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Samy M, Hamdy RM. Arrhythmic and mortality outcomes in patients with dilated cardiomyopathy receiving cardiac resynchronization therapy without defibrillator. Indian Pacing Electrophysiol J 2023; 23:171-176. [PMID: 37574049 PMCID: PMC10685097 DOI: 10.1016/j.ipej.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/27/2023] [Accepted: 08/10/2023] [Indexed: 08/15/2023] Open
Abstract
INTRODUCTION The routine implantation of cardiac resynchronization therapy with defibrillators in all patients who are candidates for this treatment is now being negotiated, mainly in patients with dilated cardiomyopathy. OBJECTIVE We investigated the arrhythmic and mortality outcomes following CRT implantation in DCM, as well as the necessity for defibrillator capabilities in that particular group of patients. METHODS we included 67- patients with DCM with EF ≤ 35%, QRS duration >130 msec and NYHA class II-IV, or those with EF ≤ 35% with indications of permanent pacing for implantation of CRT-P. Patients were followed to obtain good CRT response. Improved clinical outcomes were defined as improvement in at least one NYHA class, ≥5% increase in LVEF, and ≥15% reduction in left ventricular end-systolic volume versus baseline. Patients were classified into responder and non-responder. Patients were followed for 36 months regarding all-cause morbidity mainly ventricular tachycardia and all-cause mortality. RESULTS CRT responder patients had better clinical outcomes than CRT non-responder patients (post NYHA, 1.3 ± 0.5 vs. 2.5 ± 0.6, p < 0.0001; post LVEF 30.0 ± 1.6 vs. 20.3 ± 2.2%, p < 0.0001; LVESV, 151.7 ± 7.6 vs. 190.4 ± 9.0 ml, p < 0.0001), with lower ventricular arrhythmia (p < 0.0001), lower mortality (p = 0.015) and lower all-cause morbidity (p < 0.001). This survival advantage may be related to the response to CRT response determined by clinical and echocardiographic parameters over a 36-month period of follow-up. CONCLUSIONS Our findings suggest that CRT-P implantation without defibrillation backup is an encouraging treatment option for patients with DCM, principally those who responded to it. It may result in cost savings, a decrease in complications, and an improvement in all-cause morbidity, particularly ventricular arrhythmia and survival.
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Affiliation(s)
- Mohammed Samy
- Cardiology Department, Faculty of Medicine (For Boys), Al-Azhar University, Cairo, 11765, Egypt.
| | - Rehab M Hamdy
- Cardiology Department, Faculty of Medicine (For Girls), Al-Azhar University, Cairo, 11666, Egypt.
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Cardiac resynchronization therapy with or without defibrillation: a long-standing debate. Cardiol Rev 2021; 30:221-233. [PMID: 33758120 DOI: 10.1097/crd.0000000000000388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Cardiac resynchronization therapy (CRT) was shown to improve cardiac function, reduce heart failure hospitalizations, improve quality of life and prolong survival in patients with severe left ventricular dysfunction and intraventricular conduction disturbances, mainly left bundle branch block, on optimal medical therapy with ACE-inhibitors, β-blockers and mineralocorticoid receptor antagonists up-titrated to maximum tolerated evidence-based doses. CRT can be achieved by means of pacemaker systems (CRT-P) or devices with defibrillation capabilities (CRT-D). CRT-Ds offer an undoubted advantage in the prevention of arrhythmic death, but such an advantage may be of lesser degree in non-ischemic heart failure aetiologies. Moreover, the higher CRT-D hardware complexity compared to CRT-P may predispose to device/lead malfunctions and the higher current drainage may cause a shorter battery duration with consequent premature replacements and the well-known incremental complications. In a period of financial constraints, also device costs should be carefully evaluated, with recent reports suggesting that CRT-Ps may be favoured over CRT-Ds in patients with non-ischemic cardiomyopathy and no prior history of cardiac arrhythmias from a cost-effectiveness point of view. The choice between a CRT-P or a CRT-D device should be patient-tailored whenever straightforward defibrillator indications are not present. The Goldenberg score may facilitate this decision-making process in ambiguous settings. Age, comorbidities, kidney disease, atrial fibrillation, advanced functional class, inappropriate therapy risk, implantable device infections and malfunctions are factors potentially reducing the expected benefit from defibrillating capabilities. Future prospective, randomized controlled trials are warranted to directly compare the efficacy and safety of CRT-Ps and CRT-Ds.
