Left Ventricular Lead Location and Long-Term Outcomes in Cardiac Resynchronization Therapy Patients
Valentina Kutyifa1, Annamaria Kosztin2, Helmut U Klein3
1University of Rochester Medical Center, Rochester, New York; Semmelweis University, Heart Center, Budapest, Hungary.
Insights
Left ventricular lead placement in cardiac resynchronization therapy defibrillator (CRT-D) patients with left bundle branch block significantly reduces mortality and heart failure events, especially with posterior/lateral placement. Apical lead placement should be avoided.
Area of Science:
- Cardiology
- Medical Devices
- Clinical Trials
Background:
- Limited data exists on the impact of left ventricular (LV) lead positioning on long-term outcomes in cardiac resynchronization therapy with defibrillator (CRT-D) patients.
- Understanding lead location's role is crucial for optimizing CRT-D therapy effectiveness.
Purpose of the Study:
- To evaluate the association between left ventricular (LV) lead location and long-term clinical outcomes in patients participating in the Multicenter Automatic Defibrillator Implantation With Cardiac Resynchronization Therapy (MADIT-CRT) trial.
- To determine if specific LV lead positions correlate with reduced mortality and heart failure events.
Main Methods:
- Classified LV lead locations (apical, anterior, posterior/lateral) in 797 CRT-D patients, including those with left bundle branch block (LBBB) and non-LBBB.
- Assessed all-cause mortality and heart failure (HF) events using Kaplan-Meier and Cox proportional hazards analyses.
- Compared outcomes between CRT-D patients and 505 implantable cardioverter-defibrillator (ICD)-only patients.
Main Results:
- In CRT-D patients with LBBB, posterior/lateral LV lead placement was associated with significantly reduced long-term all-cause mortality (HR: 0.54) and HF events (HR: 0.44) compared to ICD-only therapy.
- Anterior LV lead placement in LBBB patients also reduced HF events (HR: 0.50) but not mortality.
- CRT-D therapy did not improve outcomes in non-LBBB patients, irrespective of LV lead location.
Conclusions:
- For mild heart failure patients with LBBB receiving CRT-D, posterior/lateral and anterior LV lead positions are associated with reduced HF or death events compared to ICD alone.
- The mortality benefit of CRT-D is specifically linked to posterior/lateral LV lead placement.
- Apical LV lead placement should be avoided due to increased early risk of death.
Objectives:
The authors aimed to evaluate the association of left ventricular (LV) lead location and long-term outcomes in MADIT-CRT (Multicenter Automatic Defibrillator Implantation With Cardiac Resynchronization Therapy).
Background:
There is limited data on the association of lead location with long-term clinical outcomes in patients with cardiac resynchronization therapy with defibrillator (CRT-D).
Methods:
The LV lead location was classified in 797 patients with CRT-D, in 569 patients with left bundle branch block (LBBB), in 228 patients with non-LBBB, and in 505 patients with an implantable cardioverter-defibrillator (ICD) only. Leads were classified into apical (n = 83) and non-apical (n = 486); with the non-apical LV leads further categorized into anterior (n = 99) and posterior/lateral (n = 387) within LBBB. All-cause mortality and heart failure (HF) events were assessed using Kaplan-Meier and Cox analyses.
Results:
In CRT-D patients with LBBB and posterior/lateral LV lead location, there was an association with a significant reduction in long-term all-cause mortality (hazard ratio [HR]: 0.54, 95% confidence interval [CI]: 0.37 to 0.79; p = 0.001), and HF events (HR: 0.44, 95% CI: 0.33 to 0.60; p < 0.001) compared to an ICD only, accompanied with better LV reverse remodeling. CRT-D patients with LBBB and an anterior LV lead location were shown to be associated with a significant reduction in HF events compared to an ICD only (anterior HR: 0.50, 95% CI: 0.30 to 0.82; p = 0.006); however, no association with mortality reduction was observed from CRT-D versus an ICD only. CRT-D was not associated with improved outcomes in non-LBBB patients, regardless of LV lead location.
Conclusions:
In mild HF patients with LBBB and an implanted CRT-D, lateral/posterior, and anterior LV lead locations are similarly associated with reduction in the risk of HF or death events compared to ICD alone. Mortality benefit derived from CRT-D is associated only with patients with lateral/posterior LV lead location. An apical LV lead location should be avoided due to the early risk of death whenever possible. (Multicenter Automatic Defibrillator Implantation With Cardiac Resynchronization Therapy [MADIT-CRT], NCT00180271; Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy Post Approval Registry [MADIT-CRT-PAR], NCT01294449; and MADIT-CRT Long-Term International Follow-Up Registry - Europe, NCT02060110).
Related Concept Videos
01:24Cardiac Catheterization III: Left Heart Catheterization
02:24Predicting Reaction Outcomes
01:13Outcomes of Glycolysis
Cellular respiration can occur aerobically (with oxygen) or anaerobically (without oxygen). In the presence of oxygen, cellular respiration starts with glycolysis and continues with pyruvate...
01:05Long-term Depression
01:13Location and Orientation of the Heart
01:21Perceiving Loudness, Pitch, and Location
Place theory, or place coding, suggests that different pitches are heard because various sound waves activate specific locations along the cochlea's basilar membrane. The brain determines the pitch of a sound by...