1
|
Acar B, Celikyurt U, Agacdiken A, Vural A. Prognostic value of non-alcoholic fatty liver disease fibrosis score in patients undergoing cardiac resynchronization therapy. Pacing Clin Electrophysiol 2023; 46:251-257. [PMID: 36593653 DOI: 10.1111/pace.14657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 10/10/2022] [Accepted: 12/25/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is an effective option in the treatment of patients with heart failure and wide QRS. Non-alcoholic fatty liver disease (NAFLD) fibrosis score (NFS) has been shown to predict cardiac events in several patient populations. However, the relationship between NFS and response to CRT has not been investigated. The aim of the study was to investigate the predictive role of NFS in the assessment of response after CRT. METHODS Three hundred thirty-six patients with heart failure undergoing CRT were prospectively studied. Liver fibrosis were assessed according to the non-alcoholic fatty liver disease fibrosis score (NFS), which includes age, body mass index, impaired fasting glycemia or diabetes mellitus, aspartate aminotransferase /alanine aminotransferase ratio, platelets, and albumin. Echocardiographic response to CRT was defined by a ≥15% reduction in left ventricular end-systolic volume at six months at follow-up. RESULTS Two hundred thirty-eight patients (71%) had CRT response after 6 months of follow-up. Receiver-operator characteristic curve analysis showed NFS cutoff value of < -1.12 for predicting CRT response with a sensitivity of 70.4% and a specificity of 52.9%. The patients were also divided into four groups according to the quartiles of NFS. The proportion of response to CRT was increased with lower level of NFS value. Multivariate logistic regression analysis demonstrated the NFS score < -1.12 and LVIDs were independent predictors of the CRT response. In the second model of analysis which included NFS, quartiles demonstrated that fourth NFS quartile and LVIDs were independent predictors of CRT response. CONCLUSION Liver fibrosis assessed by NFS can provide valuable information to predict reverse remodeling in patients undergoing CRT. The present study supports monitoring of NFS to improve preoperative risk stratification of these patients.
Collapse
Affiliation(s)
- Burak Acar
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Kocaeli University Medical Faculty, Kocaeli, Turkey
| | - Umut Celikyurt
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Kocaeli University Medical Faculty, Kocaeli, Turkey
| | - Aysen Agacdiken
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Kocaeli University Medical Faculty, Kocaeli, Turkey
| | - Ahmet Vural
- Arrhythmia, Electrophysiology, Pacemaker Research and Management Center, Kocaeli University Medical Faculty, Kocaeli, Turkey
| |
Collapse
|
2
|
The role of cardiac magnetic resonance in identifying appropriate candidates for cardiac resynchronization therapy - a systematic review of the literature. Heart Fail Rev 2022; 27:2095-2118. [PMID: 36045189 DOI: 10.1007/s10741-022-10263-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/04/2022]
Abstract
Despite the strict indications for cardiac resynchronization therapy (CRT) implantation, a significant proportion of patients will fail to adequately respond to the treatment. This systematic review aims to present the existing evidence about the role of cardiac magnetic resonance (CMR) in identifying patients who are likely to respond better to the CRT. A systematic search in the MedLine database and Cochrane Library from their inception to August 2021 was performed, without any limitations, by two independent investigators. We considered eligible observational studies or randomized clinical trials (RCTs) that enrolled patients > 18 years old with heart failure (HF) of ischaemic or non-ischaemic aetiology and provided data about the association of baseline CMR variables with clinical or echocardiographic response to CRT for at least 3 months. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA Statement). Following our search strategy, 47 studies were finally included in our review. CMR appears to have an additive role in identifying the subgroup of patients who will respond better to CRT. Specifically, the presence and the extent of myocardial scar were associated with increased non-response rates, while those with no scar respond better. Furthermore, existing data show that scar location can be associated with CRT response rates. CMR-derived markers of mechanical desynchrony can also be used as predictors of CRT response. CMR data can be used to optimize the position of the left ventricular lead during the CRT implantation procedure. Specifically, positioning the left ventricular lead in a branch of the coronary sinus that feeds an area with transmural scar was associated with poorer response to CRT. CMR can be used as a non-invasive optimization tool to identify patients who are more likely to achieve better clinical and echocardiographic response following CRT implantation.
