1
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Sticherling C, Ellenbogen KA, Burri H. Stepping back for good reasons: a reappraisal of the DF-1 connector for defibrillator leads. Europace 2024; 26:euae057. [PMID: 38412340 PMCID: PMC10919383 DOI: 10.1093/europace/euae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/22/2024] [Indexed: 02/29/2024] Open
Abstract
The DF-4 defibrillator standard has been rapidly adopted due to its convenience at implantation. There are however trade-offs compared to the traditional DF-1 standard that are underappreciated. This viewpoint outlines the advantages and limitations of current defibrillator lead standards that should be kept in mind, as they impact the options that are available to deal with issues that may arise.
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Affiliation(s)
- Christian Sticherling
- Department of Cardiology, University Hospital Basel, University of Basel, Petersgraben 4, CH-4059 Basel, Switzerland
| | - Kenneth A Ellenbogen
- Department of Electrophysiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Haran Burri
- Department of Cardiology, University Hospital Geneva, Geneva, Switzerland
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2
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Frey SM, Brenner R, Theuns DA, Al-Shoaibi N, Crawley RJ, Ammann P, Sticherling C, Kühne M, Osswald S, Schaer B. Follow-up of CRT-D patients downgraded to CRT-P at the time of generator exchange. Front Cardiovasc Med 2023; 10:1217523. [PMID: 37396585 PMCID: PMC10308007 DOI: 10.3389/fcvm.2023.1217523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Background Some patients with cardiac resynchronisation therapy (CRT) experience super-response (LVEF improvements to ≥50%). At generator exchange (GE), downgrading (DG) from CRT-defibrillator (CRT-D) to CRT-pacemaker (CRT-P) could be an option for these patients on primary prevention ICD indication and no required ICD therapies. Long-term data on arrhythmic events in super-responders is scarce. Methods CRT-D patients with LVEF improvement to ≥50% at GE were identified in four large centres for retrospective analysis. Mortality, significant ventricular tachyarrhythmia and appropriate ICD-therapy were determined, and patient analysis was split into two groups (downgraded to CRT-P or not). Results Sixty-six patients (53% male, 26% coronary artery disease) on primary prevention were followed for a median of 129 months [IQR: 101-155] after implantation. 27 (41%) patients were downgraded to CRT-P at GE after a median of 68 [IQR: 58-98] months (LVEF 54% ± 4%). The other 39 (59%) continued with CRT-D therapy (LVEF 52% ± 6%). No cardiac death or significant arrhythmia occurred in the CRT-P group (median follow-up (FU) 38 months [IQR: 29-53]). Three appropriate ICD-therapies occurred in the CRT-D group [median FU 70 months (IQR: 39-97)]. Annualized event-rates after DG/GE were 1.5%/year and 1.0%/year in the CRT-D group and the whole cohort, respectively. Conclusions No significant tachyarrhythmia were detected in the patients downgraded to CRT-P during follow-up. However, three events were observed in the CRT-D group. Whilst downgrading CRT-D patients is an option, a small residual risk for arrhythmic events remains and decisions regarding downgrade should be made on a case-by-case basis.
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Affiliation(s)
- Simon Martin Frey
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Roman Brenner
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Dominic A. Theuns
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Naeem Al-Shoaibi
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Richard J. Crawley
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Peter Ammann
- Department of Cardiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | | | - Michael Kühne
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Stefan Osswald
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Beat Schaer
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
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3
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Theuns DAMJ, Niazi K, Schaer BA, Sticherling C, Yap SC, Caliskan K. Reassessment of clinical variables in cardiac resynchronization defibrillator patients at the time of first replacement: Death after replacement of CRT (DARC) score. J Cardiovasc Electrophysiol 2021; 32:1687-1694. [PMID: 33825257 PMCID: PMC8251620 DOI: 10.1111/jce.15031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/10/2021] [Accepted: 03/29/2021] [Indexed: 11/29/2022]
Abstract
Introduction Cardiac resynchronization defibrillator (CRT‐D) as primary prevention is known to reduce mortality. At the time of replacement, higher age and comorbidities may attenuate the benefit of implantable cardioverter‐defibrillator (ICD) therapy. The purpose of this study was to evaluate the progression of comorbidities after implantation and their association with mortality following CRT‐D generator replacement. In addition, a risk score was developed to identify patients at high risk for mortality after replacement. Methods and Results We identified patients implanted with a primary prevention CRT‐D (n = 648) who subsequently underwent elective generator replacement (n = 218) from two prospective ICD registries. The cohort consisted of 218 patients (median age: 70 years, male gender: 73%, mean left ventricular ejection fraction [LVEF]: 36 ± 11% at replacement). Median follow‐up after the replacement was 4.2 years during which 64 patients (29%) died and 11 patients (5%) received appropriate ICD shocks. An increase in comorbidities was observed in 77 patients (35%). The 5‐year mortality rate was 41% in patients with ≥2 comorbidities at the time of replacement. A risk score incorporating age, gender, LVEF, atrial fibrillation, anemia, chronic kidney disease, and history of appropriate ICD shocks at time of replacement accurately predicted 5‐year mortality (C‐statistic 0.829). Patients with a risk score of greater than 2.5 had excess mortality at 5‐year postreplacement compared with patients with a risk score less than 1.5 (57% vs. 6%; p < .001). Conclusion A simple risk score accurately predicts 5‐year mortality after replacement in CRT‐D patients, as patients with a risk score of greater than 2.5 are at high risk of dying despite ICD protection.
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Affiliation(s)
| | - Kaijbar Niazi
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Beat A Schaer
- Department of Cardiology, University of Basel Hospital, Basel, Switzerland
| | | | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
| | - Kadir Caliskan
- Department of Cardiology, Erasmus MC, Rotterdam, The Netherlands
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4
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Sherazi S, Shah F, Kutyifa V, McNitt S, Aktas MK, Polonsky B, Zareba W, Goldenberg I. Risk of Ventricular Tachyarrhythmic Events in Patients Who Improved Beyond Guidelines for a Defibrillator in MADIT-CRT. JACC Clin Electrophysiol 2019; 5:1172-1181. [DOI: 10.1016/j.jacep.2019.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 07/29/2019] [Accepted: 08/09/2019] [Indexed: 10/25/2022]
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5
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Birgersdotter-Green U, Lupercio F. Risk of Ventricular Arrhythmias After Left Ventricular Function Improvement in Patients With Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2019; 5:1182-1184. [DOI: 10.1016/j.jacep.2019.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 08/15/2019] [Indexed: 10/25/2022]
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6
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Barra S, Duehmke R, Providência R, Narayanan K, Reitan C, Roubicek T, Polasek R, Chow A, Defaye P, Fauchier L, Piot O, Deharo JC, Sadoul N, Klug D, Garcia R, Dockrill S, Virdee M, Pettit S, Agarwal S, Borgquist R, Marijon E, Boveda S. Very long-term survival and late sudden cardiac death in cardiac resynchronization therapy patients. Eur Heart J 2019; 40:2121-2127. [PMID: 31046090 DOI: 10.1093/eurheartj/ehz238] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 12/04/2018] [Accepted: 04/03/2019] [Indexed: 01/14/2023] Open
Abstract
Abstract
Aims
The very long-term outcome of patients who survive the first few years after receiving cardiac resynchronization therapy (CRT) has not been well described thus far. We aimed to provide long-term outcomes, especially with regard to the occurrence of sudden cardiac death (SCD), in CRT patients without (CRT-P) and with defibrillator (CRT-D).
