Baseline clinical characteristics of heart failure patients with reduced ejection fraction enrolled in the BUDAPEST-CRT Upgrade trial

The BUDAPEST-CRT Upgrade study is the first prospective, randomized, multicentre clinical trial investigating the outcomes after cardiac resynchronization therapy (CRT) upgrade in heart failure (HF) patients with intermittent or permanent right ventricular pacing (RVP) with wide paced QRS. This report describes the baseline clinical characteristics of the enrolled patients and compares them to cohorts from previous milestone CRT studies.This international multicentre randomized controlled trial investigates 360 patients having a pacemaker (PM) or implantable cardioverter defibrillator (ICD) device for at least six months prior to enrollment, reduced left ventricular ejection fraction (LVEF≤35%), HF symptoms (New York Heart Association functional class II-IVa), wide paced QRS (>150 ms), and ≥20% of RVP burden without having a native left bundle branch block. At enrollment, the mean age of the patients was 73±8 years; 89% were male, 97% of the patients were in NYHA II/III functional class, and 56% had atrial fibrillation. Enrolled patients predominantly had conventional PM devices, with a mean RVP burden of 86%. Thus, this is a patient cohort with advanced HF, low baseline LVEF (25%±7%), high N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels [2231 pg/mL (25th - 75th percentile 1254/4309 pg/mL)], and frequent HF hospitalizations during the preceding 12 months (50%).When compared with prior CRT trial cohorts, the BUDAPEST-CRT Upgrade study includes older patients with a strong male predominance and a high burden of atrial fibrillation and other comorbidities. Moreover, this cohort represents an advanced HF population with low LVEFs, high NT-proBNPs, and frequent previous HF events

Upgrade of right ventricular pacing to cardiac resynchronisation therapy in heart failure : a randomised trial

De novo implanted cardiac resynchronisation therapy with defibrillator (CRT-D) reduces the risk of morbidity and mortality in patients with left bundle branch block, heart failure and reduced ejection fraction (HFrEF). However, among HFrEF patients with right ventricular pacing (RVP), the efficacy of CRT-D upgrade is uncertain.In this multicentre, randomised, controlled trial, 360 symptomatic (New York Heart Association class II-IVa) HFrEF patients with a pacemaker or implantable cardioverter defibrillator (ICD), high RVP burden ≥20%, and a wide, paced QRS complex duration ≥150 ms were randomly assigned to receive CRT-D upgrade (n = 215) or ICD (n = 145) in a 3:2 ratio. The primary outcome was the composite of all-cause mortality, heart failure hospitalisation or <15% reduction of left ventricular end-systolic volume assessed at 12 months. Secondary outcomes included all-cause mortality or heart failure hospitalisation.Over a median follow-up of 12.4 months, the primary outcome occurred in 58/179 (32.4%) in the CRT-D arm vs. 101/128 (78.9%) in the ICD arm [odds ratio 0.11; 95% confidence interval (CI) 0.06-0.19; p < 0.001]. All-cause mortality or heart failure hospitalization occurred in 22/215 (10%) in the CRT-D arm vs. 46/145 (32%) in the ICD arm (hazard ratio 0.27; 95% CI 0.16-0.47; p < 0.001). The incidence of procedure- or device-related complications was similar between the two arms [CRT-D group 25/211 (12.3%) vs. ICD group 11/142 (7.8%)].In pacemaker or ICD patients with significant RVP burden and reduced ejection fraction, upgrade to CRT-D compared to ICD therapy reduced the combined risk of all-cause mortality, heart failure hospitalisation or absence of reverse remodelling

CRT Improves LV Filling Dynamics

Echocardiographic particle imaging velocimetry allows blood flow visualization and characterization of diastolic vortex formation that may play a key role in filling efficiency. We hypothesized that abrupt withdrawal of cardiac resynchronization therapy (CRT) would alter the timing of left ventricular diastolic vortex formation and modify cardiac time intervals. In patients with heart failure (HF) who had chronically implanted CRT devices, the timing of the onset of the diastolic vortex (TDV) from mitral valve opening, transmitral flow, and cardiac time intervals was measured at baseline and after deactivation and reactivation of CRT. Compared with control patients with cardiovascular risk factors but structurally normal hearts, TDV was significantly delayed in patients with HF. Deactivation of CRT resulted in striking delay in TDV due to disorganized flow and reduced flow acceleration, and reactivation reversed these characteristics instantly. In addition, CRT deactivation also prolonged the isovolumic contraction interval, which closely correlated with the changes in the TDV. These data suggest that CRT plays an important role in optimization of left ventricular diastolic filling

Low value of simple echocardiographic indices of ventricular dyssynchrony in predicting the response to cardiac resynchronization therapy.

International audienceAIMS: A recent study suggested that no single echocardiographic index of cardiac dyssynchrony can reliably identify candidates for cardiac resynchronization therapy (CRT). We examined the value of three simple echocardiographic indices for predicting the 6-month clinical and echocardiographic responses to CRT. METHODS AND RESULTS: We analysed data from 75 CRT-D system recipients. Standard echocardiography was used to measure aortic pre-ejection delay (APED), interventricular mechanical delay (IVMD), and delayed activation of the left ventricular (LV) infero-lateral wall (OVERLAP). Clinical responders were defined as patients who had an improved status, based on rehospitalization for heart failure, NYHA class, and peak oxygen consumption. Echocardiographic responders had a > or =10% decrease in LV end-systolic volume. During the study, one patient died and five were lost to follow-up. Of the remaining 69 analysable patients, 50 (72.5%) were classed as clinical responders and 41 (59.4%) as echocardiographic responders to CRT. Before CRT implantation, APED, IVMD, and OVERLAP were similar in responders and non-responders. The value of these indices of dyssynchrony as single or combined predictors of the clinical or echocardiographic response to CRT was low, with sensitivities ranging between 4 and 63%, and specificities between 37 and 100%. CONCLUSION: Simple echocardiographic indices of dyssynchrony were poor predictors of response to CRT