Collapse
|
3
|
Saito Y, Nakai T, Ikeya Y, Kogawa R, Otsuka N, Wakamatsu Y, Kurokawa S, Ohkubo K, Nagashima K, Okumura Y. Prognostic value of the MELD-XI score in patients undergoing cardiac resynchronization therapy. ESC Heart Fail 2022; 9:1080-1089. [PMID: 34983080 PMCID: PMC8934924 DOI: 10.1002/ehf2.13776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 11/29/2021] [Accepted: 12/02/2021] [Indexed: 12/28/2022] Open
Abstract
Aims Multi‐organ dysfunction was recently reported to be a common condition in patients with heart failure (HF). The Model for End‐stage Liver Disease eXcluding International normalized ratio (MELD‐XI) score reflects liver and kidney function. The prognostic relevance of this score has been reported in patients with a variety of cardiovascular diseases who are undergoing interventional therapies. However, the relationship between the severity of hepatorenal dysfunction assessed by the MELD‐XI score and the long‐term clinical outcomes of HF patients receiving cardiac resynchronization therapy (CRT) has not been evaluated. Methods and results Clinical records of 283 patients who underwent CRT implantation between March 2003 and October 2020 were retrospectively evaluated (mean age 67 ± 12, 22.6% female). Blood samples were collected before CRT implantation. Patients were divided into three groups based on tertiles of the MELD‐XI score: first tertile (MELD‐XI = 9.44, n = 95), second tertile (9.44 < MELD‐XI < 13.4, n = 94), and third tertile (MELD‐XI ≥ 13.4, n = 94). The primary endpoint was all‐cause mortality. Compared with the other groups, the third tertile group exhibited significantly older age, higher prevalence of diabetes mellitus and hypertension, lower haemoglobin level, and higher N‐terminal pro‐brain natriuretic peptide level (all P < 0.05). The functional CRT response rate was also significantly lower in the third tertile group (P = 0.011). During a median follow‐up of 30 months (inter‐quartile range, 9–67), 105 patients (37.1%) died. Kaplan–Meier analysis revealed that patients with a higher MELD‐XI score had a greater risk of all‐cause mortality (log‐rank test: P < 0.001). Even after adjustment for clinically relevant factors and a conventional risk score, the MELD‐XI score was still associated with mortality (adjusted hazard ratio: 1.04, 95% confidence interval: 1.00–1.07, P = 0.014, and adjusted hazard ratio: 1.04, 95% confidence interval: 1.01–1.09, P = 0.005, respectively). A higher MELD‐XI score was associated with a greater risk of all‐cause mortality than a lower MELD‐XI score regardless of whether a pacemaker or defibrillator was implanted (log‐rank test: P = 0.010 and P < 0.001, respectively). Conclusions Impaired hepatorenal function assessed by the MELD‐XI score was associated with older age, higher prevalence of multiple co‐morbidities, severity of HF, lower CRT response rates, and subsequent all‐cause mortality in HF patients undergoing CRT implantation. These results suggest that the MELD‐XI score can provide additional prognostic information and may be useful for improving risk stratification in this population.
Collapse
Affiliation(s)
- Yuki Saito
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yukitoshi Ikeya
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Rikitake Kogawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Naoto Otsuka
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yuji Wakamatsu
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Sayaka Kurokawa
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| |
Collapse
|
4
|
Bertaglia E, Arena G, Pecora D, Reggiani A, D'Onofrio A, Palmisano P, De Simone A, Caico SI, Marini M, Maglia G, Ferraro A, Solimene F, Cecchetto A, Malacrida M, Botto GL, Lunati M, Stabile G. The VALID-CRT risk score reliably predicts response and outcome of cardiac resynchronization therapy in a real-world population. Clin Cardiol 2019; 42:919-924. [PMID: 31301152 PMCID: PMC6788573 DOI: 10.1002/clc.23229] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 06/24/2019] [Accepted: 06/28/2019] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The aim of the study was to confirm the value of the VALID-cardiac resynchronization therapy (CRT) risk score in predicting outcome and to assess its association with clinical response (CR) in an unselected real-world CRT population. METHODS AND RESULTS The present analysis comprised all consecutive CRT patients (pts) enrolled in the CRT-MORE registry from 2011 to 2013. Pts were stratified into five groups (quintiles 1-5) according to the VALID-CRT risk predictor index applied to the CRT-MORE population. In the analysis of clinical outcome, adverse events comprised death from any cause and non-fatal heart failure (HF) events requiring hospitalization. CR at 12-month follow-up was also assessed. We enrolled 905 pts. During a median follow-up of 1005 [627-1361] days, 134 patients died, and 79 had at least one HF hospitalization. At 12 months, 69% of pts displayed an improvement in their CR. The mean VALID-CRT risk score derived from the CRT-MOdular Registry (MORE) population was 0.317, ranging from -0.419 in Q1 to 2.59 in Q5. The risk-stratification algorithm was able to predict total mortality after CRT (survival ranging from 93%-Q1 to 77%-Q5; hazards ratio [HR] = 1.42, 95% confidence interval [CI]: 1.25-1.61, P < .0001), and HF hospitalization (ranging from 95% to 90%; HR = 1.24, 95% CI: 1.06-1.45, P = .009). CR was significantly lower in pts with a high-to-very high risk profile (Q4-5) than in pts with a low-to-intermediate risk profile (Q1-2-3) (55% vs 79%, P < .0001). CONCLUSION The VALID-CRT risk-stratification algorithm reliably predicts outcome and CRT response after CRT in an unselected, real-world population.