Methods and results
A total of 1775 patients, with ischaemic or non-ischaemic dilated cardiomyopathy, who were alive 5 years after CRT implantation, were enrolled in this multicentre European observational cohort study. Overall long-term mortality rates and specific causes of death were assessed, with a focus on late SCD. Over a mean follow-up of 30 months (interquartile range 10–42 months) beyond the first 5 years, we observed 473 deaths. The annual age-standardized mortality rates of CRT-D and CRT-P patients were 40.4 [95% confidence interval (CI) 35.3–45.5] and 97.2 (95% CI 85.5–109.9) per 1000 patient-years, respectively. The adjusted hazard ratio (HR) for all-cause mortality was 0.99 (95% CI 0.79–1.22). Twenty-nine patients in total died of late SCD (14 with CRT-P, 15 with CRT-D), corresponding to 6.1% of all causes of death in both device groups. Specific annual SCD rates were 8.5 and 5.8 per 1000 patient-years in CRT-P and CRT-D patients, respectively, with no significant difference between groups (adjusted HR 1.0, 95% CI 0.45–2.44). Death due to progressive heart failure represented the principal cause of death (42.8% in CRT-P patients and 52.6% among CRT-D recipients), whereas approximately one-third of deaths in both device groups were due to non-cardiovascular death.
Conclusion
In this first description of very long-term outcomes among CRT recipients, progressive heart failure death still represented the most frequent cause of death in patients surviving the first 5 years after CRT implant. In contrast, SCD represents a very low proportion of late mortality irrespective of the presence of a defibrillator.
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Affiliation(s)
- Sérgio Barra
- Cardiology Department, Hospital da Luz Arrabida, V. N. Gaia, Portugal
- Cardiology Department, V. N. Gaia Hospital Center, V. N. Gaia, Portugal
- Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Rudolf Duehmke
- Cardiology Department, West Suffolk Hospital, West Suffolk, UK
| | - Rui Providência
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Kumar Narayanan
- Cardiology Department, MaxCure Hospitals, Hyderabad, India
- Paris Cardiovascular Research Center (Inserm U970), Cardiovascular Epidemiology Unit, Paris, France
| | - Christian Reitan
- Department of Cardiology, Arrhythmia Clinic, Lund University, Skane University Hospital, Lund, Sweden
| | - Tomas Roubicek
- Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic
| | - Rostislav Polasek
- Department of Cardiology, Regional Hospital Liberec, Liberec, Czech Republic
| | - Antony Chow
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Pascal Defaye
- Arrhythmia Department, University Hospital, Grenoble, France
| | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau, Tours, France
- Faculté de Médecine, Université François Rabelais, Tours, France
| | - Olivier Piot
- Cardiology Department, Centre Cardiologique du Nord, Saint Denis, France
| | | | - Nicolas Sadoul
- Cardiology Division, Nancy University Hospital, Nancy, France
| | - Didier Klug
- Cardiology Division, Lille University Hospital and University of Lille, Lille, France
| | - Rodrigue Garcia
- Cardiology Division, Poitiers University Hospital, Poitiers, France
| | - Seth Dockrill
- Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Munmohan Virdee
- Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Stephen Pettit
- Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Sharad Agarwal
- Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Rasmus Borgquist
- Department of Cardiology, Arrhythmia Clinic, Lund University, Skane University Hospital, Lund, Sweden
| | - Eloi Marijon
- Paris Cardiovascular Research Center (Inserm U970), Cardiovascular Epidemiology Unit, Paris, France
- Cardiology Department, European Georges Pompidou Hospital, Paris, France
- Paris Descartes University, Paris, France
| | - Serge Boveda
- Cardiology Department, Clinique Pasteur, Toulouse, France
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7
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Al-Khatib SM, Friedman DJ, Sanders GD. When Is It Safe Not to Reimplant an Implantable Cardioverter Defibrillator at the Time of Battery Depletion? Card Electrophysiol Clin 2019; 10:137-144. [PMID: 29428135 DOI: 10.1016/j.ccep.2017.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The implantable cardioverter defibrillator (ICD) is a life-saving therapy in various patient populations. Although data on the outcomes of initial ICD implants are abundant, data on ICD replacements, especially in patients with improved left ventricular (LV) function, are scarce. Therefore, it is not known when it is safe to not replace an ICD that has reached the end of battery life. This article reviews data on patients with primary prevention ICDs who have improvement in left ventricular ejection fraction during follow-up and provides some guidance, based on the available evidence, related to circumstances when replacement of an ICD may be forgone.
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Affiliation(s)
- Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA.
| | - Daniel J Friedman
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA
| | - Gillian D Sanders
- Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA
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8
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Su H, Bao P, Chen KY, Yan J, Xu J, Yu F, Yang DM. Influence of the Right Ventricular Lead Location on Ventricular Arrhythmias in Cardiac Resynchronization Therapy. Chin Med J (Engl) 2018; 131:2402-2409. [PMID: 30334524 PMCID: PMC6202593 DOI: 10.4103/0366-6999.243560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The influence of different right ventricular lead locations on ventricular arrhythmias (VTA) in patients with a cardiac resynchronization therapy (CRT) is not clear. This study aimed to evaluate the influence on VTA in patients with a CRT when right ventricular lead was positioned at the right ventricular middle septum (RVMS) and the right ventricular apical (RVA). Methods: A total of 352 patients implanted with a CRT-defibrillator (CRT-D) between May 2012 and July 2016 in the Department of Cardiology of Anhui Provincial Hospital were included. Two-year clinical and pacemaker follow-up data were collected to evaluate the influence of the right ventricular lead location on VTA. Patients were divided into the RVMS group (n = 155) and the RVA group (n = 197) based on the right ventricular lead position. The VTA were compared between these two groups using a Kaplan-Meier curve and Cox multivariate analysis. Results: When the left ventricular lead location was not considered, RVMS and RVA locations did not affect VTA. However, the subgroup analysis results showed that when the left ventricular lead was positioned at the anterolateral cardiac vein (ALCV), the RVMS group had an increased risk of ventricular arrhythmias and appropriate defibrillation (hazard ratio [HR] = 3.29, P = 0.01 and HR = 4.33, P < 0.01, respectively); when the left ventricular lead was at the posterolateral cardiac vein (PLCV), these risks in the RVMS group decreased (HR = 0.45, P = 0.02 and HR = 0.33, P < 0.01, respectively), and when the left ventricular lead was at the lateral cardiac vein, there was no difference between the two groups. In regard to inappropriate defibrillation, there was no significant difference among all these groups. Conclusions: When the left ventricular lead was positioned at ALCV or PLCV, the right ventricular lead location was associated with VTA and appropriate defibrillation after CRT. Greater distances between leads not only improved cardiac function but also may reduce the risk of VTA.
