Growth differentiation factor-15 predicts mortality and morbidity after cardiac resynchronization therapy

The aim of this study was to determine whether growth differentiation factor-15 (GDF-15) predicts mortality and morbidity after cardiac resynchronization therapy (CRT). Growth differentiation factor-15, a transforming growth factor-beta-related cytokine which is up-regulated in cardiomyocytes via multiple stress pathways, predicts mortality in patients with heart failure treated pharmacologically

What is treatment success in cardiac resynchronization therapy?

Cardiac resynchronization therapy (CRT) is an established treatment for symptomatic patients with heart failure, a prolonged QRS duration, and impaired left ventricular (LV) function. Identification of ‘responders’ and ‘non-responders’ to CRT has attracted considerable attention. The response to CRT can be measured in terms of symptomatic response or clinical outcome, or both. Alternatively, the response to CRT can be measured in terms of changes in surrogate measures of outcome, such as LV volumes, LV ejection fraction, invasive measures of cardiac performance, peak oxygen uptake, and neurohormones. This review explores whether these measures can be used in assessing the symptomatic and prognostic response to CRT. The role of these parameters to the management of individual patients is also discussed

Effects of cardiac resynchronization therapy in patients unselected for mechanical dyssynchrony

BACKGROUND Observational echocardiographic studies have suggested that pre-implant dyssynchrony is required for a response to cardiac resynchronization therapy. Some clinical guidelines on CRT have adopted dyssynchrony as a requirement prior to CRT. AIMS To assess the effects of CRT in patients with heart failure who are unselected for mechanical dyssynchrony. METHODS 248 consecutive patients with heart failure (sinus rhythm, NYHA class III [n=171, 89%]) or IV (n=77, 31%; LVEFor=120 ms) underwent a clinical assessment, including NYHA class, 6-min walking distance and quality of life (Minnesota Living with Heart Failure questionnaire) before and after CRT. Clinical event variables included mortality and hospitalizations for major cardiovascular events and for heart failure. RESULTS At follow-up, NYHA class was reduced from 3.25+/-0.56 to 2.06+/-0.84 (mean+/-SD, por=1 NYHA classes or>or=25% in 6-min walking distance, was 81% (202/248 patients). Over a follow-up period of up to 7.4 years (median 720 days), the annualized total and cardiovascular mortality rates were 11.7% and 9.89%, respectively. CONCLUSIONS In patients undergoing CRT, the improvements in functional capacity and quality of life as well as the event rates expected from landmark trials are achievable by selecting patients on the basis of NYHA class, LVEF and QRS duration alone. The added value of echocardiographic measures of dyssynchrony remains questionable

Cost-Effectiveness Analysis of Quadripolar Versus Bipolar Left Ventricular Leads for Cardiac Resynchronization Defibrillator Therapy in a Large, Multicenter UK Registry

AbstractObjectivesThe objective of this study was to evaluate the cost-effectiveness of quadripolar versus bipolar cardiac resynchronization defibrillator therapy systems.BackgroundQuadripolar left ventricular (LV) leads for cardiac resynchronization therapy reduce phrenic nerve stimulation (PNS) and are associated with reduced mortality compared with bipolar leads.MethodsA total of 606 patients received implants at 3 UK centers (319 Q, 287 B), between 2009 and 2014; mean follow-up was 879 days. Rehospitalization episodes were costed at National Health Service national tariff rates, and EQ-5D utility values were applied to heart failure admissions, acute coronary syndrome events, and mortality data, which were used to estimate quality-adjusted life-year differences over 5 years.ResultsGroups were matched with regard to age and sex. Patients with quadripolar implants had a lower rate of hospitalization than those with bipolar implants (42.6% vs. 55.4%; p = 0.002). This was primarily driven by fewer hospital readmissions for heart failure (51 [16%] vs. 75 [26.1%], respectively, for quadripolar vs. bipolar implants; p = 0.003) and generator replacements (9 [2.8%] vs. 19 [6.6%], respectively; p = 0.03). Hospitalization for suspected acute coronary syndrome, arrhythmia, device explantation, and lead revisions were similar. This lower health-care utilization cost translated into a cumulative 5-year cost saving for patients with quadripolar systems where the acquisition cost was <£932 (US $1,398) compared with bipolar systems. Probabilistic sensitivity analysis results mirrored the deterministic calculations. For the average additional price of £1,200 (US$1,800) over a bipolar system, the incremental cost-effective ratio was £3,692 per quality-adjusted life-year gained ($5,538), far below the usual willingness-to-pay threshold of £20,000 (US$30,000).ConclusionsIn a UK health-care 5-year time horizon, the additional purchase price of quadripolar cardiac resynchronization defibrillator therapy systems is largely offset by lower subsequent event costs up to 5 years after implantation, which makes this technology highly cost-effective compared with bipolar systems

Long-term effects of upgrading from right ventricular pacing to cardiac resynchronization therapy in patients with heart failure.

In patients with heart failure who are RV-paced, upgrading to CRT is associated with a similar long-term risk of mortality and morbidity to patients undergoing de novo CRT. Symptomatic improvements and degree of reverse remodelling are also comparable