Long-term outcome and mortality predictors in patients with extremely enlarged left ventricle end-diastolic diameter undergoing cardiac resynchronization therapy

Background

Data on efficacy of cardiac resynchronization therapy (CRT) and prognosis of CRT recipients with extremely enlarged left ventricular prior to device implantation are scarce.

Aim

To determine outcome and mortality predictors in patients with heart failure (HF) and extremely increased left ventricle end-diastolic diameter (LVEDD) treated with cardiac resynchronization therapy.

Methods

Study population consisted of 1059 consecutive patients with CRT implanted between 2002 and 2019 in a tertiary care university hospital, in a densely inhabited, urban region of Poland (949 subjects [89.6%] with CRT-D; 110 patients with CRT-P [10.4%]).

Results

The median LVEDD before CRT implantation was 68 mm (56–80). We divided all CRT patients into quartiles as per LVEDD: I <61 mm, II 61–67 mm, III 68–73 mm and IV ≥74 mm. During the median follow-up of 1661 days (10th and 90th percentile: 323–3995) mortality rates for quartiles I–IV were 41.2, 49.6, 55.9 and 68.1%, respectively (P<0.001). The LVEDD ≥74 mm (quartile IV) appeared to be an independent risk factor for death (HR 1.29, 95% CI 1.05–1.6, P=0.02). On multivariable analysis, severe mitral regurgitation (MR; HR 1.54, 95% CI 1.1–2.16, P=0.01) and advanced age (HR 1.02, 95% CI 1.01–1.03, P=0.02) were independent risk factors for death in quartile IV. During observation, mortality rate for quartile IV patients aged >65 years and with severe MR was 90%. Exclusion of subjects with severe MR and aged >65 from quartile IV resulted in similar mortality rate (53.1%) as for patients in lower quartiles.

Conclusions

Mortality rates in CRT recipients with extremely enlarged LVEDD is significantly higher compared to those with LVEDD <74 mm. CRT offer to HF patients with LVEDD ≥74 mm (and in particular those with accompanying severe MR and aged >65 years) should be very carefully assessed and other HF therapies (i.e. left ventricular assist devices) should be considered, as more than 90% of those die within 4 years since CRT implantation.

Funding Acknowledgement

Type of funding sources: None.

Long-term outcome in patients with heart failure after cardiac surgery other than coronary artery bypass grafting treated with cardiac resynchronization therapy

Background

Cardiac resynchronization therapy (CRT) has been proven therapy in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, little is known about the prognosis, and the risk of cardiac device-related infective endocarditis (CDRIE) in patients with HF after cardiac surgery other than coronary artery bypass grafting (CABG) treated with CRT.

Aim

To assess the long-term outcome, mortality predictors, and the risk of CDRIE in patients with HF after cardiac surgery other than CABG treated with CRT.

Methods

The study population consisted of 1059 consecutive patients with CRT implanted between 2002 and 2019 in a tertiary care university hospital in a densely inhabited, urban region of Poland (949 subjects [89.6%] with CRT-D; 110 patients with CRT-P [10.4%]).

Results

The studied population was divided into two groups according to be or not after cardiac surgery other than CABG (n=74 patients [6.9%] vs. n=985 patients [93.1%]). During the median follow-up of 1661 days (10th and 90th percentile: 323–3995), all-cause mortality in patients after cardiac surgery other than CABG did not differ significantly in comparison to other CRT recipients (50% vs. 54.4%, P=0.46). Also, the risk of CDRIE was not statistically significant differ (2.7% vs. 5.7%, P=0.28). On multivariable regression analysis, only older age (HR 1.04, 95% CI 1.01–1.07, P=0.02) was identified as independent predictor of higher mortality in patients after cardiac surgery treated with CRT.

Kaplan-Meier curves of survival of patients after cardiac surgery other than CABG treated with cardiac resynchronization therapy in comparison to other CRT recipients are presented on Picture 1.