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9
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Deif B, Ballantyne B, Almehmadi F, Mikhail M, McIntyre WF, Manlucu J, Yee R, Sapp JL, Roberts JD, Healey JS, Leong-Sit P, Tang AS. Cardiac resynchronization is pro-arrhythmic in the absence of reverse ventricular remodelling: a systematic review and meta-analysis. Cardiovasc Res 2018; 114:1435-1444. [PMID: 30010807 DOI: 10.1093/cvr/cvy182] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 09/27/2018] [Indexed: 11/14/2022] Open
Abstract
Aims Cardiac resynchronization therapy (CRT) has been shown to reduce mortality and heart failure (HF) hospitalization but its effects on the rate of ventricular arrhythmias (VAs) appears to be neutral. We hypothesize that CRT with LV epicardial stimulation is inherently pro-arrhythmic and increases VA rates in the absence of reverse ventricular remodelling while conferring an anti-arrhythmic effect in mechanical responders. Methods and results In this systematic review and meta-analysis, we considered retrospective cohort, prospective cohort, and randomized controlled trials comparing VA rates between cardiac resynchronization therapy-defibrillator (CRT-D) non-responders, CRT-D responders and those with implantable cardioverter-defibrillator (ICD) only. Studies were eligible if they defined CRT-D responders using a discrete left ventricular volumetric value as assessed by any imaging modality. Studies were identified through searching electronic databases from their inception to July 2017. We identified 2579 citations, of which 23 full-text articles were eligible for final analysis. Our results demonstrated that CRT-D responders were less likely to experience VA than CRT-D non-responders, relative risk (RR) 0.49 [95% confidence interval (CI) 0.41-0.58, P < 0.01] and also less than patients with ICD only: RR 0.59 (95% CI 0.50-0.69, P < 0.01). However, CRT-D mechanical non-responders had a greater likelihood of VA compared with ICD only, RR 0.76 (95% CI 0.63-0.92, P = 0.004). Conclusion CRT-D non-responders experienced more VA than CRT-D responders and also more than those with ICD only, suggesting that CRT with LV epicardial stimulation may be inherently pro-arrhythmic in the absence of reverse remodelling.
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Affiliation(s)
- Bishoy Deif
- Division of Cardiology, Department of Medicine, Western University, 339 Windermere Road, London, Ontario, Canada
| | - Brennan Ballantyne
- Division of Cardiology, Department of Medicine, Western University, 339 Windermere Road, London, Ontario, Canada
| | - Fahad Almehmadi
- Division of Cardiology, Department of Medicine, Western University, 339 Windermere Road, London, Ontario, Canada
| | - Michael Mikhail
- School of Biomedical Sciences, Department of Graduate Studies, Rowan University, Stratford, New Jersey, USA
| | - William F McIntyre
- Population Health Research Institute & Division of Cardiology, Department of Medicine McMaster University, Hamilton, Canada
| | - Jaimie Manlucu
- Division of Cardiology, Department of Medicine, Western University, 339 Windermere Road, London, Ontario, Canada
| | - Raymond Yee
- Division of Cardiology, Department of Medicine, Western University, 339 Windermere Road, London, Ontario, Canada
| | - John L Sapp
- Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax, Canada
| | - Jason D Roberts
- Division of Cardiology, Department of Medicine, Western University, 339 Windermere Road, London, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute & Division of Cardiology, Department of Medicine McMaster University, Hamilton, Canada
| | - Peter Leong-Sit
- Division of Cardiology, Department of Medicine, Western University, 339 Windermere Road, London, Ontario, Canada
| | - Anthony S Tang
- Division of Cardiology, Department of Medicine, Western University, 339 Windermere Road, London, Ontario, Canada
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10
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Cvijić M, Antolič B, Klemen L, Zupan I. Repolarization heterogeneity in patients with cardiac resynchronization therapy and its relation to ventricular tachyarrhythmias. Heart Rhythm 2018; 15:1784-1790. [PMID: 29908369 DOI: 10.1016/j.hrthm.2018.06.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has been shown to induce left ventricular reverse remodeling, but little is known about its influence on ventricular repolarization. OBJECTIVE The purpose of this study was to evaluate changes in ventricular repolarization of native conduction after CRT and its relation to ventricular tachycardia (VT) and ventricular fibrillation (VF) during long-term follow-up. METHODS We prospectively included 64 patients with heart failure treated with CRT. QT interval, TpTe, and TpTe/QT ratio were analyzed from 20-minute high-resolution ECGs that were recorded at baseline and 1, 3, 6, 9, and 12 months after CRT implantation. CRT was temporary inhibited during follow-up to record intrinsic ECG. Patients with a decrease of left ventricular end-systolic volume ≥15% at 12-month follow-up (mid-term follow-up) were considered as responders. Occurrences of VT/VF during follow-up were noted. RESULTS Significant increase of repolarization heterogeneity in the first months after implantation was observed (P <.05) but then declined during 12 months of follow-up. Patients with VT/VF during long-term follow-up had higher repolarization heterogeneity at mid-term follow-up than patients without VT/VF (TpTe/QT ratio: 0.263 [0.204-0.278] vs 0.225 [0.204-0.239]; P = .045). Echocardiographic response at mid-term follow-up did not significantly influence the rate of VT/VF (log-rank P = .252). In multivariate Cox regression analysis, only high repolarization heterogeneity at mid-term follow-up (TpTe/QT ratio >0.260) was independently associated with high risk of VT/VF (hazard ratio 4.29; 95% confidence interval 1.40-13.15; P = .011). CONCLUSION CRT induces time-dependent changes in repolarization parameters in the first year after implantation. High repolarization heterogeneity at mid-term follow-up was associated with higher rate of VT/VF during long-term follow-up.
