Cardiac resynchronisation therapy: pacemaker versus internal cardioverter-defibrillator in patients with impaired left ventricular function (original) (raw)
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Europace, 2016
Cardiac resynchronization therapy (CRT) reduces the incidence of sudden cardiac death and the use of appropriate implantable cardioverter-defibrillator (ICD) therapies (AICDTs); however, this antiarrhythmic effect is only observed in certain groups of patients. To gain insight into the effects of CRT on ventricular arrhythmia (VA) burden, we compared the incidence of AICDT use in four groups of patients: patients with ischaemic cardiomyopathy vs. non-ischaemic dilated cardiomyopathy (NIDC) and patients implanted with an ICD vs. CRT-ICD. Methods and results We analysed 689 consecutive patients (mean follow-up 37 + 16 months) included in the Umbrella registry, a multicentre prospective registry including patients implanted with ICD or CRT-ICD devices with remote monitoring capabilities in 48 Spanish Hospitals. The primary outcome was the time to first AICDT. Despite a worse clinical risk profile, NIDC patients receiving a CRT-ICD had a lower cumulative probability of first AICDT use at 2 years compared with patients implanted with an ICD [24.7 vs. 41.6%, hazard ratio (HR): 0.49, P ¼ 0.003]; on the other hand, there were no significant differences in the incidence of first AICDT use at 2 years in ischaemic patients (22.6 vs. 21.9%, P ¼ NS). Multivariate analysis confirmed the association of CRT with lower AICDT rates amongst NIDC patients (Adjusted HR: 0.55, CI 95% 0.35-0.87). Conclusions These data suggest that CRT is associated with significantly lower rates of first AICDT use in NIDC patients, but not in ischaemic patients. This study suggests that ICD patients with NIDC and left bundle branch block experiencing VAs may benefit from an upgrade to CRT-ICD despite being in a good functional class.
Cardiac Electrophysiology Review, 2003
Objective Cardiac resynchronization therapy (CRT) is an important treatment modality for heart failure with reduced ejection fraction and ventricular conduction delay. Considering limited health care budgets in an aging population, adding a defi brillator function to CRT remains a matter of debate. Our aim was to describe the experience of a high-volume Belgian implantation centre with CRT with/without defi brillator (CRT-D/P). Methods and results Consecutive CRT patients (n = 221), implanted between October 2008 and April 2011 in Ziekenhuis Oost-Limburg (Genk), were reviewed. From 209 primo-implantations, 74 CRT-D and 98 CRT-P patients with complete follow-up inside the centre, were analysed. Despite diff erences in baseline characteristics, both groups demonstrated similar reverse left ventricular remodelling, improvement in New York Heart Association functional class and maximal aerobic capacity. During mean follow-up of 18 ± 9 months, 21 patients died and 83 spent a total of 1200 days in hospital. Annual mortality was 8% and equal among the groups. The mode of death diff ered between CRT-D (predominantly pump failure) and CRT-P patients (pump failure, comorbidity and sudden death). The yearly population attributable risk of malignant ventricular arrhythmia was 8.16% in CRT-D and 1.38% in CRT-P patients. Conclusions With current guidelines applied to the Belgian reimbursement criteria and at physicians' discretion, patient selection for CRT-D/ CRT-P was appropriate, with similar reverse remodelling, functional capacity improvement and good clinical outcome in both groups. High-risk patients for malignant ventricular arrhythmia were more likely to receive CRT-D, although the yearly attributable risk remained 1.38% in CRT-P patients. Keywords Cardiac resynchronization therapy-epidemiology-implantable cardioverter/defi brillator-outcome. (EF) and evidence of ventricular conduction delay, who are under optimal pharmacological therapy 1,2. CRT compared with optimal medical treatment reduces all-cause mortality and HF admissions in patients residing in New York Heart Association (NYHA) functional class II-IV, with less clear benefits on sudden cardiac death 3-9. Importantly, by definition, most patients who fit guideline-recommended criteria for CRT also have an indication for an implantable cardioverter/defibrillator (ICD) to prevent sudden cardiac death 10. However, no adequately powered randomized clinical trial has been conducted to prove an additional mortality benefit with a CRT device with defibrillator function (CRT-D) over one without (CRT-P). Moreover, CRT-P might lead to
The American Journal of Cardiology, 2012
Background: Cardiac resynchronization therapy (CRT) is indicated in symptomatic heart failure patients with a wide QRS and low left ventricular ejection fraction. In the absence of defibrillator (CRT-D) sudden death remains major cause of mortality in heart failure. There is paucity of large scale data comparing CRT-D versus CRT-P therapies. The aim of this study is to compare the outcome of heart failure (both ischemic & non ischemic) patients undergoing CRT-P of CRT-D implantation and role of CRT-D in non ischemic cardiomyopathy. Methods: This was a single-center retrospective cohort study of 108 consecutive patients who underwent an implantation of CRT device in Apollo hospital secunderabad, between January 2007 and January 2011. Medical records of patients were reviewed for baseline characteristics and medical history, post-implantation hospital admissions for cardiovascular causes and post-procedural complications. The primary end-point of the study was one year all-cause mortality. The secondary end-points were complication rates and hospital admissions following implantation. Results: There were 72 patients implanted with CRT-P device and 36 patients with CRT-D device. No difference was found between the groups regarding major comorbidities and risk factors except for a higher incidence rate in non ischemic cardiomyopathy (CRT-P). The all-cause 1-year mortality rate was 15% in the CRT-P group and 9.5% in the CRT-D group. After adjustment for multiple confounders, using propensity score, the RR of death was 2.9 (95% CI) in the CRTP group as compared to the CRTD group (pϭ0.036). Conclusion: CRT-D implantation as compared to implantation of CRT-P was associated with lower risk of one year mortality in ischemic cardiomyopathy group with no difference in dilated or non ischemic cardiomyopathy group. Based on this, it seems reasonable to prefer a combination of CRT-P and defibrillator in ischemia driven HF patients. Selection of appropriate defibrillator therapy in patients with non ischemic chronic heart failure is necessary to improve risk stratification and cost effectiveness.