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Loboda D, Gibinski M, Zietek K, Wilczek J, Gardas R, Gladysz-Wanha S, Golba KS. Survival of patients with pacing-induced cardiomyopathy upgraded to CRT does not depend on defibrillation therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:471-478. [PMID: 32198771 DOI: 10.1111/pace.13906] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 02/15/2020] [Accepted: 03/15/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Permanent right ventricular pacing (RVP) results in cardiac dyssynchrony that may lead to heart failure and may be an indication for the use of cardiac resynchronization therapy (CRT). The study aimed to evaluate predictors of outcomes in patients with pacing-induced cardiomyopathy (PICM) if upgraded to CRT. METHODS One hundred fifteen patients, 75.0 years old (IQR 67.0-80.0), were upgraded to CRT due to the decline in left ventricle ejection fraction (LVEF) caused by the long-term RVP. A retrospective analysis was performed using data from hospital and outpatient clinic records and survival data from the National Health System. RESULTS The prior percentage of RVP was 100.0% (IQR 97.0-100.0), with a QRS duration of 180.0 ms (IQR 160.0-200.0). LVEF at the time of the upgrade procedure was 27.0% (IQR 21.0-32.75). The mean follow-up was 980 ± 522 days. The primary endpoint, death from any cause, was met by 26 (22%) patients. Age > 82 years (HR 5.96; 95% CI 2.24-15.89; P = .0004) and pre-CRT implantation LVEF < 20% (HR 5.63; 95%CI 2.19-14.47; P = .0003), but neither the cardioverter-defibrillator (ICD) implantation (HR 1.00; 95%CI 0.45-2.22; P = 1.00), nor the presence of atrial fibrillation (HR 1.22; 95%CI 0.56-2.64; P = .62), were independently associated with all-cause mortality. CONCLUSION Advanced age and an extremely low LVEF, but neither the presence of atrial fibrillation nor implanting an additional high voltage lead, influence the all-cause mortality in patients after long-term RVP, when upgraded to CRT.
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Affiliation(s)
- Danuta Loboda
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Michal Gibinski
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Karolina Zietek
- Faculty of Medicine, Medical University of Silesia, Katowice, Poland
| | - Jacek Wilczek
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Rafal Gardas
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Sylwia Gladysz-Wanha
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
| | - Krzysztof S Golba
- Department of Electrocardiology and Heart Failure, Medical University of Silesia, Katowice, Poland
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Barra S, Providência R, Narayanan K, Boveda S, Duehmke R, Garcia R, Leyva F, Roger V, Jouven X, Agarwal S, Levy WC, Marijon E. Time trends in sudden cardiac death risk in heart failure patients with cardiac resynchronization therapy: a systematic review. Eur Heart J 2019; 41:1976-1986. [DOI: 10.1093/eurheartj/ehz773] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/07/2019] [Accepted: 10/25/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
While data from randomized trials suggest a declining incidence of sudden cardiac death (SCD) among heart failure patients, the extent to which such a trend is present among patients with cardiac resynchronization therapy (CRT) has not been evaluated. We therefore assessed changes in SCD incidence, and associated factors, in CRT recipients over the last 20 years.
Methods and results
Literature search from inception to 30 April 2018 for observational and randomized studies involving CRT patients, with or without defibrillator, providing specific cause-of-death data. Sudden cardiac death was the primary endpoint. For each study, rate of SCD per 1000 patient-years of follow-up was calculated. Trend line graphs were subsequently constructed to assess change in SCD rates over time, which were further analysed by device type, patient characteristics, and medical therapy. Fifty-three studies, comprising 22 351 patients with 60 879 patient-years of follow-up and a total of 585 SCD, were included. There was a gradual decrease in SCD rates since the early 2000s in both randomized and observational studies, with rates falling more than four-fold. The rate of decline in SCD was steeper than that of all-cause mortality, and accordingly, the proportion of deaths which were due to SCD declined over the years. The magnitude of absolute decline in SCD was more prominent among CRT-pacemaker (CRT-P) patients compared to those receiving CRT-defibrillator (CRT-D), with the difference in SCD rates between CRT-P and CRT-D decreasing considerably over time. There was a progressive increase in age, use of beta-blockers, and left ventricular ejection fraction, and conversely, a decrease in QRS duration and antiarrhythmic drug use.
