Prognostic implications of invasive hemodynamics during cardiac resynchronization therapy: Stroke work outperforms
Philippe C Wouters1, Alwin Zweerink2, Wouter M van Everdingen3
1Department of Cardiology, UMC Utrecht, Utrecht, the Netherlands.
Insights
Left ventricular stroke work (LVSW) is a better predictor of long-term outcomes and response to cardiac resynchronization therapy (CRT) than the maximum rate of LV pressure rise (LV dP/dtmax). LVSW measurements during CRT implantation can guide patient selection and treatment strategies for improved prognosis.
Area of Science:
- Cardiology
- Cardiovascular Physiology
- Medical Device Technology
Background:
- Invasive hemodynamic monitoring is crucial for assessing acute responses to cardiac resynchronization therapy (CRT).
- Evaluating left ventricular (LV) performance metrics is essential for predicting patient outcomes after CRT implantation.
Purpose of the Study:
- To compare the prognostic value of LV stroke work (LVSW) versus the maximum rate of LV pressure rise (LV dP/dtmax) in CRT patients.
- To determine which hemodynamic parameter best predicts long-term mortality and echocardiographic response following CRT.
Main Methods:
- Prospective study of 82 CRT patients from three academic centers.
- Invasive pressure-volume loop measurements during implantation to assess LV dP/dtmax and LVSW at baseline and during biventricular pacing (BVP).
- Analysis of 8-year all-cause mortality (primary outcome) and echocardiographic response (secondary outcome) using Cox proportional hazards models.
Main Results:
- Higher LVSW during BVP (≥4400 mL∙mm Hg) and increased ΔLVSW% (≥10%) were associated with significantly better survival.
- In multivariate analysis, only ΔLVSW% remained significantly associated with the primary endpoint (HR 0.982 per percentage point, P = .028).
- LVSW during BVP and ΔLVSW% showed significant associations with echocardiographic response, unlike LV dP/dtmax.
Conclusions:
- LV stroke work, not LV dP/dtmax, is consistently associated with long-term prognosis and treatment response after CRT.
- Stroke work is a superior hemodynamic parameter for predicting long-term outcomes in patients undergoing CRT.
Background:
Invasive measurements of left ventricular (LV) hemodynamic performance can evaluate acute response to cardiac resynchronization therapy (CRT).
Objective:
The study sought to determine which metric, maximum rate of LV pressure rise (LV dP/dtmax) or LV stroke work (LVSW), is more strongly associated with long-term prognosis.
Methods:
CRT patients were prospectively included from 3 academic centers. Invasive pressure-volume loop measurements during implantation were performed, and LV dP/dtmax and LVSW were determined at baseline and during biventricular pacing (BVP) as well as their relative increase (%Δ). Hazard ratios (HRs) for the primary outcome of 8-year all-cause mortality were derived using Cox proportional hazards. The secondary endpoint was echocardiographic response, defined as 6-month LV end-systolic volume reduction ≥15%.
Results:
Paired data from 82 patients were analyzed (67% male; age 66 ± 9 years; QRS duration 158 ± 22 ms, median survival time 72 months). Survival was better when LVSW during BVP was ≥4400 mL∙mm Hg (HR 0.21, 95% CI 0.08-0.58, P < .003) or when ΔLVSW% was ≥10% (HR 0.22, 95% CI 0.08-0.65, P = .006). In multivariate analysis, following direct comparison of continuous measures of acute ΔLV dP/dtmax% and ΔLVSW%, only ΔLVSW% remained associated with the primary endpoint (HR 0.982 per percentage point, P = .028). In contrast to LV dP/dtmax (all P > .05), significant associations with echocardiographic response were found for stroke work during BVP (area under the receiver-operating characteristic curve 0.745, P = .001) and ΔLVSW% (area under the receiver-operating characteristic curve 0.803, P < .001).
Conclusion:
Stroke work, but not LV dP/dtmax, is consistently associated with long-term prognosis and response after CRT. Our results therefore favor the use of stroke work as the hemodynamic parameter to predict long-term outcome after CRT.