Conclusions

The mortality rate in patients after cardiac surgery other than CABG is similar to other subjects treated with CRT and reaches 50% within 4.5 years. The risk of device-related infective endocarditis is not higher than in other patients treated with CRT. Advanced age is an independent mortality predictor in subjects after cardiac surgery other than CABG undergoing CRT.

Funding Acknowledgement

Type of funding sources: None.

Effects of the Atrial fibrillation Better Care (ABC) pathway on outcomes among clinically complex chinese patients with atrial fibrillation with multimorbidity and polypharmacy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with atrial fibrillation (AF) commonly have complex clinical backgrounds. In this ancillary analysis we assessed the adherence to and the effectiveness of the Atrial fibrillation Better Care (ABC) pathway in reducing adverse outcomes in Chinese AF patients with a complex clinical background of multimorbidity and/or polypharmacy.

Methods

The ChiOTEAF registry[1] is a prospective, multicentre nationwide study conducted from October 2014 to December 2018. The primary outcomes of interest were the composite endpoint of all-cause death and thromboembolic (TE) events, as well as individual endpoints of all-cause death, TE events, and major bleeding. ’Multimorbidity’ was defined as the presence of ≥2 co-morbidities, ’polypharmacy’ was defined as the concomitant use of ≥5 medications. The participants were assessed against the ABC pathway criteria: patients qualified for the ‘A’ criterion (Avoid stroke) if they were treated with oral anticoagulants according to their TE risk; ‘B’ criterion (Better symptom control) if they demonstrated optimal symptom control defined as European Heart Rhythm Association score of I/II at baseline; ‘C’ criterion (Cardiovascular risk factor and Comorbidity optimisation) if they received disease-specific treatment(s) according to current guidelines at baseline. Patients were considered as ABC-adherent if they fulfilled all three criteria.

Results

The eligible cohort included 4644 patients with multimorbidity and 2262 patients with polypharmacy (Fig 1.), of whom 56.2% (mean age 74.4±10.2; 42.8% female) and 58.7% (mean age 74.6±10.1; 43.3% female) respectively had available data to assess the ABC pathway utilisation. Adherence to the ABC pathway was associated with lower odds ratio (OR) of the primary composite outcome in the multimorbidy (OR: 0.48; 95% CI: 0.29-0.79) and polypharmacy (OR: 0.39; 95% CI: 0.19-0.78) groups (Table 1.). Adherence to the ABC pathway was associated with a lower risk of all-cause death in multimorbid patients (OR: 0.51; 95% CI: 0.27-0.95) and TE events in patients with polypharmacy (OR: 0.31; 95% CI: 0.10-0.95). In a subgroup of patients with concomitant multimorbidity and polypharmacy the risk of composite outcome (OR: 0.38; 95% CI: 0.18-0.79) and TE events (OR: 0.31; 95% CI: 0.10-0.94) were lower in the ABC-adherent patients. There were no significant differences in the incidence of major bleeding among patients with multimorbidity, polypharmacy or both in the ABC-adherent compared to the non-ABC adherent groups. Health-related quality of life (QoF) was lower in the non-ABC adherent compared to the ABC-adherent patients.

Conclusion

This study shows that adherence to the ABC pathway is associated with improved clinical outcomes and QoF in Chinese AF patients with multimorbidity and/or polypharmacy. There is no evidence to suggest that adhering to the ABC pathway is associated with a higher risk of major bleeding events compared to standard practice.

10-year survival in patients undergoing cardiac resynchronization therapy

Background

Advanced heart failure with reduced ejection fraction (HFrEF) is associated with poor prognosis. Cardiac resynchronization therapy (CRT) is an effective method of treatment for advanced HFrEF to reduce HF hospitalizations and mortality. Nonetheless, very long-term observation of HF patients undergoing CRT implantation is scarce.

Aim

To assess very long-term survival (≥10 years) and predictors of shorter survival (death within 10 years from CRT implantation).