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Affiliation(s)
- Marta Cvijić
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia.
| | - Bor Antolič
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Luka Klemen
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Igor Zupan
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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11
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Galve E, Oristrell G, Acosta G, Ribera-Solé A, Moya-Mitjans À, Ferreira-González I, Pérez-Rodon J, García-Dorado D. Cardiac resynchronization therapy is associated with a reduction in ICD therapies as it improves ventricular function. Clin Cardiol 2018; 41:803-808. [PMID: 29604094 DOI: 10.1002/clc.22958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/23/2018] [Accepted: 03/29/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Repeated implantable cardioverter-defibrillator (ICD) therapies cause myocardial damage and, thus, an increased risk of arrhythmias and mortality. HYPOTHESIS Cardiac resynchronization therapy-defibrillator (CRT-D) reduces the number of appropriate therapies in patients with left ventricular dysfunction (left ventricular ejection fraction [LVEF] <50%). METHODS The retrospective study involved 175 consecutive patients (mean age, 64.6 ±10.4 years; 86.9% males) with reduced LVEF of 27.9% ±7.6% treated with an ICD (56.6%) or CRT-D (43.4%), according to standard indications, between January 2009 and July 2014. Devices were placed for either primary (54.3%) or secondary prevention (45.7%). Mean follow-up was 2.5 ±1.5 years. Predictors of first appropriate therapy were assessed using Cox regression analysis. RESULTS Forty-four (25.1%) patients received ≥1 appropriate therapy. Although patients treated with CRT-D had lower LVEF and poorer New York Heart Association class, CRT-D patients with LVEF improvement >35% at the end of follow-up had a significantly lower risk of receiving a first appropriate therapy relative to those with an ICD (adjusted hazard ratio: 0.24, 95% confidence interval: 0.07-0.83, P = 0.025), independently of ischemic cardiomyopathy, baseline LVEF, and secondary prevention. There were no differences in mortality between the ICD and the CRT-D groups. CONCLUSIONS Although patients receiving CRT-D had a worse clinical profile, they received fewer device therapies in comparison with those receiving an ICD. This reduction is associated with a significant improvement in LVEF.
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Affiliation(s)
- Enrique Galve
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Gerard Oristrell
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Gabriel Acosta
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Aida Ribera-Solé
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Àngel Moya-Mitjans
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Ignacio Ferreira-González
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Jordi Pérez-Rodon
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - David García-Dorado
- Department of Cardiology, Vall d'Hebron University Hospital, Barcelona, Spain.,Vall d'Hebron Research Institute (VHIR), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Barcelona, Spain
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12
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Jørgensen ME, Andersson C, Vasan RS, Køber L, Abdulla J. Characteristics and prognosis of heart failure with improved compared with persistently reduced ejection fraction: A systematic review and meta-analyses. Eur J Prev Cardiol 2018; 25:366-376. [PMID: 29313369 DOI: 10.1177/2047487317750437] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Aims We assessed the clinical characteristics and prognosis of chronic heart failure patients with improved ejection fraction (HFIEF) compared with persistently reduced ejection fraction (HFpREF) after evidence-based therapy. Methods and results We performed a meta-analysis including 24 eligible observational studies comparing 2663 HFIEF (≥5% left ventricular ejection fraction (LVEF) improvement) versus 8355 HFpREF patients who received recommended drug therapy, cardiac resynchronization therapy and/or intracardiac defibrillator. LVEF was assessed at baseline and reassessed after 19 ± 19 months. The primary endpoints were all-cause mortality and appropriate shocks. The mean duration of follow-up was 39 ± 12 months. Among HFIEF patients, LVEF improved 16.3 percentage points (95% confidence interval 15.9-16.6, p < 0.0001). Compared with HFpREF patients, HFIEF patients had a comparable mean age (60.9 years vs. 62.4 years, p = 0.11), were more often women (33% vs. 25%), had a higher prevalence of non-ischaemic heart failure (58% vs. 53%), less diabetes (27% vs. 28%), higher systolic blood pressure (127.5 ± 9 vs. 122 ± 12 mmHg) and lower left ventricle end-diastolic diameter (64.1 ± 3.7 vs. 67.4 ± 4.9 mmHg), all p-values < 0.05. Absolute risk of all-cause mortality was lower in HFIEF (5.8%) compared with HFpREF (17.5%) with a risk ratio of 0.34 (95% confidence interval 0.28-0.41), p < 0.001. Risk of appropriate shocks was significantly lower in HFIEF versus HFpREF (risk ratio 0.58 (95% confidence interval 0.46-0.74), p < 0.001). Conclusion In heart failure patients, we identified several baseline characteristics in favour of an improved LVEF, in response to evidence based therapy. Patients with improved LVEF had significantly lower risks of mortality and appropriate shocks compared with patients with persistently reduced LVEF.
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Affiliation(s)
- Mads E Jørgensen
- 1 Division of Cardiology, Department of Medicine, Glostrup University Hospital, Copenhagen, Denmark.,2 The Cardiovascular Research Centre, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - Charlotte Andersson
- 1 Division of Cardiology, Department of Medicine, Glostrup University Hospital, Copenhagen, Denmark.,2 The Cardiovascular Research Centre, Herlev-Gentofte University Hospital, Copenhagen, Denmark
| | - Ramachandran S Vasan
- 3 Sections of Preventive Medicine and Epidemiology, and Departments of Cardiology and Epidemiology, Boston University Schools of Medicine and Public Health, Boston, USA
| | - Lars Køber
- 4 Department of Cardiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Denmark
| | - Jawdat Abdulla
- 1 Division of Cardiology, Department of Medicine, Glostrup University Hospital, Copenhagen, Denmark
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13
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Smer A, Saurav A, Azzouz MS, Salih M, Ayan M, Abuzaid A, Akinapelli A, Kanmanthareddy A, Rosenfeld LE, Merchant FM, Abuissa H. Meta-analysis of Risk of Ventricular Arrhythmias After Improvement in Left Ventricular Ejection Fraction During Follow-Up in Patients With Primary Prevention Implantable Cardioverter Defibrillators. Am J Cardiol 2017; 120:279-286. [PMID: 28532779 DOI: 10.1016/j.amjcard.2017.04.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 04/05/2017] [Accepted: 04/05/2017] [Indexed: 11/17/2022]
Abstract
Implantable cardioverter defibrillators (ICDs) reduce the risk of sudden cardiac death in patients with impaired left ventricular ejection fraction (LVEF). However, there are limited data on the long-term benefit of ICD therapy in patients whose LVEF subsequently improves. We conducted a meta-analysis to evaluate the effect of LVEF improvement on ICD therapy during follow-up. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated using random-effects modeling. Sixteen studies with 3,959 patients were included in our analysis. Study arms were defined by LVEF improvement at follow-up (improved LVEF [>35%]: 1,622; low LVEF [≤35%] 2,337). Mean age (64.8 vs 64.9 years, p = 0.97) was similar, whereas men were overrepresented in the persistent low LVEF group (79% vs 72%, p <0.001). Appropriate ICD therapy rate was 9.7% (improved LVEF) versus 21.8% (low LVEF) over a median follow-up period of 2.9 years. In the meta-analysis, improved LVEF group had significantly lower (3.3% vs 7.2% per year IRR 0.52; CI 0.38 to 0.70; p <0.001) appropriate ICD therapies which was uniformly seen across all subgroups (ICD-only studies: IRR 0.59; p = 0.004) (cardiac resynchronization therapy-defibrillator-only studies: IRR 0.31; p = 0.002) (super-responder studies [mean LVEF > 45%]: IRR 0.53; p = 0.002). Inappropriate ICD therapy rates were, however, similar in both groups (3.01% vs 2.56% per year IRR 0.76; CI 0.43 to 1.36; p = 0.35). All-cause mortality rates in our meta-analysis favored (3.63% vs 8.23% per year IRR 0.49; CI 0.35 to 0.69; p <0.001) the improved LVEF group. In conclusion, our meta-analysis demonstrates that an improvement in LVEF is associated with a significantly reduced risk of ventricular arrhythmia and mortality. However, inappropriate ICD therapy rates remain similar.