Collapse
Affiliation(s)
- Emanuele Bertaglia
- Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padua, Italy
| | | | | | | | | | - Pietro Palmisano
- Cardiology Unit, 'Card. G. Panico' Hospital, Tricase (LE), Italy
| | | | | | | | | | | | | | | | | | - Giovanni L Botto
- U.O. Electrophysiology, ASST Rhodense, Rho-Garbagnate Milanese (MI), Italy
| | - Maurizio Lunati
- Cardiotoracovascular Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | |
Collapse
|
5
|
Doumouras BS, Lee DS, Levy WC, Alba AC. An Appraisal of Biomarker-Based Risk-Scoring Models in Chronic Heart Failure: Which One Is Best? Curr Heart Fail Rep 2019; 15:24-36. [PMID: 29404976 DOI: 10.1007/s11897-018-0375-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW While prediction models incorporating biomarkers are used in heart failure, these have shown wide-ranging discrimination and calibration. This review will discuss externally validated biomarker-based risk models in chronic heart failure patients assessing their quality and relevance to clinical practice. RECENT FINDINGS Biomarkers may help in determining prognosis in chronic heart failure patients as they reflect early pathologic processes, even before symptoms or worsening disease. We present the characteristics and describe the performance of 10 externally validated prediction models including at least one biomarker among their predictive factors. Very few models report adequate discrimination and calibration. Some studies evaluated the additional predictive value of adding a biomarker to a model. However, these have not been routinely assessed in subsequent validation studies. New and existing prediction models should include biomarkers, which improve model performance. Ongoing research is needed to assess the performance of models in contemporary patients.
Collapse
Affiliation(s)
- Barbara S Doumouras
- Heart Failure and Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
| | - Douglas S Lee
- Institute for Clinical Evaluative Sciences, Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON, Canada
| | | | - Ana C Alba
- Heart Failure and Transplant Program, Toronto General Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
6
|
Upshaw JN, Konstam MA, Klaveren DV, Noubary F, Huggins GS, Kent DM. Multistate Model to Predict Heart Failure Hospitalizations and All-Cause Mortality in Outpatients With Heart Failure With Reduced Ejection Fraction: Model Derivation and External Validation. Circ Heart Fail 2017; 9:CIRCHEARTFAILURE.116.003146. [PMID: 27514751 DOI: 10.1161/circheartfailure.116.003146] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 07/20/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Outpatients with heart failure (HF) who are at high risk for HF hospitalization and death may benefit from early identification. We sought to develop and externally validate a model to predict both HF hospitalization and mortality that accounts for the semicompeting nature of the 2 outcomes and captures the risk associated with the transition from the stable outpatient state to the post-HF hospitalization state. METHODS AND RESULTS A multistate model to predict HF hospitalization and all-cause mortality was derived using data (n=3834) from the HEAAL study (Heart Failure Endpoint evaluation of Angiotensin II Antagonist Losartan), a multinational randomized trial in symptomatic patients with reduced left ventricular ejection fraction. Twelve easily and reliably obtainable demographic and clinical predictors were prespecified for model inclusion. Model performance was assessed in the SCD-HeFT cohort (Sudden Cardiac Death in Heart Failure Trial; n=2521). At 1 year, the probability of being alive without HF hospitalization was 94% for a typical patient in the lowest risk quintile and 77% for a typical patient in the highest risk quintile and this variability in risk continued through 7 years of follow-up. The model c-index was 0.72 in the derivation cohort, 0.66 in the validation cohort, and 0.69 in the implantable cardiac defibrillator arm of the validation cohort. There was excellent calibration across quintiles of predicted risk. CONCLUSIONS Our findings illustrate the advantages of a multistate modeling approach, providing estimates of HF hospitalization and death in the same model, comparison of predictors for the different outcomes and demonstrating the different trajectories of patients based on baseline characteristics and intermediary events. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifiers: NCT00000609 and NCT00090259.
