Long term outcomes in patients with chronic right ventricular pacing upgraded to cardiac resynchronization therapy
John Rickard1, Eiran Z Gorodeski1, Divyang Patel1
1Cleveland Clinic Heart and Vascular Institute, Section of Cardiovascular Medicine Cleveland, Cleveland, Ohio.
Insights
Upgrading patients with systolic heart failure and frequent right ventricular pacing to cardiac resynchronization therapy (CRT) leads to worse long-term outcomes than de novo CRT, despite similar LVEF improvements.
Area of Science:
- Cardiology
- Medical Devices
- Heart Failure Management
Background:
- Frequent right ventricular pacing (RVP) is common in systolic heart failure.
- Upgrading to cardiac resynchronization therapy (CRT) is a frequent practice for these patients.
- Lack of randomized trials necessitates outcome evaluation for CRT upgrades from RVP.
Purpose of the Study:
- To compare long-term outcomes of CRT upgrades from chronic RVP versus de novo CRT implants.
- To evaluate the impact of pre-CRT QRS morphology on outcomes after CRT.
- To assess left ventricular ejection fraction (LVEF) improvement across different patient groups.
Main Methods:
- Retrospective chart review of 1260 patients with LVEF ≤ 35% and QRSd ≥ 120 ms undergoing CRT.
- Comparison of survival free of left ventricular assist device (LVAD) or heart transplant.
- Multivariate Cox regression analysis to identify predictors of outcomes.
- Analysis of LVEF improvement based on pre-CRT QRS morphology (native LBBB, non-LBBB, and chronic RVP).
Main Results:
- 233 out of 1260 patients were upgraded from chronic RVP.
- Upgraded patients showed worse long-term outcomes compared to native LBBB (HR 1.3, P=0.007).
- Outcomes for chronic RVP were similar to non-LBBB patients (HR 0.96).
- LVEF improvement was similar between chronic RVP and LBBB groups, and superior to non-LBBB.
Conclusions:
- Patients with systolic heart failure upgraded to CRT from chronic RVP have inferior long-term outcomes versus native LBBB.
- Long-term outcomes are similar for CRT in chronic RVP, RBBB, and IVCD.
- Despite comparable LVEF gains, RVP upgrade patients face poorer survival.
- CRT upgrade from RVP warrants careful consideration due to adverse long-term prognosis.
Introduction:
In patients with chronic systolic heart failure and frequent right ventricular pacing (RVP), upgrade to cardiac resynchronization therapy (CRT) has become common practice despite a lack of randomized clinical trials. We aimed to evaluate long term outcomes in patients upgraded to CRT from chronic RVP compared with de novo CRT implants.
Methods And Results:
We reviewed medical charts on consecutive patients with a left ventricular ejection fraction (LVEF) ≤ 35% and a QRSd ≥ 120 ms undergoing CRT. Survival free of left ventricular assist device (LVAD) and a heart transplant was compared amongst patients on the basis of pre-CRT QRS morphology. Improvement in LVEF was also compared across groups. A total of 1260 patients met inclusion criteria of whom 233 were upgraded from chronic RVP. Over a mean follow up 6.5 ± 4.0 years there were 821 endpoints (27 LVAD, 30 heart transplants, and 764 deaths). In a multivariate Cox regression model, upgraded patients had worse outcomes (HR 1.3(1.1-1.7) P = .007) compared with those with native LBBB and similar outcomes to patients with non-LBBB(HR 0.96(0.76-1.21) P = .7). The survival curve for chronic RVP parallels native LBBB for approximately 2.5 years before dropping sharply. Patients with chronic RVP derive similar improvements in LVEF compared with those with LBBB and superior improvements compared with those with non-LBBB.
Conclusions:
Despite achieving similar levels of LVEF improvement, patients with systolic heart failure with chronic RVP undergoing upgrade to CRT have inferior long term outcomes compared with patients with native LBBB. Long term outcomes with CRT in patients with chronic RVP, RBBB, and IVCD are similar.
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