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Affiliation(s)
- Aiman Smer
- Department of Cardiovascular Medicine, CHI Health Creighton University School of Medicine, Omaha, Nebraska.
| | - Alok Saurav
- Department of Cardiovascular Medicine, CHI Health Creighton University School of Medicine, Omaha, Nebraska
| | - Muhammad Soubhi Azzouz
- Department of Cardiovascular Medicine, CHI Health Creighton University School of Medicine, Omaha, Nebraska
| | - Mohsin Salih
- Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Mohamed Ayan
- Department of Cardiovascular Medicine, University of Arkansas Medical Science, Little Rock, Arkansas
| | - Ahmed Abuzaid
- Department of Cardiovascular Medicine, Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, Delaware
| | - Abhilash Akinapelli
- Department of Cardiovascular Medicine, CHI Health Creighton University School of Medicine, Omaha, Nebraska
| | - Arun Kanmanthareddy
- Department of Cardiovascular Medicine, CHI Health Creighton University School of Medicine, Omaha, Nebraska
| | - Lynda E Rosenfeld
- Section of Cardiovascular Medicine, Department of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Faisal M Merchant
- Cardiology Division, Section of Cardiac Electrophysiology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Hussam Abuissa
- Department of Cardiovascular Medicine, CHI Health Creighton University School of Medicine, Omaha, Nebraska
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14
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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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15
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Barra S, Boveda S, Providência R, Sadoul N, Duehmke R, Reitan C, Borgquist R, Narayanan K, Hidden-Lucet F, Klug D, Defaye P, Gras D, Anselme F, Leclercq C, Hermida JS, Deharo JC, Looi KL, Chow AW, Virdee M, Fynn S, Le Heuzey JY, Marijon E, Agarwal S. Adding Defibrillation Therapy to Cardiac Resynchronization on the Basis of the Myocardial Substrate. J Am Coll Cardiol 2017; 69:1669-1678. [DOI: 10.1016/j.jacc.2017.01.042] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 01/10/2017] [Indexed: 12/28/2022]
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16
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Barra S, Duehmke R, Providencia R, Marijon E, Boveda S, Virdee M, Heck P, Fynn S, Begley D, Grace A, Agarwal S. Patients upgraded to cardiac resynchronization therapy due to pacing-induced cardiomyopathy are at low risk of life-threatening ventricular arrhythmias: a long-term cause-of-death analysis. Europace 2016; 20:89-96. [DOI: 10.1093/europace/euw321] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 09/19/2016] [Indexed: 11/14/2022] Open
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17
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Karaca O, Gunes HM, Omaygenc MO, Cakal B, Cakal SD, Demir GG, Kizilirmak F, Gokdeniz T, Barutcu I, Boztosun B, Kilicaslan F. Predicting Ventricular Arrhythmias in Cardiac Resynchronization Therapy: The Impact of Persistent Electrical Dyssynchrony. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:969-77. [PMID: 27333978 DOI: 10.1111/pace.12908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 05/03/2016] [Accepted: 06/09/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although response to cardiac resynchronization therapy (CRT) has been conventionally assessed with left ventricular volume reduction, ventricular arrhythmias (ventricular tachycardia/ventricular fibrillation [VT/VF]) are of critical importance associated with unfavorable outcomes even in the "superresponders" to therapy. We evaluated the predictors of VT/VF and the association of residual dyssynchrony during follow-up. METHODS Ninety-five patients receiving CRT were followed-up for 9 ± 3 months. Post-CRT dyssynchrony was defined as a prolonged QRS duration (QRSd) for persistent electrical dyssynchrony (ED), and a Yu index ≥ 33 ms for persistent mechanical dyssynchrony. The first VT/VF episode, including nonsustained VT detected on device interrogation and/or appropriate antitachycardia pacing or shock for VT/VF, were the end points of the study. RESULTS Forty-five patients who reached the study end points had significantly lower mean ΔQRS (baseline QRSd - post-CRT QRSd) values than those without VT/VF (-20.8 ± 28.9 ms vs -6.6 ± 30.7 ms, P = 0.022). Both the baseline and post-CRT QRSds, along with the Yu index values, were not different in two groups. Patients with VT/VF were statistically more likely to have persistent ED (38% vs 9%, P = 0.021). Kaplan-Meier curves showed that a negative ΔQRS was associated with a higher incidence of VT/VF during follow-up (P = 0.016). A multivariate Cox model revealed that QRS prolongation was an independent predictor of VT/VF after CRT (P = 0.029). CONCLUSIONS A negative ΔQRS, also called persistent ED, is associated with VT/VF. Narrowest possible QRSd might be a reliable goal of both implantation and optimization of devices to reduce arrhythmic events after CRT.
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Affiliation(s)
- Oguz Karaca
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey.