Collapse
Affiliation(s)
- Jenica N Upshaw
- From The CardioVascular Center (J.N.U., M.A.K., G.S.H.) and The Institute for Clinical Research and Health Policy Studies (D.v.K., F.N., D.M.K.), Tufts Medical Center, Boston, MA; and The Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands (D.v.K.).
| | - Marvin A Konstam
- From The CardioVascular Center (J.N.U., M.A.K., G.S.H.) and The Institute for Clinical Research and Health Policy Studies (D.v.K., F.N., D.M.K.), Tufts Medical Center, Boston, MA; and The Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands (D.v.K.)
| | - David van Klaveren
- From The CardioVascular Center (J.N.U., M.A.K., G.S.H.) and The Institute for Clinical Research and Health Policy Studies (D.v.K., F.N., D.M.K.), Tufts Medical Center, Boston, MA; and The Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands (D.v.K.)
| | - Farzad Noubary
- From The CardioVascular Center (J.N.U., M.A.K., G.S.H.) and The Institute for Clinical Research and Health Policy Studies (D.v.K., F.N., D.M.K.), Tufts Medical Center, Boston, MA; and The Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands (D.v.K.)
| | - Gordon S Huggins
- From The CardioVascular Center (J.N.U., M.A.K., G.S.H.) and The Institute for Clinical Research and Health Policy Studies (D.v.K., F.N., D.M.K.), Tufts Medical Center, Boston, MA; and The Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands (D.v.K.)
| | - David M Kent
- From The CardioVascular Center (J.N.U., M.A.K., G.S.H.) and The Institute for Clinical Research and Health Policy Studies (D.v.K., F.N., D.M.K.), Tufts Medical Center, Boston, MA; and The Department of Public Health, Erasmus MC, University Medical Center Rotterdam, The Netherlands (D.v.K.)
| |
Collapse
|
7
|
Morishima I, Okumura K, Tsuboi H, Morita Y, Takagi K, Yoshida R, Nagai H, Tomomatsu T, Ikai Y, Terada K, Sone T, Murohara T. Impact of basal inferolateral scar burden determined by automatic analysis of 99mTc-MIBI myocardial perfusion SPECT on the long-term prognosis of cardiac resynchronization therapy. Europace 2017; 19:573-580. [PMID: 28431062 DOI: 10.1093/europace/euw068] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/23/2016] [Indexed: 11/12/2022] Open
Abstract
AIMS Left-ventricular (LV) scarring may be associated with a poor response to cardiac resynchronization therapy (CRT). The automatic analysis of myocardial perfusion single-photon emission computed tomography (MP-SPECT) may provide objective quantification of LV scarring. We investigated the impact of LV scarring determined by an automatic analysis of MP-SPECT on short-term LV volume response as well as long-term outcome. METHODS AND RESULTS We studied consecutive 51 patients who were eligible to undergo 99mTc-MIBI MP-SPECT both at baseline and 6 months after CRT (ischaemic cardiomyopathies 31%). Quantitative perfusion SPECT was used to evaluate the defect extent (an index of global scarring) and the LV 17-segment regional uptake ratio (an inverse index of regional scar burden). The primary outcome was the composite of overall mortality or first hospitalization for worsening heart failure. A high global scar burden and a low mid/basal inferolateral regional uptake ratio were associated with volume non-responders to CRT at 6 months. The basal inferolateral regional uptake ratio remained as a predictor of volume non-response after adjusting for the type of cardiomyopathy. During a median follow-up of 36.1 months, the outcome occurred in 28 patients. The patients with a low basal inferolateral regional uptake ratio with a cutoff value of 57% showed poor prognosis (log-rank P= 0.006). CONCLUSION The scarring determined by automatic analysis of MP-SPECT images may predict a poor response to CRT regardless of the pathogenesis of cardiomyopathy. The basal inferolateral scar burden in particular may have an adverse impact on long-term prognosis.