Pacing and Clinical Electrophysiology, 2020
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 pacinginduced cardiomyopathy (PICM) if upgraded to CRT. Methods: 115 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 180.0ms (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=0.0004) and pre-CRT implantation LVEF <20% (HR 5.63; 95%CI 2.19-14.47; p=0.0003), 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=0.62), were independently associated with all-cause mortality.
Background: Cardiac resynchronization therapy (CRT) is an effective treatment option for systolic heart failure, but the benefit of an additional implantable cardioverter-defibrillator (ICD) in elderly patients is not well established. The aim of our study was to evaluate the impact of an additional ICD on survival in elderly CRT recipients. Methods: Patients aged ≥75 years with an indication for CRT and primary preventive ICD therapy, which underwent implantation of either a CRT-pacemaker (CRT-P) or CRT-defibrillator (CRT-D) were included in the study. Patient characteristics, procedural and follow-up data, and subsequent all-cause mortality were analyzed. Results: A total of 775 consecutive patients underwent CRT implantation, whereof 177 patients fulfilled the inclusion criteria. Of these, 80 patients with CRT-P and 97 with CRT-D formed the two study groups. Patients in the CRT-P group were significantly older (82.6 ± 4.5 vs. 77.8 ± 1.9 years, p b 0.001) and more often female (44 vs. 25%; p b 0.001), had a better left ventricular ejection fraction (29.5 ± 5.7 vs. 27.4 ± 6.0%; p = 0.019) and narrower QRS-complex (150 ± 19 vs. 158 ± 18 ms; p = 0.025). During a mean follow-up of 26 ± 19 months, 62 (35%) study patients died, 28 (35%) in the CRT-P and 34 (35%) in the CRT-D group (p = 0.994). The Kaplan-Meier analysis of survival probability showed no significant difference between the two groups (p = 0.562). Conclusion: In our study, an additional ICD had no impact on survival in elderly patients undergoing implantation of a CRT device. Randomized controlled trials have to confirm this finding.
Archives of Medical Science, 2018
Introduction: Cardiac resynchronization therapy combined with an implantable cardioverter defibrillator (CRT-D) is widely applied in heart failure patients. Sufficient data on arrhythmia and defibrillator therapies during long-term follow-up of more than 4 years are lacking and data on mortality are conflicting. We aimed to characterize the occurrence of ventricular arrhythmia, respective defibrillator therapies and mortality for several years following CRT-D implantation or upgrade. Material and methods: Eighty-eight patients with ischemic (ICM) or non-ischemic dilated cardiomyopathy (DCM) and at least one CRT-D replacement were included in this study and analyzed for incidence of non-sustained ventricular tachycardia (NSVT), defibrillator shocks, anti-tachycardia pacing (ATP) and mortality. Results: ICM was the underlying disease in 59%, DCM in 41% of patients. During a mean follow-up of 76.4 ±24.8 months the incidence of appropriate defibrillator therapies (shock or ATP) was 46.6% and was elevated in ICM compared to DCM patients (57.7% vs. 30.6%, respectively; p = 0.017). Kaplan-Meier analysis revealed significantly higher ICD therapy-free survival rates in DCM patients (p = 0.031). Left ventricular ejection fraction, NSVT per year and ICM (vs. DCM) were independent predictors of device intervention. ICM patients showed increased mortality compared to DCM patients, with cumulative all-cause mortality at 9 years of follow-up of 45.4% and 10.6%, respectively. Chronic renal failure, peripheral artery disease and chronic obstructive pulmonary disease were independent predictors of mortality. Conclusions: The clinical course of patients with ICM and DCM treated with CRT-D differs significantly during long-term follow-up, with increased mortality and incidence of ICD therapies in ICM patients.