| | - Haci M Gunes
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | | | - Beytullah Cakal
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Sinem Deniz Cakal
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | | | - Filiz Kizilirmak
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Tayyar Gokdeniz
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Irfan Barutcu
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Bilal Boztosun
- Cardiology Department, Medipol University Faculty of Medicine, Istanbul, Turkey
| | - Fethi Kilicaslan
- Cardiac Electrophysiology, Medipol University Faculty of Medicine, Istanbul, Turkey
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18
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Saini A, Kannabhiran M, Reddy P, Gopinathannair R, Olshansky B, Dominic P. Cardiac Resynchronization Therapy May Be Antiarrhythmic Particularly in Responders. JACC Clin Electrophysiol 2016; 2:307-316. [DOI: 10.1016/j.jacep.2015.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 10/22/2015] [Indexed: 02/09/2023]
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BERTHELOT-RICHER MAXIME, BONENFANT FRANCIS, CLAVEL MARIEANNICK, FARAND PAUL, PHILIPPON FRANÇOIS, AYALA-PAREDES FELIX, ESSADIQI BTISSAMA, BADRA-VERDU MG, ROUX JEANFRANÇOIS. Arrhythmic Risk Following Recovery of Left Ventricular Ejection Fraction in Patients with Primary Prevention ICD. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:680-9. [DOI: 10.1111/pace.12868] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 03/16/2016] [Accepted: 03/26/2016] [Indexed: 11/29/2022]
Affiliation(s)
| | - FRANCIS BONENFANT
- Department of Medicine, Cardiovascular Division; Centre Hospitalier Universitaire de Sherbrooke; Quebec Canada
| | - MARIE-ANNICK CLAVEL
- Faculty of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec; Université Laval; Quebec City Quebec Canada
| | - PAUL FARAND
- Department of Medicine, Cardiovascular Division; Centre Hospitalier Universitaire de Sherbrooke; Quebec Canada
| | - FRANÇOIS PHILIPPON
- Faculty of Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec; Université Laval; Quebec City Quebec Canada
| | - FELIX AYALA-PAREDES
- Department of Medicine, Cardiovascular Division; Centre Hospitalier Universitaire de Sherbrooke; Quebec Canada
| | - BTISSAMA ESSADIQI
- Department of Medicine, Cardiovascular Division; Centre Hospitalier Universitaire de Sherbrooke; Quebec Canada
| | - Mariano Gonzalo BADRA-VERDU
- Department of Medicine, Cardiovascular Division; Centre Hospitalier Universitaire de Sherbrooke; Quebec Canada
| | - JEAN-FRANÇOIS ROUX
- Department of Medicine, Cardiovascular Division; Centre Hospitalier Universitaire de Sherbrooke; Quebec Canada
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20
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Ter Horst IAH, van 't Sant J, Wijers SC, Vos MA, Cramer MJ, Meine M. The risk of ventricular arrhythmias in a Dutch CRT population: CRT-defibrillator versus CRT-pacemaker. Neth Heart J 2016; 24:204-13. [PMID: 26797979 PMCID: PMC4771627 DOI: 10.1007/s12471-015-0800-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Patients eligible for cardiac resynchronisation therapy (CRT) have an indication for primary prophylactic implantable cardioverter defibrillator (ICD) therapy. However, response to CRT might influence processes involved in arrhythmogenesis and therefore change the necessity of ICD therapy in certain patients. Method In 202 CRT-defibrillator patients, the association between baseline variables, 6-month echocardiographic outcome (volume response: left ventricular end-systolic volume decrease < ≥15 % and left ventricular ejection fraction (LVEF) ≤ >35 %) and the risk of first appropriate ICD therapy was analysed retrospectively. Results Fifty (25 %) patients received appropriate ICD therapy during a median follow-up of 37 (23–52) months. At baseline ischaemic cardiomyopathy (hazard ratio (HR) 2.0, p = 0.019) and a B-type natriuretic peptide level > 163 pmol/l (HR 3.8, p < 0.001) were significantly associated with the risk of appropriate ICD therapy. After 6 months, 105 (52 %) patients showed volume response and 51 (25 %) reached an LVEF > 35 %. Three (6 %) patients with an LVEF > 35 % received appropriate ICD therapy following echocardiography at ± 6 months compared with 43 patients (29 %) with an LVEF ≤ 35 % (p = 0.001). LVEF post-CRT was more strongly associated to the risk of ventricular arrhythmias than volume response (LVEF > 35 %, HR 0.23, p = 0.020). Conclusion Assessing the necessity of an ICD in patients eligible for CRT remains a challenge. Six months post-CRT an LVEF > 35 % identified patients at low risk of ventricular arrhythmias. LVEF might be used at the time of generator replacement to identify patients suitable for downgrading to a CRT-pacemaker.
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Affiliation(s)
- I A H Ter Horst
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, PO Box 85500, Utrecht, The Netherlands.
| | - J van 't Sant
- Department of Cardiology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - S C Wijers
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, PO Box 85500, Utrecht, The Netherlands.,Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M A Vos
- Department of Medical Physiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M J Cramer
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, PO Box 85500, Utrecht, The Netherlands
| | - M Meine
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3508 GA, PO Box 85500, Utrecht, The Netherlands
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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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22
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Cardiac resynchronization therapy defibrillator at the end of battery life: In an era of economic uncertainty, do super-responders provide an opportunity for resource optimization? Int J Cardiol 2015; 199:384-5. [DOI: 10.1016/j.ijcard.2015.07.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2015] [Revised: 07/07/2015] [Accepted: 07/29/2015] [Indexed: 11/20/2022]
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Chatterjee NA, Roka A, Lubitz SA, Gold MR, Daubert C, Linde C, Steffel J, Singh JP, Mela T. Reduced appropriate implantable cardioverter-defibrillator therapy after cardiac resynchronization therapy-induced left ventricular function recovery: a meta-analysis and systematic review. Eur Heart J 2015; 36:2780-9. [PMID: 26264552 DOI: 10.1093/eurheartj/ehv373] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 07/15/2015] [Indexed: 01/25/2023] Open
Abstract
AIMS For patients undergoing cardiac resynchronization therapy (CRT) with implantable cardioverter-defibrillator (ICD; CRT-D), the effect of an improvement in left ventricular ejection fraction (LVEF) on appropriate ICD therapy may have significant implications regarding management at the time of ICD generator replacement. METHODS AND RESULTS We conducted a meta-analysis to determine the effect of LVEF recovery following CRT on the incidence of appropriate ICD therapy. A search of multiple electronic databases identified 709 reports, of which 6 retrospective cohort studies were included (n = 1740). In patients with post-CRT LVEF ≥35% (study n = 4), the pooled estimated rate of ICD therapy (5.5/100 person-years) was significantly lower than patients with post-CRT LVEF <35% [incidence rate difference (IRD): -6.5/100 person-years, 95% confidence interval (95% CI): -8.8 to -4.2, P < 0.001]. Similarly, patients with post-CRT LVEF ≥45% (study n = 4) demonstrated lower estimated rates of ICD therapy (2.3/100 person-years) compared with patients without such recovery (IRD: -5.8/100 person-years, 95% CI: -7.6 to -4.0, P < 0.001). Restricting analysis to studies discounting ICD therapies during LVEF recovery (study n = 3), patients with LVEF recovery (≥35 or ≥45%) had significantly lower rates of ICD therapy compared with patients without such recovery (P for both <0.001). Patients with primary prevention indication for ICD, regardless of LVEF recovery definition, had very low rates of ICD therapy (0.4 to 0.8/100-person years). CONCLUSION Recovery of LVEF post-CRT is associated with significantly reduced appropriate ICD therapy. Patients with improvement of LVEF ≥45% and those with primary prevention indication for ICD appear to be at lowest risk.