Collapse
Affiliation(s)
- Itsuro Morishima
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Kenji Okumura
- Department of Cardiology, Tohno Kosei Hospital, 76-1 Tokicho, Mizunai, Japan
| | - Hideyuki Tsuboi
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Yasuhiro Morita
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Kensuke Takagi
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Ruka Yoshida
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Hiroaki Nagai
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Toshiro Tomomatsu
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Yoshihiro Ikai
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Kazushi Terada
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Takahito Sone
- Department of Cardiology, Ogaki Municipal Hospital, 4-86 Minaminokawa-cho, Ogaki, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Japan
| |
Collapse
|
8
|
Gasparini M, Klersy C, Leclercq C, Lunati M, Landolina M, Auricchio A, Santini M, Boriani G, Proclemer A, Leyva F. Validation of a simple risk stratification tool for patients implanted with Cardiac Resynchronization Therapy: the VALID-CRT risk score. Eur J Heart Fail 2015; 17:717-24. [PMID: 25903349 DOI: 10.1002/ejhf.269] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Revised: 03/06/2015] [Accepted: 03/10/2015] [Indexed: 11/08/2022] Open
Abstract
AIMS Mortality after cardiac resynchronization therapy (CRT) is difficult to predict. We sought to design and validate a simple prognostic score for patients implanted with CRT, based on readily available clinical variables, including age, gender, left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) class, presence/absence of atrial fibrillation, presence/absence of atrioventricular junction ablation, coronary heart disease, diabetes, and implantation of a CRT device with defibrillation. METHODS For predictive modelling, 5153 consecutive patients enrolled in 72 European centres (79% male; LVEF 25.9 ± 6.85%; NYHA class III-IV 77.5%; QRS 158.4 ± 32.3 ms) were randomly split into derivation (70%) and validation (30%) samples. The primary endpoint was total mortality and the secondary endpoint was cardiovascular mortality. The final predictive model fit was assessed by plotting observed vs. predicted survival. RESULTS In the entire cohort, 1004 deaths occurred over a follow-up of 14 409 person years. Total mortality ranged from 3.1% to 28.2% at 2 years in the first and fifth quintile of the risk score, respectively. At 5 years, total mortality was 10.3%, 18.6%, 27.6%, 36.1%, and 58.8%, from the first to the fifth quintile. Compared with the lowest quintile (Q), total mortality was significantly higher in the other four quintiles [Q2 hazard ratio (HR) = 1.71; Q3 HR = 2.20; Q4 HR = 4.03; Q5 HR = 8.03; all P < 0.001). The final model, which was based on the entire cohort using the above variables, showed a good discrimination (Harrell's c = 0.70) and high explained variation (0.26). The mean predicted survival fitted well with the observed survival for up to 6 years of follow-up. CONCLUSIONS The VALID-CRT risk score, which is based on routine, readily available clinical variables, reliably predicted the long-term total and cardiovascular mortality in patients undergoing CRT. While this score cannot be used to predict the benefit of CRT, it may be useful for predicting survival after CRT. This may have useful implications for follow-up.
Collapse
Affiliation(s)
- Maurizio Gasparini
- Electrophysiology and Pacing Unit, Humanitas Research Hospital IRCCS, Via Manzoni 56 Rozzano (Milano), 20089, Italy
| | - Catherine Klersy
- Biometry and Clinical Epidemiology, Research Department, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | | | - Maurizio Lunati
- Cardiology Department, Niguarda Ca' Granda Hospital, Milano, Italy
| | - Maurizio Landolina
- Cardiology Department, Fondazione Policlinico S. Matteo IRCCS, Pavia, Italy
| | | | - Massimo Santini
- Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Giuseppe Boriani
- Institute of Cardiology, University of Bologna and Azienda Ospedaliera S.Orsola-Malpighi, Bologna, Italy
| | | | - Francisco Leyva
- Aston University Medical School and Queen Elizabeth Hospital, Birmingham, UK
| |
Collapse
|
9
|
Suever JD, Hartlage GR, Magrath III RP, Iravanian S, Lloyd MS, Oshinski JN. Relationship between mechanical dyssynchrony and intra-operative electrical delay times in patients undergoing cardiac resynchronization therapy. J Cardiovasc Magn Reson 2014; 16:4. [PMID: 24393383 PMCID: PMC3895745 DOI: 10.1186/1532-429x-16-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 12/27/2013] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND It is important to understand the relationship between electrical and mechanical ventricular activation in CRT patients. By measuring local electrical activation at multiple locations within the coronary veins and myocardial contraction at the same locations in the left ventricle, we determined the relationship between electrical and mechanical activation at potential left ventricular pacing locations. METHODS In this study, mechanical contraction times were computed using high temporal resolution cine cardiovascular magnetic resonance (CMR) data, while electrical activation times were derived from intra-procedural local electrograms. RESULTS In our cohort, there was a strong correlation between electrical and mechanical delay times within each patient (R2=0.78 ± 0.23). Additionally, the latest electrically activated location corresponded with the latest mechanically contracting location in 91% of patients. CONCLUSIONS This study provides initial evidence that our method of obtaining non-invasive mechanical activation patterns accurately reflects the underlying electromechanical substrate of intraventricular dyssynchrony.
