Background: In just a few years, cardiac resynchronization therapy (CRT) has emerged as a key player in the treatment of advanced heart failure (HF). However, approximately 30% of patients with CRT device implantation do not achieve a favorable response. The purpose of the present study was to identify clinical, electrocardiographic, and echocardiographic predictors of a positive response to biventricular pacing in patients with advanced decompensated HF.
Methods: This prospective, observational study involved 42 consecutive patients admitted in emergency settings in our clinic with HF in New York Heart Association (NYHA) functional class III/IV, with QRS duration ≥120 ms and left ventricle ejection fraction (LVEF) ≤35%, who underwent cardiac resynchronization therapy (CRT-P or CRT-D) between January 2010 and July 2014. Statistical analysis was performed using IBM SPSS statistical software.
Results: The clinical response (improvement in NYHA class) was recorded in 6 patients (14.3%), while echocardiographic response (change in ejection fraction and/or in endsystolic or end-diastolic volumes) was recorded in 10 patients (23.8%). The most frequently observed type of response to CRT was the double (clinical plus echocardiographic) response, recorded in 23 out of 42 patients (54.8%). ROC analysis identified the absence of chronic renal disease and the duration from onset of symptoms to CRT implantation as good predictors for clinical improvement after CRT (AUC = 0.625, 95% CI: 0.400–0.850 for absence of renal failure and AUC = 0.516, 95% CI: 0.369–0.853 for symptoms duration). However, gender, age, duration from symptom onset, and comorbidities were not good predictors for the echocardiographic response (AUC <0.600).
Conclusions: CRT represents an important therapeutic option for selected patents with advanced decompensated HF and prolonged QRS interval; however, only some of the commonly used criteria can predict a favorable outcome in patients undergoing CRT.
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1. Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: the Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J. 2013;34:2281-2329. doi:10.1093/eurheartj/eht150.
2. Ponikowski P, Voors AA, Anker SD, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;18:891-975. doi:10.1002/ejhf.592.
3. Bui AL, Horwich TB, Fonarow GC. Epidemiology and risk profile of heart failure. Nat Rev Cardiol. 2011;8:30-41. doi: 10.1038/nrcardio.2010.165.
4. Arsenescu Georgescu C, Gaitan A, Stătescu C. On Cardiac Resynchronization Therapy. Romanian Journal of Artistic Creativity. 2014;2:7-13.
5. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549. doi: 10.1056/NEJMoa050496.
6. Rinkuniene D, Bucynte S, Abrasmavicius S, et al. Predictors of positive response to cardiac resynchronization therapy. BMC Cardiovascular Disorders. 2014;14:55. doi: 10.1186/1471-2261-14-55.
7. Thibault B, Harel F, Ducharme A, et al. Cardiac resynchronization therapy in patients with heart failure and a QRS complex <120 milliseconds: the Evaluation of Resynchronization Therapy for Heart Failure (LESSEREARTH) trial. Circulation. 2013;127:873-881. doi: 10.1161/CIRCULATIONAHA.112.001239.
8. Sipahi I, Carrigan TP, Rowland DY, Stambler BS, Fang JC. Impact of QRS duration on clinical event reduction with cardiac resynchronization therapy: meta-analysis of randomized controlled trials. Arch Intern Med. 2011;171:1454-1462. doi: 10.1001/archinternmed.2011.247.
9. Cheng A, Landman SR, Stadler RW. Reasons for loss of cardiac resynchronization therapy pacing insights from 32844 patients. Circulation: Arrhythmia and Electrophysiology. 2012;5:884-888. doi: 10.1161/CIRCEP.112.973776
10. Florea M, Arsenescu Georgescu C. Atrial Fibrilation from Phisyopathology to Ablation. Iași: Editura Grigore T. Popa University of Medicine, 2013; p. 264-305.
11. Santangeli P, Di Biase L, Pelargonio G, et al. Cardiac resynchronization therapy in patients with mild heart failure: a systematic review and meta-analysis. J Interv Card Electrophysiol. 2011;32:125-135. doi: 10.1007/s10840-011-9584-y.
12. Arsenescu Georgescu C, Stătescu C, Macovei L. Interventional Cardiology in elderly. In: News in geriatrics. Iași: Editura Grigore T. Popa University of Medicine, 2011; p. 125-136.
13. Linde C, Leclercq C, Rex S, et al. Long-term benefits of biventricular pacing in congestive heart failure: results from the MUltisite STimulation in cardiomyopathy (MUSTIC) study. J Am Coll Cardiol. 2002;40:111-118.
14. Pires LA, Abraham WT, Young JB, et al. Clinical predictors and timing of New York Heart Association class improvement with cardiac resynchronization therapy in patients with advanced chronic heart failure: results from the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) and Multicenter InSync ICD Randomized Clinical Evaluation (MIRACLEICD) trials. Am Heart J. 2006;151:837-843. doi: 10.1016/j.ahj.2005.06.024.
15. Anand IS, Carson P, Galle E, et al. Cardiac resynchronization therapy reduces the risk of hospitalizations in patients with advanced heart failure: results from the Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure (COMPANION) trial. Circulation. 2009;119:969-977. doi: 10.1161/CIRCULATIONAHA.108.793273.
16. Cleland JGF, Daubert JC, Erdmann E, et al. The Effect of Cardiac Resynchronization on Morbidity and Mortality in Heart Failure. N Engl J Med. 2005;352:1539-1549. doi: 10.1056/NEJMoa050496.
17. Stătescu C, Arsenescu Georgescu C. The prognosis of patients with cardiac pacemaker by pacing site. In: News in geriatrics. Iași: Editura Grigore T. Popa University of Medicine, 2011; p. 143-152.
19. Luderitz B. We have come a long way with device therapy: historical perspective on antiarythmic electrotherapy. J Cardiovasc Electrophysiol. 2002;13(1 Suppl):S2-8.
20. Garcia Seara J, Martinez-Saude JL, Cid B, et al. Influence of the Preimplantation QRS Axis on Responses to Cardiac Resynchronization Therapy. Rev Esp. Cardiol. 2008;61:1245-1255. doi: 10.1016/S1885-5857(09)60051-7.
21. Teh AW, Medi C, Rosso R, Lee G, Gurvitch R, Mond HG. Pacing from the right septum is there a danger to the coronary arteries? Pacing Clin Electrophysiol. 2009;32:894-897. doi: 10.1111/j.1540-8159.2009.02405.x.
22. Thibault B, Ducharme A, Harel F, et al. Left ventricular versus simultaneous biventricular pacing in patients with heart failure and a QRS complex >120ms. Circulation. 2011;124:2874-2881. doi: 10.1161/CIRCULATIONAHA.111.032904.
23. Stătescu C, Arsenescu Georgescu C. Pacing Site – From Theory to Practice. In: Kibos AS et al., Cardiac Arrhythmias. London: Springer, 2014; p. 605-609.