Interaction of Left Ventricular Remodeling and Regional Dyssynchrony on Long-Term Prognosis after Cardiac
Bhupendar Tayal1, Peter Sogaard2, Antonia Delgado-Montero3
1Division of Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
Insights
Severe left ventricular (LV) remodeling in heart failure (HF) patients receiving cardiac resynchronization therapy (CRT) is linked to worse outcomes. Less dilated ventricles showed better prognosis and resynchronization potential after CRT.
Area of Science:
- Cardiology
- Heart Failure Research
- Medical Device Technology
Background:
- Left ventricular (LV) remodeling, characterized by chamber dilation, is a known predictor of poor outcomes in heart failure (HF).
- The influence of LV dilation on the effectiveness of cardiac resynchronization therapy (CRT) and its impact on prognosis remains incompletely understood.
Purpose of the Study:
- To investigate the association between LV end-diastolic volume (EDVI) and long-term outcomes in CRT patients.
- To assess the impact of LV dilation on the potential for resynchronization and its relationship with prognosis after CRT.
Main Methods:
- Prospective study of 260 CRT patients (NYHA class II-IV, LVEF ≤ 35%, QRS ≥ 120 ms).
- Quantitative echocardiography assessed LV volumes and mechanical dyssynchrony (radial strain) at baseline and 6-month follow-up.
- Primary outcome: all-cause death or HF hospitalization over 4 years; Secondary outcome: all-cause death.
Main Results:
- Patients with severely dilated LV (EDVI ≥ 90 mL/m²) had significantly worse prognosis for both primary (aHR, 2.20) and secondary (aHR, 1.94) events compared to those with less dilated LV.
- Reduced baseline dyssynchrony was associated with better prognosis (primary: HR, 0.39; secondary: HR, 0.41), with a linear relationship between dyssynchrony reduction and event rates.
- Patients with less dilated LV demonstrated significantly higher rates of dyssynchrony improvement post-CRT (OR, 4.10) compared to those with severe dilation.
Conclusions:
- Severe LV remodeling (EDVI ≥ 90 mL/m²) predicts a poor prognosis in patients undergoing CRT.
- Impaired resynchronization efficacy in severely dilated ventricles likely contributes to the worse outcomes observed after CRT implantation.
Background:
Left ventricular (LV) remodeling in heart failure (HF) manifested by chamber dilatation is associated with worse clinical outcomes. However, the impact of LV dilatation on the association of measures of dyssynchrony with long-term prognosis and resynchronization potential after cardiac resynchronization therapy (CRT) remains unclear.
Methods:
Two hundred sixty CRT patients in New York Heart Association classes II to IV, with ejection fractions ≤ 35% and QRS intervals ≥ 120 msec, were prospectively studied. Quantitative echocardiographic assessment of LV volumes and mechanical dyssynchrony by radial strain was conducted at both baseline and 6-month follow-up. Primary outcome events were predefined as death or HF hospitalization, and secondary outcome events were defined as all-cause death over the 4 years after CRT.
Results:
Patients were divided into two groups using the median of the baseline indexed LV end-diastolic volume (EDVI). Patients with less dilated left ventricles (EDVI < 90 mL/m2) had improved prognosis compared to those with severely dilated left ventricles (EDVI ≥ 90 mL/m2) for both primary (adjusted hazard ratio [HR], 2.20; 95% CI, 1.44-3.38; P < .01) and secondary (adjusted HR, 1.94; 95% CI, 1.21-3.11; P < .01) events. Similarly, reduction in baseline dyssynchrony was associated with good prognosis for both the primary (HR, 0.39; 95% CI, 0.23-0.68; P = .001) and secondary (HR, 0.41; 95% CI, 0.22-0.75; P = .004) events. A linear association was found between each 10% reduction in dyssynchrony and events (P < .01). Notably, patients with less dilated left ventricles had nearly fourfold more frequent improvement in dyssynchrony compared to those with severely dilated left ventricles (odds ratio, 4.10; 95% CI, 1.81-9.28; P < .01). No other baseline prognostic marker was associated with the resynchronization ability of CRT.
Conclusions:
Patients with severe LV remodeling (EDVI ≥ 90 mL/m2) have a poor prognosis following CRT device implantation. This is most likely due to impaired resynchronization efficacy.
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