Collapse
Affiliation(s)
- Jonathan D Suever
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology / Emory University, 1364 Clifton Road, Suite AG30, Atlanta, GA 30322, USA
| | - Gregory R Hartlage
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - R Patrick Magrath III
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology / Emory University, 1364 Clifton Road, Suite AG30, Atlanta, GA 30322, USA
| | - Shahriar Iravanian
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael S Lloyd
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - John N Oshinski
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology / Emory University, 1364 Clifton Road, Suite AG30, Atlanta, GA 30322, USA
- Department of Radiology & Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
10
|
Leyva F, Taylor RJ, Foley PWX, Umar F, Mulligan LJ, Patel K, Stegemann B, Haddad T, Smith REA, Prasad SK. Left ventricular midwall fibrosis as a predictor of mortality and morbidity after cardiac resynchronization therapy in patients with nonischemic cardiomyopathy. J Am Coll Cardiol 2012; 60:1659-67. [PMID: 23021326 DOI: 10.1016/j.jacc.2012.05.054] [Citation(s) in RCA: 149] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 04/30/2012] [Accepted: 05/15/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether left ventricular (LV) midwall fibrosis, detected by midwall hyperenhancement (MWHE) on late gadolinium enhancement cardiovascular magnetic resonance (CMR) imaging, predicts mortality and morbidity in patients with dilated cardiomyopathy (DCM) undergoing cardiac resynchronization therapy (CRT). BACKGROUND Midwall fibrosis predicts mortality and morbidity in patients with DCM. METHODS Patients with DCM with (+) or without (-) MWHE (n = 20 and n = 77, respectively) as well as 161 patients with ischemic cardiomyopathy (ICM) undergoing CRT (n = 258) were followed up for a maximum of 8.7 years. RESULTS Among patients with DCM, +MWHE predicted cardiovascular mortality (hazard ratio [HR]: 18.6; 95% confidence intervals [CI]: 3.51 to 98.5; p = 0.0008), total mortality or hospitalization for major adverse cardiovascular events (HR: 7.57; 95% CI: 2.71 to 21.2; p < 0.0001), and cardiovascular mortality or heart failure hospitalizations (HR: 9.56; 95% CI: 2.72 to 33.6; p = 0.0004), independent of New York Heart Association class, QRS duration, atrial fibrillation, LV volumes, LV ejection fraction, and a CMR-derived measure of dyssynchrony. Among patients with DCM and ICM, the risk of cardiovascular mortality for DCM +MWHE (adjusted HR: 18.5; 95% CI: 3.93 to 87.3; p = 0.0002) was similar to that for ICM (adjusted HR: 21.0; 95% CI: 5.06 to 87.2; p < 0.0001). Both DCM +MWHE and ICM were predictors of pump failure death as well as sudden cardiac death. LV reverse remodeling was observed in DCM -MWHE and in ICM but not in DCM +MWHE. CONCLUSIONS Midwall fibrosis is an independent predictor of mortality and morbidity in patients with DCM undergoing CRT. The outcome of DCM with midwall fibrosis is similar to that of ICM. This relationship is mediated by both pump failure and sudden cardiac death.
Collapse
Affiliation(s)
- Francisco Leyva
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, Birmingham, United Kingdom.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Risum N, Williams ES, Khouri MG, Jackson KP, Olsen NT, Jons C, Storm KS, Velazquez EJ, Kisslo J, Bruun NE, Sogaard P. Mechanical dyssynchrony evaluated by tissue Doppler cross-correlation analysis is associated with long-term survival in patients after cardiac resynchronization therapy. Eur Heart J 2012; 34:48-56. [DOI: 10.1093/eurheartj/ehs035] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
12
|
Abstract
'Multimodality' imaging--the side-by-side interpretation of data obtained from various noninvasive imaging techniques, such as echocardiography, radionuclide techniques, multidetector CT (MDCT), and MRI--allows anatomical, morphological, and functional data to be combined, increases diagnostic accuracy, and improves the efficacy of cardiovascular interventions and clinical outcomes. During the past decade, advances in software and hardware have allowed co-registration of various imaging modalities, resulting in cardiac 'hybrid' or 'fusion' imaging. In this Review, we discuss the roles of both multimodality and hybrid imaging in three broad areas of cardiology--coronary artery disease (CAD), heart failure, and valvular heart disease. In the evaluation of CAD, integration of either single-photon emission computed tomography (SPECT) or PET with CT coronary angiography provides both morphological and functional data in a single procedure. Accordingly, the functional consequences (myocardial hypoperfusion on SPECT or PET) of anatomical pathology (coronary anatomy on MDCT or MRI) can be assessed. Co-registration of PET and MRI data sets to provide cellular and molecular information on plaque composition and stability is now possible. Furthermore, novel imaging modalities have been implemented to guide electrophysiological and transcatheter-based procedures, such as cardiac resynchronization therapy (an established treatment for patients with heart failure), and transcatheter valve repair or replacement procedures.
