Clinical Implications of Complete Left-Sided Reverse Remodeling With Cardiac Resynchronization Therapy: A MADIT-CRT
Andrew Mathias1, Arthur J Moss1, Scott McNitt1
1Heart Research Follow-Up Program, Cardiology Division, University of Rochester Medical Center, Rochester, New York.
Insights
Complete left-sided reverse remodeling in cardiac resynchronization therapy with a defibrillator (CRT-D) patients with left bundle branch block (LBBB) significantly lowers heart failure and death risk. This remodeling indicates a better long-term prognosis for CRT-D recipients.
Area of Science:
- Cardiology
- Medical Devices
- Heart Failure Management
Background:
- The clinical significance of complete left-sided reverse remodeling, defined by reductions in left ventricular end-systolic volume (LVESV) and left atrial volume (LAV), following cardiac resynchronization therapy with a defibrillator (CRT-D) remains unclear.
- Left-sided reverse remodeling encompasses changes in both the left ventricle and left atrium, crucial components of cardiac function.
Purpose of the Study:
- To determine the rate of complete left-sided reverse remodeling in patients with left bundle branch block (LBBB) receiving CRT-D.
- To evaluate the predictive value of complete left-sided reverse remodeling on the risk of heart failure (HF) and death in this patient cohort.
- To compare outcomes among patients with complete, discordant, or lesser reverse remodeling.
Main Methods:
- Analysis of 533 CRT-D patients with LBBB from the MADIT-CRT trial.
- Categorization of patients into three groups: complete reverse remodeling (n=212), discordant reverse remodeling (n=115), and lesser reverse remodeling (n=206).
- Primary endpoint: composite of HF or death; secondary endpoints: HF alone and death alone, assessed during long-term follow-up.
Main Results:
- Patients with complete left-sided reverse remodeling demonstrated a significantly lower rate of HF or death compared to those with discordant or lesser reverse remodeling (p < 0.001).
- Multivariate analysis confirmed a reduced risk of HF and death (HR: 0.66; 95% CI: 0.50-0.85; p = 0.002) in the complete reverse remodeling group.
- Similar risk reductions were observed for HF alone and death alone endpoints.
Conclusions:
- Complete left-sided reverse remodeling is achieved by a significant proportion of CRT-D patients with LBBB.
- Complete left-sided reverse remodeling is a strong predictor of favorable long-term outcomes, significantly reducing the risk of heart failure and death.
- Discordant reverse remodeling, observed in over 20% of patients, represents a distinct subgroup with potentially different prognostic implications.
Background:
Clinical implications of complete left-sided reverse remodeling due to cardiac resynchronization therapy with a defibrillator (CRT-D), defined as reduction in both left ventricular end-systolic volume (LVESV) and left atrial volume (LAV), are unknown.
Objectives:
This study aimed to evaluate the rate and predictive value of complete left-sided reverse remodeling on heart failure (HF) and death events in CRT-D patients with left bundle branch block (LBBB) enrolled in MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy).
Methods:
The study population comprised 533 CRT-D patients with LBBB, 212 (40%) with complete left-sided reverse remodeling (above-median change in both LAV and LVESV), 115 (22%) with discordant reverse remodeling (above-median change in only LAV or LVESV), and 206 (38%) with lesser reverse remodeling (below-median LAV and LVESV change). The primary endpoint was HF or death; secondary endpoints included HF alone and death alone during long-term follow-up.
Results:
Patients with complete left-sided reverse remodeling had a significantly lower rate of HF or death than those with discordant reverse remodeling or lesser reverse remodeling (p < 0.001). Multivariate Cox proportional hazard models consistently showed a decreased risk for HF and death in patients with complete reverse remodeling compared with discordant reverse remodeling or lesser reverse remodeling (hazard ratio: 0.66 per each group; 95% CI: 0.50 to 0.85; p = 0.002). This finding was similar for HF alone and death alone.
Conclusions:
In MADIT-CRT, >20% of CRT-D patients exhibited discordant reverse remodeling in the left ventricle and the left atrium. CRT-D patients with LBBB and complete left-sided reverse remodeling had a significantly lower risk of HF and death, HF alone, and death alone during long-term follow-up than patients with discordant or lesser reverse remodeling. (MADIT-CRT: Multicenter Automatic Defibrillator Implantation With Cardiac Resynchronization Therapy [MADIT-CRT]; NCT00180271).
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