Should cardiac resynchronization therapy be a rescue therapy for inotrope-dependent patients with advanced heart
Teruhiko Imamura1, Koichiro Kinugawa1, Daisuke Nitta2
1Department of Therapeutic Strategy for Heart Failure, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
Insights
Cardiac resynchronization therapy with defibrillator (CRT-D) offers uncertain benefits for advanced heart failure patients. Inotrope dependence and high BNP levels predict poor outcomes, suggesting left ventricular assist device (LVAD) may be a better option.
Area of Science:
- Cardiology
- Heart Failure Management
Background:
- Off-label use of cardiac resynchronization therapy with defibrillator (CRT-D) is increasing in advanced heart failure (HF) patients.
- The clinical effectiveness of CRT-D in this population remains uncertain.
Purpose of the Study:
- To evaluate the clinical effect of CRT-D in advanced HF patients.
- To identify predictors of cardiac death and stratify survival in patients receiving CRT-D.
Main Methods:
- Retrospective analysis of 84 in-hospital patients (<65 years) with advanced HF undergoing CRT-D.
- Cox regression analysis to identify independent predictors of cardiac death.
- Stratification of 1-year ventricular assist device (VAD)-free survival based on inotrope dependence and B-type natriuretic peptide (BNP) levels.
Main Results:
- Inotrope dependence and elevated BNP (>690 pg/mL) at implantation were independent predictors of 1-year cardiac death (P < 0.05).
- These factors significantly stratified 1-year VAD-free survival across four groups (98% to 17%, P < 0.001).
- No significant difference in actual 1-year survival was observed among the four stratified groups.
Conclusions:
- Patients dependent on inotropes may receive CRT-D as a last resort.
- Left ventricular assist device (LVAD) implantation should be considered over CRT-D in advanced HF patients with poor prognosis.
- CRT-D therapy shows poor prognosis in selected advanced HF patients.
Background:
Although the "off-label usage" of cardiac resynchronization therapy with defibrillator (CRT-D) has spread recently in advanced heart failure (HF) patients in the real-world practice, its clinical effect remained uncertain.
Methods And Results:
A total of 84 in-hospital <65-year old patients with advanced HF undergoing CRT-D were enrolled. Seventeen patients (20%) had been dependent on inotropes at the time of CRT-D implantation, and 17 suffered cardiac death within a year. Both inotrope dependence and elevated plasma levels of B-type natriuretic peptide (BNP) (>690 pg/mL) at the time of CRT-D implantation were independent predictors of cardiac death within a year by Cox regression analyses (P < 0.05 for both). These 2 parameters could significantly stratify 1-year ventricular assist device (VAD)-free survival: inotrope-free low (1) or high BNP (2), or inotrope-dependent low (3) or high BNP groups (4) (98, 77, 57, and 17%, respectively, P < 0.001). In contrast, there were no significant differences in actual 1-year survival among the four groups.
Conclusion:
Patients dependent on inotropes sometimes receive CRT-D therapy as the last treatment resort in clinical practice, but LVAD implantation should be considered instead of CRT-D in advanced HF patients because of their poor prognosis with CRT-D therapy.
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