Long-term survival following upgrade compared with de novo cardiac resynchronization therapy implantation: a
Walter Richard Schwertner1, Anett Behon1, Eperke Dóra Merkel1
1Heart and Vascular Centre, Semmelweis University, Városmajor 68, H-1122 Budapest, Hungary.
Insights
Cardiac resynchronization therapy (CRT) upgrades in patients with pacemakers or implantable cardioverter-defibrillators showed similar long-term mortality to de novo CRT. However, upgrade patients experienced more lead dysfunction and pocket infections, likely due to higher comorbidity burdens.
Area of Science:
- Cardiology
- Medical Devices
- Heart Failure Management
Background:
- Patients with pacemakers or implantable cardioverter-defibrillators are candidates for cardiac resynchronization therapy (CRT).
- Comprehensive long-term outcome data for CRT in these specific patient groups are limited.
Purpose of the Study:
- To evaluate and compare the long-term outcomes of cardiac resynchronization therapy (CRT) in patients undergoing de novo implantation versus upgrade from a pre-existing pacemaker or implantable cardioverter-defibrillator.
- To identify differences in adverse events and complications between de novo and upgrade CRT patient cohorts.
Main Methods:
- A retrospective registry analysis of 2524 patients with heart failure symptoms, reduced ejection fraction (LVEF ≤35%), and wide QRS duration (≥130ms).
- Patients were categorized into de novo CRT implantation (n=1977) and upgrade from existing devices (n=547).
- Primary outcome: composite of all-cause mortality, heart transplantation (HTX), or left ventricular assist device (LVAD) implantation; secondary outcomes: all-cause mortality and device-related complications.
Main Results:
- Upgrade patients were older, less frequently female, and had more comorbidities than de novo patients.
- The primary composite endpoint occurred in 63% of upgrade patients versus 55% of de novo patients (univariable HR: 1.41; P<0.001).
- After adjustment for covariates and propensity score matching, the difference in the primary endpoint between groups was no longer significant (adjusted HR: 1.12; P=0.402).
- Lead dysfunction (3.1% vs 1%; P<0.001) and pocket infections (3.7% vs 1.8%; P=0.014) were more frequent in the upgrade group.
Conclusions:
- While upgrade patients had a higher unadjusted risk for mortality/HTX/LVAD, this was attributed to their greater comorbidity burden, as the difference became non-significant after statistical adjustment.
- Device-related complications, specifically lead dysfunction and pocket infections, were more prevalent in the upgrade cohort compared to de novo CRT patients.
Aims:
Patients with a pacemaker or implantable cardioverter-defibrillator are often considered for cardiac resynchronization therapy (CRT). However, limited comprehensive data are available regarding their long-term outcomes.
Methods And Results:
Our retrospective registry included 2524 patients [1977 (78%) de novo, 547 (22%) upgrade patients] with mild to severe symptoms, left ventricular ejection fraction ≤35%, and QRS ≥ 130ms. The primary outcome was the composite of all-cause mortality, heart transplantation (HTX), or left ventricular assist device (LVAD) implantation; secondary endpoints were death from any cause and post-procedural complications. In our cohort, upgrade patients were older [71 (65-77) vs. 67 (59-73) years; P < 0.001], were less frequently females (20% vs. 27%; P = 0.002) and had more comorbidities than de novo patients. During the median follow-up time of 3.7 years, 1091 (55%) de novo and 342 (63%) upgrade patients reached the primary endpoint. In univariable analysis, upgrade patients exhibited a higher risk of mortality/HTX/LVAD than the de novo group [hazard ratio (HR): 1.41; 95% confidence interval (CI): 1.23-1.61; P < 0.001]. However, this difference disappeared after adjusting for covariates (adjusted HR: 1.12; 95% CI: 0.86-1.48; P = 0.402), or propensity score matching (propensity score-matched HR: 1.10; 95% CI: 0.95-1.29; P = 0.215). From device-related complications, lead dysfunction (3.1% vs. 1%; P < 0.001) and pocket infections (3.7% vs. 1.8%; P = 0.014) were more frequent in the upgrade group compared to de novo patients.
Conclusion:
In our retrospective analysis, upgrade patients had a higher risk of all-cause mortality than de novo patients, which might be attributable to their more significant comorbidity burden. The occurrence of lead dysfunction and pocket infections was more frequent in the upgrade group.
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