Collapse
|
13
|
Auger D, Schalij MJ, Bax JJ, Delgado V. [Three-dimensional imaging in cardiac resynchronization therapy]. Rev Esp Cardiol 2011; 64:1035-44. [PMID: 21943554 DOI: 10.1016/j.recesp.2011.06.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 06/03/2011] [Indexed: 01/25/2023]
Abstract
Cardiac resynchronization therapy improves clinical symptoms and prognosis of heart failure patients. However, it has been shown that up to 40% of patients do not respond to this therapy. Three main determinants of cardiac resynchronization therapy response have been identified: left ventricular dyssynchrony, left ventricular lead position, and extent and location of myocardial scar tissue. Two-dimensional echocardiography is the first imaging technique to evaluate patients who may be candidates for cardiac resynchronization therapy. However, a multimodality approach based on 3-dimensional imaging techniques may provide a more comprehensive evaluation of these patients by combining the assessment of the aforementioned pathophysiological determinants of cardiac resynchronization therapy response.
Collapse
Affiliation(s)
- Dominique Auger
- Department of Cardiology, Leiden University Medical Centre, Leiden, Países Bajos
| | | | | | | |
Collapse
|
14
|
Delgado V, Bax JJ. Assessment of systolic dyssynchrony for cardiac resynchronization therapy is clinically useful. Circulation 2011; 123:640-55. [PMID: 21321180 DOI: 10.1161/circulationaha.110.954404] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, ZA Leiden, The Netherlands.
| | | |
Collapse
|
15
|
[The role of cardiovascular magnetic resonance imaging in the diagnosis and prognosis of patients with heart failure]. Herz 2011; 36:84-93. [PMID: 21424346 DOI: 10.1007/s00059-010-3418-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Cardiovascular magnetic resonance (CMR) imaging is a tomographic technique, which allows three-dimensional slice orientation without limitations from acoustic windows inherent to echocardiography. Further advantages of CMR are its high temporal and spatial resolution, its excellent soft tissue resolution and its high blood-to-tissue contrast. Cardiovascular magnetic resonance is currently the only imaging technique, which provides a comprehensive study of both structure and function of the heart as well as myocardial perfusion and viability. Moreover, post-processing of CMR images does not require any geometric assumptions as in echocardiography to determine ventricular dimensions. This is particularly important when evaluating ventricles of patients with chronic heart failure with severely altered morphology that may have regional variations in wall thickness and contractility at least in ischemic cardiomyopathy. The highly reproducible results of CMR imaging have turned this technique into a reference standard for the non-invasive assessment of ventricular dimensions, mass and function. In cases with indeterminate results of clinical, electrocardiographic and particularly echocardiographic findings CMR should be used early in the process of diagnosis of patients with heart failure. Not only can altered structure and degree of ventricular and valvular dysfunctions be accurately assessed but also regional perfusion deficits and/or myocardial scars are easily detected. For therapeutic and prognostic reasons a simple differentiation between ischemic and non-ischemic cardiomyopathy should be achieved as the first diagnostic step. In addition, the type and localization of the late gadolinium enhancement (LGE) phenomenon may aid in non-invasively differentiating the etiology of non-ischemic cardiomyopathy. CMR may also improve the assessment and extent of interventricular and intraventricular dyssynchrony in patients to be selected for cardiac resynchronization therapy (CRT). Lastly, the LGE phenomenon may provide independent prognostic information in patients with a CRT system implanted, as well as in patients with ischemic and non-ischemic cardiomyopathy. Thus, CMR imaging should be implemented early in the diagnostic process of patients with heart failure to significantly improve the speed and accuracy of diagnostic procedures, to control the effect of therapeutic measures, and to select patients with a limited prognosis by assessing the degree of ventricular dysfunction and the extent of myocardial scarring.
