Does defibrillation testing influence outcomes after CRT-D implantation? A cause-of-death analysis from the DAI-PP
Tilman Perrin1, Alexis Mechulan1, Serge Boveda2
1CHU La Timone, Marseille, France.
Insights
Defibrillation testing (DT) after CRT-D implantation did not increase sudden cardiac death risk. Patients undergoing DT had lower midterm mortality, reflecting less severe cardiac disease, not improved ICD response.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Limited data exist on defibrillation testing (DT) usefulness in patients with prolonged QRS duration and advanced myocardial disease.
- Cardiac resynchronization therapy with a defibrillator (CRT-D) is implanted for heart failure management.
- Understanding DT's role post-CRT-D implantation is crucial for optimizing patient outcomes.
Purpose of the Study:
- To compare baseline characteristics and outcomes of patients who underwent defibrillation testing (DT+) versus those who did not (DT-) immediately after CRT-D implantation.
- To evaluate the impact of DT on perioperative mortality and long-term survival.
- To determine if DT influences sudden cardiac death rates in this patient population.
Main Methods:
- A retrospective analysis of 1516 patients with ischemic or non-ischemic cardiomyopathy who received a primary prevention CRT-D between 2002 and 2012 across 12 French centers.
- Patients were categorized into DT+ (n=958) and DT- (n=558) groups.
- Comparison of baseline characteristics, perioperative events, and long-term mortality, including sudden cardiac death, between the two groups.
Main Results:
- DT+ patients showed no significant differences in age, LVEF, or heart failure etiology compared to DT- patients.
- DT+ patients were less likely to have atrial fibrillation, renal insufficiency, or advanced NYHA functional class.
- While perioperative deaths occurred in the DT+ group, adjusted long-term mortality was lower in DT+ patients (HR 0.6). ICD-unresponsive sudden deaths were rare and similar between groups.
Conclusions:
- The higher midterm mortality observed in DT- patients is primarily attributed to their more severe cardiac disease, not a higher incidence of ICD-unresponsive sudden death.
- Defibrillation testing immediately after CRT-D implantation is safe and associated with improved long-term survival.
- DT does not appear to increase the risk of sudden cardiac death and may help identify patients with less severe disease.
Background:
Little data address the usefulness of defibrillation testing in patients with prolonged QRS duration, known for more advanced myocardial disease. We aimed to compare baseline characteristics and outcomes between patients who underwent defibrillation testing (DT+) and those who did not (DT-), immediately after the implantation of a cardiac resynchronization therapy with defibrillator (CRT-D).
Methods:
Data from all patients with ischemic or non-ischemic cardiomyopathy implanted in primary prevention with a CRT-D in 12 French centers were considered for analysis (2002-2012).
Results:
Out of the 1516 patients with DT information available, DT was performed in 958(63%) patients. Compared to DT- patients, DT+ patients presented no significant differences in terms of age (65.1±10.8 vs 64.7±10.3years, p=0.45), LVEF (25%[20.0-30.0] vs 25%[20.5-30.0], p=0.30), or etiologies of heart failure (ischemic: 49.6% vs 46.9%, p=0.32). By contrast, DT+ patients were less likely to present atrial fibrillation (25.3% vs 33.4%, p=0.001), renal insufficiency (eGFR<60ml/min in 45.3% vs 51.7%, p=0.04) and NYHA functional class≥III (68.9% vs 77.4%, p=0.0006). All of the three perioperative deaths occurred in the DT+ group and were related to DT itself. After a mean follow-up of 3.1±2.1years, the adjusted incidence of overall mortality was lower among DT+ patients (adjusted HR 0.6, 95%CI 0.4-0.7, p<0.0001). However, ICD-unresponsive sudden deaths remained very rare and no more frequently observed among DT- patients (p=0.41).
Conclusions:
In our cohort, the higher (up to 40%) mortality at midterm among DT- patients is mainly reflecting their more severe cardiac disease, rather than a higher rate of ICD-unresponsive sudden death.
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