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Affiliation(s)
- Neal A Chatterjee
- Department of Medicine and the Cardiac Arrhythmia Service, GRB 109, Massachusetts General Hospital Heart Center, 55 Fruit Street, Boston, MA 02411, USA
| | - Attila Roka
- Department of Medicine and the Cardiac Arrhythmia Service, GRB 109, Massachusetts General Hospital Heart Center, 55 Fruit Street, Boston, MA 02411, USA
| | - Steven A Lubitz
- Department of Medicine and the Cardiac Arrhythmia Service, GRB 109, Massachusetts General Hospital Heart Center, 55 Fruit Street, Boston, MA 02411, USA
| | - Michael R Gold
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Claude Daubert
- Cardiology Division, Rennes University Hospital, Rennes, France
| | - Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Steffel
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Jagmeet P Singh
- Department of Medicine and the Cardiac Arrhythmia Service, GRB 109, Massachusetts General Hospital Heart Center, 55 Fruit Street, Boston, MA 02411, USA
| | - Theofanie Mela
- Department of Medicine and the Cardiac Arrhythmia Service, GRB 109, Massachusetts General Hospital Heart Center, 55 Fruit Street, Boston, MA 02411, USA
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Ruwald MH, Solomon SD, Foster E, Kutyifa V, Ruwald AC, Sherazi S, McNitt S, Jons C, Moss AJ, Zareba W. Left ventricular ejection fraction normalization in cardiac resynchronization therapy and risk of ventricular arrhythmias and clinical outcomes: results from the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy (MADIT-CRT) trial. Circulation 2014; 130:2278-86. [PMID: 25301831 DOI: 10.1161/circulationaha.114.011283] [Citation(s) in RCA: 135] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Appropriate guideline criteria for use of implantable cardioverter-defibrillators (ICDs) do not take into account potential recovery of left ventricular ejection fraction (LVEF) in patients treated with CRT-defibrillator. METHODS AND RESULTS Patients randomized to CRT-defibrillator from the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy (MADIT-CRT) trial who survived and had paired echocardiograms at enrollment and at 12 months (n=752) were included. Patients were evaluated by LVEF recovery in 3 groups (LVEF ≤35% [reference], 36%-50%, and >50%) on outcomes of ventricular tachyarrhythmias (VTAs), VTA ≥200 bpm, ICD shock, heart failure or death, and inappropriate ICD therapy by multivariable Cox models. A total of 7.3% achieved LVEF normalization (>50%). The average follow-up was 2.2±0.8 years. The risk of VTA was reduced in patients with LVEF >50% (hazard ratio [HR], 0.24; 95% confidence interval [CI], 0.07-0.82; P=0.023) and LVEF of 36% to 50% (HR, 0.44; 95% CI, 0.28-0.68; P<0.001). Among patients with LVEF >50%, only 1 patient had VTA ≥200 bpm (HR, 0.16; 95% CI, 0.02-1.51), none were shocked by the ICD, and 2 died of nonarrhythmic causes. The risk of HF or death was reduced with improvements in LVEF (LVEF >50%: HR, 0.29; 95% CI, 0.09-0.97; P=0.045; and LVEF of 36%-50%: HR, 0.44; 95% CI, 0.28-0.69; P<0.001). For inappropriate ICD therapy, no additional risk reduction for LVEF>50% was seen compared with an LVEF of 36% to 50%. A total of 6 factors were associated with LVEF normalization, and patients with all factors present (n=42) did not experience VTAs (positive predictive value, 100%). CONCLUSIONS Patients who achieve LVEF normalization (>50%) have very low absolute and relative risk of VTAs and a favorable clinical course within 2.2 years of follow-up. Risk of inappropriate ICD therapy is still present, and these patients could be considered for downgrade from CRT-defibrillator to CRT-pacemaker at the time of battery depletion if no VTAs have occurred. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00180271.
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Affiliation(s)
- Martin H Ruwald
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.).
| | - Scott D Solomon
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.)
| | - Elyse Foster
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.)
| | - Valentina Kutyifa
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.)
| | - Anne-Christine Ruwald
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.)
| | - Saadia Sherazi
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.)
| | - Scott McNitt
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.)
| | - Christian Jons
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.)
| | - Arthur J Moss
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.)
| | - Wojciech Zareba
- From the Heart Research Follow-up Program, Division of Cardiology, University of Rochester Medical Center, Rochester, NY (M.H.R., V.K., A.-C.R., S.S., S.M., A.J.M., W.Z.); Department of Cardiology, Gentofte Hospital, Hellerup, Denmark (M.H.R., A.-C.R., C.J.); Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S.D.S.); and Division of Cardiology, Department of Medicine, University of California, San Francisco (E.F.)
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25
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La Rovere MT, Pinna GD, Maestri R, Barlera S, Bernardinangeli M, Veniani M, Nicolosi GL, Marchioli R, Tavazzi L. Autonomic markers and cardiovascular and arrhythmic events in heart failure patients: still a place in prognostication? Data from the GISSI-HF trial. Eur J Heart Fail 2014; 14:1410-9. [DOI: 10.1093/eurjhf/hfs126] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Maria Teresa La Rovere
- Divisione di Cardiologia, e Bioingegneria, Fondazione ‘Salvatore Maugeri’, IRCCS; Istituto Scientifico di Montescano; Montescano Italy
| | - Gian Domenico Pinna
- Divisione di Cardiologia, e Bioingegneria, Fondazione ‘Salvatore Maugeri’, IRCCS; Istituto Scientifico di Montescano; Montescano Italy
| | - Roberto Maestri
- Divisione di Cardiologia, e Bioingegneria, Fondazione ‘Salvatore Maugeri’, IRCCS; Istituto Scientifico di Montescano; Montescano Italy
| | - Simona Barlera
- Dipartimento di Ricerca Cardiovascolare; Istituto Mario Negri; Milano Italy
| | | | | | | | | | - Luigi Tavazzi
- GVM Care and Research; Maria Cecilia Hospital Cotignola; (Ravenna) Italy
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26
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Affiliation(s)
- Kevin Damman
- Department of Cardiology; University Medical Centre Groningen; PO Box 30.001, 9700 RB Groningen The Netherlands
| | - Alexander H. Maass
- Department of Cardiology; University Medical Centre Groningen; PO Box 30.001, 9700 RB Groningen The Netherlands
| | - Peter van der Meer
- Department of Cardiology; University Medical Centre Groningen; PO Box 30.001, 9700 RB Groningen The Netherlands
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27
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Rogers DP, Lambiase PD, Lowe MD, Chow AW. A randomized double-blind crossover trial of triventricular versus biventricular pacing in heart failure. Eur J Heart Fail 2014; 14:495-505. [DOI: 10.1093/eurjhf/hfs004] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Affiliation(s)
- Dominic P.S. Rogers
- The Heart Hospital; Institute of Cardiovascular Medicine, UCLH; London W1G 8PH UK
| | - Pier D. Lambiase