Conclusion
Sudden cardiac death rates have progressively declined in the CRT heart failure population over time, with the difference between CRT-D vs. CRT-P recipients narrowing considerably.
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Affiliation(s)
- Sérgio Barra
- Cardiology Department, Hospital da Luz Arrabida, Praceta de Henrique Moreira 150, 4400-346 V. N. Gaia, Portugal
- Cardiology Department, V. N. Gaia Hospital Center, Rua Conceição Fernandes 4434-502 V. N. Gaia, Portugal
- Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Cambridge CB2 0AY, UK
| | - Rui Providência
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, W Smithfield, London EC1A 7BE, UK
| | - Kumar Narayanan
- Cardiology Department, Medicover Hospitals, Hyderabad, India
- Paris Cardiovascular Research Center (Inserm U970), Cardiovascular Epidemiology Unit, 56 Rue Leblanc, 75015 Paris, France
| | - Serge Boveda
- Cardiology Department, Clinique Pasteur, 45 Avenue de Lombez - BP 27617 - 31076 TOULOUSE, 31300 Toulouse, France
| | - Rudolf Duehmke
- Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Cambridge CB2 0AY, UK
- Cardiology Department, James Paget University Hospital, Lowestoft Road Gorleston-on-Sea, Great Yarmouth NR31 6LA, UK
| | - Rodrigue Garcia
- Cardiology Department, Poitiers University Hospital, 2 Rue de la Milétrie, 86021 Poitiers, France
| | - Francisco Leyva
- Aston Medical Research Institute, Aston University Medical School, 295 Aston Express Way, Birmingham B4 7ET, UK
- Cardiology Department, Queen Elizabeth Hospital, Mindelsohn Way, Birmingham B15 2TH, UK
| | - Véronique Roger
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, 200 1st St SW, Rochester, MN 55905, USA
- Department of Health Sciences Research, Mayo Clinic College of Medicine and Science, 200 1st St SW, Rochester, MN 55905, USA
| | - Xavier Jouven
- Paris Cardiovascular Research Center (Inserm U970), Cardiovascular Epidemiology Unit, 56 Rue Leblanc, 75015 Paris, France
- Cardiology Department, European Georges Pompidou Hospital, 20 Rue Leblanc, 75015 Paris, France
- Paris Descartes University, 12 Rue de l'École de Médecine, 75006 Paris, France
| | - Sharad Agarwal
- Cardiology Department, Royal Papworth Hospital NHS Foundation Trust, Papworth Rd, Cambridge CB2 0AY, UK
| | - Wayne C Levy
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Eloi Marijon
- Paris Cardiovascular Research Center (Inserm U970), Cardiovascular Epidemiology Unit, 56 Rue Leblanc, 75015 Paris, France
- Cardiology Department, European Georges Pompidou Hospital, 20 Rue Leblanc, 75015 Paris, France
- Paris Descartes University, 12 Rue de l'École de Médecine, 75006 Paris, France
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Monkhouse C, Whittaker-Axon S, Chow AWC. Undersensing of ventricular tachycardia in a pacemaker patient: What is the mechanism? Pacing Clin Electrophysiol 2018; 41:553-556. [DOI: 10.1111/pace.13313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 01/12/2018] [Accepted: 02/13/2018] [Indexed: 11/30/2022]
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Barra S, Providência R, Duehmke R, Boveda S, Begley D, Grace A, Narayanan K, Tang A, Marijon E, Agarwal S. Cause-of-death analysis in patients with cardiac resynchronization therapy with or without a defibrillator: a systematic review and proportional meta-analysis. Europace 2017; 20:481-491. [DOI: 10.1093/europace/eux094] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 03/15/2017] [Indexed: 02/05/2023] Open
Affiliation(s)
- Sérgio Barra
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
| | - Rui Providência
- Cardiology Department, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Rudolf Duehmke
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
| | - Serge Boveda
- Cardiology Department, Clinique Pasteur, Toulouse, France
| | - David Begley
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
| | - Andrew Grace
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
| | | | - Anthony Tang
- Cardiology Department, University of Western Ontario, London, Ontario, Canada
| | - Eloi Marijon
- Paris Cardiovascular Research Center, Cardiovascular Epidemiology Unit, Paris, France
- Cardiology Department, European Georges Pompidou Hospital, Paris, France
- Paris Descartes University, Paris, France
| | - Sharad Agarwal
- Cardiology Department, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK
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Barra S, 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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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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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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