Methods

We screened a large dataset of CRT population from a tertiary care university hospital comprising consecutive HF patients implanted with CRT from 2002 through 2019 to select those who were alive ≥10 years and those who died within 10 years since device implantation. We analyzed various patients' baseline, clinical and procedural characteristics and sought for predictors of mortality within 10 years from CRT implantation.

Results

Of 1059 CRT patients, 143 (13.5%) were alive ≥10 years since CRT implantation. On multivariable regression analysis the independent predictors for all-cause death up to 10 years from CRT implantation were as follows: age, HR 1.02, 95% CI 1.01–1.31; male sex, 1.27, 95% CI 1.01–1.60; primary prevention of sudden cardiac death (SCD), HR 0.72, 95% CI 0.58–0.89; ischemic cardiomyopathy, HR 1.41, 95% CI 1.76–1.70; NYHA class at implantation, HR 1.38, 95% CI 1.17–1.62; baseline left ventricle ejection fraction (EF), HR 0.97, 95% CI 0.96–0.98; severe mitral regurgitation, HR 1.38; 95% CI 1.08–1.75; baseline NT-proBNP concentration, HR 1.00, 95% CI 1.00–1.00; and creatinine level, HR 1.00, 95% CI 1.00–1.01.

Conclusions

In a real-life patient population with CRT only 13.5% survived over 10 years since device implantation. Independent predictors for death within 10 years since CRT implantation were older age, male sex, secondary prevention of SCD, ischemic and more advanced heart failure along with renal impairment.

Funding Acknowledgement

Type of funding sources: None.

The frequency of electrodes replacement in patients undergoing cardiac resynchronizaton therapy during long term follow up

Background

Cardiac resynchronization therapy (CRT) is an effective method of treatment in patients with HF, but as complex device with three electrodes, it is prone to electrode dysfunctions and the need to replace them. However little is known about the frequency of need for leads replacement in subjects undergone CRT in a very long-term follow up.

Aim

To determine the frequency of leads replacement in patients undergoing CRT during long term follow-up.

Methods

Study population consisted of 1059 consecutive patients with CRT implanted between 2002 and 2019 in tertiary care university hospital, in a densely inhabited, urban region of Poland. The data about lead replacement was collected.

Results

During the median follow-up of 1661 days (IQR: 815–2792) for non-infectious reasons (dislocation, dysfunction, fracture etc.) a total of 324 leads in 251 patients (23.7%) were replaced. Median time from CRT implantation to the first lead replacement was 359 days (42–1413). The electrode replacement within first year after CRT implantation was performed in 126 subjects (50.2%), in the rest of patients (49.8%) the leads were replaced after one year of device implantation. In patients with above ten years of follow up (n=143; 13.5%) 67 subjects (46.8%) had one or more lead replacement during follow up.

Patients with electrode replacement during follow-up were younger (63 vs 66 years, P<0.001), more often with nonischemic cardiomyopathy (52.6% vs 41.6%, P=0.002), less often with permanent atrial fibrillation (12.4% vs 24.4%, P<0.001) and had higher left ventricle end-diastolic diameter (68 vs 67 mm, P=0.02). The duration of the first CRT device implantation were longer with higher fluoroscopy time in comparison with patients without lead replacement during follow up (135 vs 120 min, P<0.001 and 20.5 vs 16 min, P<0.001, respectively) and these were an independent predictors of lead replacement during FU (HR 1.002, 95% CI 1.000–1.006, P=0.03 and HR 1.005, 95% CI 1.002–1.008, P<0.001, respectively).

Conclusions

The need for leads replacement due to non-infectious reasons reaches almost 25% of patients with CRT within 4.5 years. Half of the patients have lead replacement within one year after CRT implantation and the other half during long term follow up. The duration of the first procedure (CRT device implantation) is strong predictor of lead replacement during follow up.

Funding Acknowledgement

Type of funding sources: None.