Left atrial volume and the benefit of cardiac resynchronization therapy in the MADIT-CRT trial
Rafael Kuperstein1, Ilan Goldenberg, Arthur J Moss
1Leviev Heart Center, Sheba Medical Center.
Insights
Left atrial volume (LAV) predicts outcomes in heart failure (HF) patients receiving cardiac resynchronization therapy with a defibrillator (CRT-D). A reduction in LAV after CRT-D implantation independently correlates with improved clinical outcomes.
Area of Science:
- Cardiology
- Medical Devices
- Heart Failure Research
Background:
- Left atrial volume (LAV) is a key indicator of heart failure (HF) severity.
- Cardiac resynchronization therapy with a defibrillator (CRT-D) is a treatment for HF.
- The prognostic value of LAV in CRT-D recipients requires further investigation.
Purpose of the Study:
- To investigate if LAV independently correlates with clinical outcomes in patients receiving CRT-D.
- To assess if LAV can improve risk stratification in this patient population.
- To evaluate the impact of CRT-D on LAV and its relationship with outcomes.
Main Methods:
- Analysis of 1785 patients from the MADIT-CRT study comparing CRT-D with defibrillator-only therapy.
- Dichotomization of LAV at the upper quartile (>52 mL/m2) for risk assessment.
- Multivariable and landmark analyses to evaluate the association between LAV, CRT-D response, and clinical outcomes.
Main Results:
- Higher baseline LAV was independently associated with increased hazard for HF or death (69%) and all-cause mortality (59%).
- CRT-D significantly reduced LAV (-28%) compared to defibrillator-only therapy (-10%).
- Each 1% reduction in LAV post-CRT-D was linked to a 4% decrease in subsequent HF or death risk.
Conclusions:
- Left atrial volume is an independent predictor of clinical outcomes in mildly symptomatic HF patients treated with CRT-D.
- CRT-D therapy induces significant reverse remodeling of the left atrium.
- LAV changes after CRT implantation provide valuable prognostic information, improving risk prediction compared to left ventricular volume changes.
Background:
Left atrial volume (LAV) is an important marker of heart failure (HF) severity. We hypothesized that LAV independently correlates with clinical outcomes in patients who receive cardiac resynchronization therapy with a defibrillator (CRT-D) and can be used for improved risk assessment in this population.
Methods And Results:
The benefit of CRT-D versus defibrillator-only therapy in reducing the risk of HF or death was assessed by LAV (dichotomized at the upper quartile>52 mL/m2) among 1785 patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) study. Landmark analysis was used to evaluate the relationship between LAV response to CRT-D and subsequent clinical outcomes. Multivariable analysis showed that patients with a higher baseline LAV experienced 69% (P<0.001) and 59% (P=0.02) increased hazard for HF or death and for all-cause mortality, respectively, independently of baseline left ventricular volume. CRT-D was associated with a significant reduction in LAV compared with defibrillator-only therapy (-28% versus -10%, respectively; P<0.001). Landmark analysis showed that after CRT-D implantation each 1% reduction in LAV was independently associated with a corresponding 4% reduction in the hazard of subsequent HF or death (P<0.001). The assessment of LAV change after CRT implantation improved prediction of clinical response to the device compared with assessment of the corresponding changes in left ventricular volume.
Conclusions:
LAV is an independent correlate of clinical outcomes in mildly symptomatic HF patients treated with CRT-D. CRT exerts pronounced reverse remodeling effects on the left atrium that independently correlate with improved clinical outcomes after device implantation.
Clinical Trial Registration:
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00180271.
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