Collapse
|
16
|
Current and future role of cardiovascular magnetic resonance in cardiac resynchronization therapy. Heart Fail Rev 2011; 16:251-62. [DOI: 10.1007/s10741-010-9213-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
17
|
Leyva F. Cardiac resynchronization therapy guided by cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2010; 12:64. [PMID: 21062491 PMCID: PMC2994940 DOI: 10.1186/1532-429x-12-64] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 11/09/2010] [Indexed: 12/12/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for patients with symptomatic heart failure, severely impaired left ventricular (LV) systolic dysfunction and a wide (> 120 ms) complex. As with any other treatment, the response to CRT is variable. The degree of pre-implant mechanical dyssynchrony, scar burden and scar localization to the vicinity of the LV pacing stimulus are known to influence response and outcome. In addition to its recognized role in the assessment of LV structure and function as well as myocardial scar, cardiovascular magnetic resonance (CMR) can be used to quantify global and regional LV dyssynchrony. This review focuses on the role of CMR in the assessment of patients undergoing CRT, with emphasis on risk stratification and LV lead deployment.
Collapse
Affiliation(s)
- Francisco Leyva
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, UK.
| |
Collapse
|
18
|
Gorcsan J, Oyenuga O, Habib PJ, Tanaka H, Adelstein EC, Hara H, McNamara DM, Saba S. Relationship of echocardiographic dyssynchrony to long-term survival after cardiac resynchronization therapy. Circulation 2010; 122:1910-8. [PMID: 20975000 DOI: 10.1161/circulationaha.110.954768] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The ability of echocardiographic dyssynchrony to predict response to cardiac resynchronization therapy (CRT) has been unclear. METHODS AND RESULTS A prospective, longitudinal study was designed with predefined dyssynchrony indexes and outcome variables to test the hypothesis that baseline dyssynchrony is associated with long-term survival after CRT. We studied 229 consecutive class III to IV heart failure patients with ejection fraction ≤35 and QRS duration ≥120 milliseconds for CRT. Dyssynchrony before CRT was defined as tissue Doppler velocity opposing-wall delay ≥65 milliseconds, 12-site SD (Yu Index) ≥32 milliseconds, speckle tracking radial strain anteroseptal-to-posterior wall delay ≥130 milliseconds, or pulsed Doppler interventricular mechanical delay ≥40 milliseconds. Outcome was defined as freedom from death, heart transplantation, or left ventricular assist device implantation. Of 210 patients (89) with dyssynchrony data available, there were 62 events: 47 deaths, 9 transplantations, and 6 left ventricular assist device implantations over 4 years. Event-free survival was associated with Yu Index (P=0.003), speckle tracking radial strain (P=0.003), and interventricular mechanical delay (P=0.019). When adjusted for confounding baseline variables of ischemic origin and QRS duration, Yu Index and radial strain dyssynchrony remained independently associated with outcome (P<0.05). Lack of radial dyssynchrony was particularly associated with unfavorable outcome in those with QRS duration of 120 to 150 milliseconds (P=0.002). CONCLUSIONS The absence of echocardiographic dyssynchrony was associated with significantly less favorable event-free survival after CRT. Patients with narrower QRS duration who lacked dyssynchrony had the least favorable long-term outcome. These observations support the relationship of dyssynchrony and CRT response.
Collapse
Affiliation(s)
- John Gorcsan
- University of Pittsburgh, Scaife 564, 200 Lothrop St, Pittsburgh, PA 15213-2582, USA.
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Yu CM, Sanderson JE, Gorcsan J. Echocardiography, dyssynchrony, and the response to cardiac resynchronization therapy. Eur Heart J 2010; 31:2326-37. [PMID: 20709721 DOI: 10.1093/eurheartj/ehq263] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Biventricular pacing or cardiac resynchronization therapy (CRT) has been a considerable advance in the therapy of chronic heart failure. However, it is clear that not all patients benefit either in terms of symptoms or cardiac function, and some may be worsened by CRT. In this review, we consider the arguments, both clinical and economical, in favour of improved selection of patients for CRT other than those in current guidelines. It also seems clear that the fundamental mechanism of CRT is correction of dyssynchrony, and we review the various methodologies available to detect dyssynchrony. Other factors are probably also important in determining outcomes such as lead position, the extent and form of myocardial damage, optimizing pacemaker performance, and clinical expertise. The potential costs of inappropriate CRT implantation are high to our patients and to the health economy, and it behooves the cardiology community to develop better selection criteria. The current guidelines can and should be improved.
Collapse
Affiliation(s)
- Cheuk-Man Yu
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China.
| | | | | |
Collapse
|
20
|
Speckle Tracking Echocardiography for Cardiac Resynchronization Therapy: Has the Right Ultrasound Technique Finally Been Found? J Am Soc Echocardiogr 2010; 23:190-4. [DOI: 10.1016/j.echo.2009.12.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|