candidates for CRT; the usefulness of combining BVP with automatic defibrillation backup; the value of CRT in patients with atrial fibrillation; the importance of alternative sites of pacing, such as the atrial septum and the right ventricular (RV) outflow tract; the harmful effects of the long-standing practice of producing an iatrogenic left bundle branch block by conventional RV pacing in patients receiving standard permanent pacemakers; the question of precisely where on the left ventricle optimal pacing is achieved; and the potential applications of CRT in patients with pediatric or congenital heart disease. Considering how major advances have been achieved since the first clinical application of CRT in 1994, one can be optimistic about the future of the electrotherapeutic management of heart failure.
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Affiliation(s)
- Salvatore Rosanio
- Department of Internal Medicine, Division of Cardiology, University of Texas Medical Branch, Galveston, Texas, USA.
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Chugh A, Scharf C, Hall B, Cheung P, Good E, Horwood L, Oral H, Pelosi F, Morady F. Prevalence and Management of Inappropriate Detection and Therapies in Patients with First-Generation Biventricular Pacemaker-Defibrillators. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:44-50. [PMID: 15660802 DOI: 10.1111/j.1540-8159.2005.09499.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tachycardia detection in first-generation biventricular pacemaker-implantable cardioverter defibrillators (BiV ICD) occurs through both the right ventricular (RV) and left ventricular (LV) leads, creating the potential for inappropriate detection and therapies. Little is known regarding the prevalence and management of patients with BiV ICDs and inappropriate detection. METHODS AND RESULTS A transvenous, first-generation BiV ICD was implanted in 77 consecutive patients (age 61 +/- 11 years) for drug-refractory heart failure. The mean New York Heart Association class, QRS duration, and ejection fraction were 3.1 +/- 0.4, 168 +/- 24 ms, and 0.19 +/- 0.07, respectively. Among the 77 patients, 17 (22%) experienced inappropriate detection at a mean of 154 +/- 140 days after implantation. Fifteen of the 17 patients (88%) experienced inappropriate ICD therapy. In 16 of the 17 (94%) patients, the cause of inappropriate detection was double counting during sinus (8) or atrial rhythm (3), and nonsustained ventricular tachycardia (5). Despite reprogramming of the ICD, 9 patients (53%) required an additional procedure because of inappropriate therapies, including an upgrade to a dedicated BiV ICD (5), revision of the LV lead (2), ablation of the atrioventricular junction (1), and repeat defibrillation threshold testing (2). CONCLUSIONS Inappropriate detection in patients with a first-generation BiV ICD is common and often results in inappropriate ICD therapy. The most common mechanism of inappropriate detection is double counting that often creates the need for additional procedures. Although devices in which tachycardia detection occurs only through the RV lead now are available, close follow-up of the many patients who received a first-generation BiV ICD is necessary.
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Affiliation(s)
- Aman Chugh
- Division of Cardiology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109-0311, USA.
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Rosen MR, Binah O, Marom S. Cardiac memory and cortical memory: do learning patterns in neural networks impact on cardiac arrhythmias? Circulation 2003; 108:1784-9. [PMID: 14557342 DOI: 10.1161/01.cir.0000091402.34219.6c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Memory is a property of diverse biological systems, including brain and heart. Studies in cortical neuronal networks have identified an increased sensitivity to infrequent (rare) stimulation patterns that can result in their achieving dominance over network firing. This adaptive behavior is applied to the heart in an attempt to explain the ability of pulmonary venous and other ectopic foci to achieve dominance over cardiac rhythm. Developmental changes in determinants of cardiac rhythm are explored as possible determinants of the range of rhythms expressed by the heart. By understanding the mechanisms for these behavior patterns, we may obtain new means for manipulating memory to return dysrhythmic hearts to normal sinus rhythm.
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Affiliation(s)
- Michael R Rosen
- Department of Pharmacology, Center for Molecular Therapeutics, New York, NY, USA.
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Abstract
Sudden cardiac death is responsible for >40% of patients with heart failure losing their lives. Thus, the prevention of life-threatening cardiac arrhythmias is a major goal in the management of heart failure. In several randomized clinical trials, electrical therapy with the implantable cardioverter defibrillator (ICD) has proved superior to medical antiarrhythmic therapy in both the secondary and primary prevention of sudden cardiac death in patients with reduced left ventricular function. In addition to the severity of left ventricular dysfunction, the etiology of the cardiomyopathy appears to be a determinant in the benefit derived from this form of electrical therapy. Whereas patients with ischemic cardiomyopathy clearly show improved survival with ICD therapy, outcome data in patients with nonischemic cardiomyopathy are less convincing. The major challenge lies in the risk stratification of patients with heart failure for arrhythmic death. Catheter ablation is another form of electrical therapy that can help in the treatment of patients with heart failure. In patients with a tachycardia-mediated cardiomyopathy because of drug-refractory atrial fibrillation with rapid ventricular response, catheter ablation of the atrioventricular node and pacemaker implantation can effectively restore a physiologic heart rate, often with dramatic regression of left ventricular dysfunction. In patients with frequent ICD therapies because of frequent recurrences of ventricular tachyarrhythmias, catheter ablation of ventricular tachycardia can be an effective adjunctive therapy. New catheter ablation techniques and new atrial pacing algorithms can also significantly reduce the atrial fibrillation burden in patients with heart failure who are particularly susceptible to decompensation because of atrial fibrillation. Pacing for hemodynamic benefit in heart failure has evolved from dual-chamber pacing modes with optimized atrioventricular delay to biventricular pacing resulting in cardiac resynchronization. This new treatment modality for advanced heart failure has been shown to result in significant symptomatic and hemodynamic improvement.
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Affiliation(s)
- Erica D Engelstein
- Cardiac Electrophysiology Section, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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