- The Heart Hospital; Institute of Cardiovascular Medicine, UCLH; London W1G 8PH UK
| | - Martin D. Lowe
- The Heart Hospital; Institute of Cardiovascular Medicine, UCLH; London W1G 8PH UK
| | - Anthony W.C. Chow
- The Heart Hospital; Institute of Cardiovascular Medicine, UCLH; London W1G 8PH UK
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28
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BOVEN NICKVAN, BOGAARD KJELL, RUITER JAAP, KIMMAN GEERT, THEUNS DOMINIC, KARDYS ISABELLA, UMANS VICTOR. Functional Response to Cardiac Resynchronization Therapy is Associated with Improved Clinical Outcome and Absence of Appropriate Shocks. J Cardiovasc Electrophysiol 2012; 24:316-22. [DOI: 10.1111/jce.12037] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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29
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Wijers SC, Vos MA, Meine M. Microvolt T-wave alternans in an unselected heart failure population: pros and cons. Eur J Heart Fail 2012; 14:344-7. [PMID: 22431405 DOI: 10.1093/eurjhf/hfs032] [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] [Indexed: 11/14/2022] Open
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30
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Zizek D, Cvijic M, Tasic J, Jan M, Frljak S, Zupan I. Effect of cardiac resynchronization therapy on beat-to-beat T-wave amplitude variability. Europace 2012; 14:1646-52. [DOI: 10.1093/europace/eus055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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31
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Jackson CE, Myles RC, Tsorlalis IK, Dalzell JR, Spooner RJ, Rodgers JR, Bezlyak V, Greenlaw N, Ford I, Cobbe SM, Petrie MC, McMurray JJV. Profile of microvolt T-wave alternans testing in 1003 patients hospitalized with heart failure. Eur J Heart Fail 2012; 14:377-86. [PMID: 22334727 DOI: 10.1093/eurjhf/hfs010] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Observational studies in selected populations have suggested that microvolt T-wave alternans (MTWA) testing may identify patients with heart failure (HF) at risk of sudden cardiac death. The aims of this study were to investigate the utility of MTWA testing in an unselected population of patients with HF and to evaluate the clinical characteristics associated with the MTWA results. METHODS AND RESULTS A total of 1003 patients hospitalized with decompensated HF were enrolled. MTWA testing was planned 1 month post-discharge; 648 patients returned for MTWA testing. Mean age was 70.8 ± 10.6 years and 58% were male. Of these patients who returned, 318 (49%) were ineligible for MTWA testing due to atrial fibrillation (AF), pacemaker dependency, or physical inability to undertake the test. Of the MTWA tests, 100 (30%) were positive, 78 (24%) were negative, and 152 (46%) were indeterminate; 112/152 indeterminate tests (74%) occurred because of failure to achieve target heart rate (HR) due to chronotropic incompetence or physical limitations. There were differences in patient characteristics according to MTWA result. Independent predictors of a negative result included younger age and higher left ventricular ejection fraction (LVEF). Independent predictors of a positive result included higher HR during MTWA testing and lower LVEF. Independent predictors of an indeterminate result included older age and history of previous/paroxysmal AF. CONCLUSIONS Only half of patients with HF are eligible for MTWA testing and the most common result is an indeterminate test. Patients with positive and indeterminate tests have different clinical characteristics. MTWA treadmill testing is not widely applicable in typical HF patients and is unlikely to refine risk stratification for sudden death on a population level.
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Affiliation(s)
- Colette E Jackson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, UK
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32
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Maass AH. Cardiac resynchronization in mild heart failure: all issues resolved? Editorial to "Cardiac resynchronization therapy in patients with mild heart failure: a systematic review and meta-analysis of randomized controlled trials" by Ronghui Tu et al. Cardiovasc Drugs Ther 2011; 25:281-3. [PMID: 21769572 PMCID: PMC3151404 DOI: 10.1007/s10557-011-6318-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Alexander H. Maass
- Department of Cardiology, Thoraxcenter, University Medical Center Groningen, University of Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
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Boriani G, Gasparini M, Landolina M, Lunati M, Proclemer A, Lonardi G, Iacopino S, Rahue W, Biffi M, DiStefano P, Grammatico A, Santini M. Incidence and clinical relevance of uncontrolled ventricular rate during atrial fibrillation in heart failure patients treated with cardiac resynchronization therapy. Eur J Heart Fail 2011; 13:868-76. [PMID: 21558331 DOI: 10.1093/eurjhf/hfr046] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
AIMS Uncontrolled ventricular rate (VR) during atrial fibrillation (AF) may cause clinical deterioration in heart failure (HF) patients who need continuous biventricular pacing to achieve cardiac resynchronization therapy (CRT). We aimed at evaluating the association between AF, uncontrolled VR, and sub-optimal CRT, defined as low biventricular pacing percentage (BIVP%). METHODS AND RESULTS All 1404 patients had HF, New York Heart Association (NYHA) ≥II, left ventricular ejection fraction (LVEF) ≤35%, and QRS ≥120 ms, and received an implantable CRT defibrillator (CRT-D). Occurrence of AF, VR during AF and lifetime BIVP% were estimated from device data. Ventricular rate during AF was defined as uncontrolled in patients with mean VR>80 bpm and maximum VR>110 bpm. Over a median follow-up of 18 months, AF was detected in 443 of 1404 patients (32%). In this sub-group of AF patients, VR during AF was uncontrolled in 150 of 443 patients (34%). Multivariate Cox regression analysis showed that age [hazard ratio (HR) = 1.03, 95% confidence interval (CI) = 1.00-1.06, P= 0.028], and uncontrolled VR [HR = 1.69 (CI = 1.01-2.83), P= 0.046] were the only independent predictors of clinical outcome, assessed by HF hospitalizations and death. The median lifetime BIVP% was 95% (25-75 percentile range 91-99%). Biventricular pacing percentage was significantly and inversely correlated to VR, decreasing by 7% for each 10 bpm increase in VR. Sub-optimal CRT, defined as BIVP% <95%, was predicted by the occurrence of persistent or permanent AF [odds ratio (OR) = 3.77, CI = 2.44-5.82, P< 0.001], and uncontrolled VR [OR = 2.25, CI = 1.35-3.73, P= 0.002]. CONCLUSION Uncontrolled VR occurs in one-third of CRT-D patients, who experience AF, and is associated with HF hospitalizations and death and with sub-optimal CRT (lifetime BIVP%<95%).
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Affiliation(s)
- Giuseppe Boriani
- Institute of Cardiology, University of Bologna and Azienda Ospedaliera S. Orsola-Malpighi, Via Massarenti 9, 40138 Bologna, Italy.
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