Increased mortality and ICD therapies in ischemic versus non-ischemic dilated cardiomyopathy patients with cardiac resynchronization having survived until first device replacement (original) (raw)
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Very long-term survival and late sudden cardiac death in cardiac resynchronization therapy patients
European Heart Journal, 2019
Introduction: 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: 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. Results: Over a mean follow-up of 30 months [interquartile range 10-42 months] beyond the first 5 years, we observed 473 deaths, giving an unadjusted mortality rate of 139 and 94.7 per 1000 patient-year in CRT-P and CRT-D patients, 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 noncardiovascular death. Conclusions: 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 five years after CRT implant. By contrast, SCD represents a very low proportion of late mortality irrespective of the presence of a defibrillator.
European journal of heart failure, 2016
The impact on long-term outcomes of implantable cardioverter defibrillators (ICDs) and biventricular defibrillators for cardiac resynchronization (CRT-D) devices in 'real world' patients with heart failure (HF) needs to be assessed in terms of clinical effectiveness. A registry including consecutive HF patients who underwent a first implant of an ICD (891 patients) or a CRT-D device (709 patients) in 2006-2010 was followed (median 1487 days and 1516 days, respectively), collecting administrative data on survival, all-cause hospitalizations, cardiovascular or HF hospitalizations, and days alive and out of hospital (DAOH). Survival free from death/cardiac transplant was 61.9% and 63.8% at 5 years for ICD and CRT-D patients, respectively. Associated comorbidities (Charlson Comorbidity Index) had a significant impact on death/cardiac transplant, as well as on hospitalizations. The median values of DAOH% were 97.4% for ICD and 97.7% for CRT-D patients, but data were highly skewed...
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.
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.
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.
Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology, 2017
Ventricular tachycardia (VT)/ventricular fibrillation (VF) occurrence after cardiac resynchronization therapy-defibrillator (CRT-D) replacement is unknown; hence, there is no practical guideline to recommend either CRT-D or CRT-pacemaker at the time of device replacement. We observed the 1-year VT/VF occurrence after CRT-D replacement in a subanalysis of the Detect Long-term Complications after ICD Replacement (DECODE) registry. A total of 332 consecutive patients who had undergone CRT-D replacement from 2013 to 2015 were enrolled in 36 Italian centres. The primary endpoint was the number of patients with any appropriate implantable cardioverter-defibrillator (ICD) interventions during 12-month follow-up. The secondary endpoint comprised death from any cause and appropriate ICD interventions. At replacement, 214 (64.5%) patients had a left ventricular ejection fraction ≤ 35% and 138 (41.6%) patients had a secondary prevention indication for ICD. Seventy (21.1%) patients had no longe...
Heart, 2014
Objective Studies have shown beneficial effects of cardiac resynchronisation therapy (CRT) on mortality among patients with heart failure. However the incremental benefits in survival from CRT with a defibrillator (CRT-D) are unclear. The choice of appropriate device remains unanswered. Method This is a single-centre observational study in a tertiary cardiac centre. Patients (n=500) implanted with a CRT device with pacing alone (CRT-P) (n=354) and CRT-D (n=146) were followed for at least 2 years (mean 29 months, SD 14 months). The primary end point was all-cause mortality. Results A total of 116 deaths (23.2%) were recorded: 88 (24.8%) and 28 (19.2%), in the CRT-P and CRT-D groups, respectively. At 1 year there was a trend favouring CRT-D (HR 0.54, 95% CI 0.27 to 1.07, p=0.08) but this was attenuated by the 2nd year and became insignificant at the end of follow-up (HR 0.76, 95% CI 0.50 to 1.170, p=0.21). There was no survival benefit from having an internal cardioverter-defibrillator if patients were deemed non-responders to CRT. 27% of the CRT-P patients with ischaemic cardiomyopathy met indications for potential internal cardioverter-defibrillator implantation for primary prevention. These were older patients with poorer baseline function in comparison with CRT-D patients with devices for primary prevention. Once these differences were adjusted for, there was no difference in outcome between the groups. Conclusions CRT-D did not offer additional survival advantage over CRT-P at longer-term follow-up, as the clinical benefit of a defibrillator attenuated with time. Further work is needed to define which subset of patients benefit from CRT-D.