van der Wall, E. E.

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E. E. van der Wall

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Cardiac resynchronisation improves survival
in mild heart failure!
E. E. van der Wall
Published online: 27 January 2011
# The Author(s) 2011. This article is published with open access at Springerlink.com
Several studies have already established the superiority of
cardiac resynchronisation therapy (CRT)-defibrillator (D)
over implantable cardioverter-defibrillator (ICD) alone in
patients with severely symptomatic chronic heart failure
(New York Heart Association (NYHA) class III/IV), left
ventricular (LV) systolic dysfunction, and a wide QRS
complex. Synchronous pacing of opposing LV walls in
malfunctioning asynchronously contracting LV regions
creates resynchronisation with restoration of LV motion
dynamics. In the Multicenter Automatic Defibrillator
Implantation Trial-CRT (MADIT-CRT) study, a reduction
in mortality or hospitalisation for congestive heart failure
with CRT-D was observed compared with ICD. However,
no difference in mortality was noted between the two
groups. The COMPANION study established the superi-
ority of CRT-D over optimal medical management alone
in reducing all-cause mortality patients with NYHA class
III/IV symptoms. While improvements in LV dimensions
with CRT in patients with mildly asymptomatic heart
failure were observed in the MIRACLE ICD-II and
REVERSE trials, there were no significant differences in
clinical endpoints in these studies. The MADIT-CRT
study showed a significant reduction in the composite
endpoint of mortality or heart failure events in similar
patients with NYHA class I/II symptoms over a mean
follow-up of 2 years. However, no significant difference
in all-cause mortality between the two groups was noted.
At the November 2010 meeting of the AHA in Chicago,
the results of the Resynchronization–Defibrillation for
Ambulatory Heart Failure Trial (RAFT) study were
presented by Dr. Anthony Tang, Ottawa, Canada and
recently published in the New England Journal of Medicine
[1]. In the RAFT study, the safety and efficacy of CRT-D
compared with ICD alone were investigated in patients with
NYHA class II/III, LV systolic dysfunction (left ventricular
ejection fraction (LVEF), ≤30%), and a wide QRS complex.
All patients had been scheduled for ICD implantation for
primary or secondary prevention of sudden cardiac death.
The primary endpoint of the study was all-cause mortality
or hospitalisation for worsening congestive heart failure. A
total of 1798 patients (mean age, 66 years; 17% women)
were randomised to either CRT-D (n=894) or to ICD alone
(n=904). Two thirds of the patients had ischaemic
cardiomyopathy. The majority of patients (80%) had
NYHA class II and a mean LVEF of 22%. Permanent
atrial fibrillation or flutter was seen in 13% of the patients.
Patients were optimally treated, and the mean duration of
follow-up was 40 months. Medtronic transvenous devices
and leads were used in both groups. The LV lead was
positioned in the lateral or posterolateral walls. Programming
was set to minimise right ventricular pacing in the ICD arm
and to maximise biventricular pacing in the CRT-D arm. The
mean nonpaced QRS complex was 158 ms, and the mean
paced QRS complex was 208 ms. A left bundle branch block
(LBBB) pattern was noted in 72% of the patients. An LV lead
was successfully placed in 95% of the patients in the CRT-D
arm, and there was a 10% crossover to the CRT-D arm from
the ICD arm.
The main results of the RAFT study showed that the
primary endpoint of all-cause mortality or hospitalisation
for heart failure was significantly reduced in the CRT-D
arm compared with ICD (40.3% versus 33.2%, p<0.001).
All-cause mortality was also significantly decreased (26.1%
versus 20.8%, p=0.003). This corresponded to a number
needed to treat of 14 patients for 5 years to prevent one
E. E. van der Wall (*)
Department of Cardiology, P 28,
Leiden University Medical Center,
PO Box 9600, Leiden, the Netherlands
e-mail: e.e.van_der_wall@lumc.nl
Neth Heart J (2011) 19:103–104
DOI 10.1007/s12471-011-0080-x
death with CRT-D compared with ICD alone. Hospital-
isation for congestive heart failure was similarly reduced
(26.1% versus 19.5%, p<0.001). Results for the primary
and secondary endpoints were similar for NYHA class II or
III patients. Subgroup analysis showed a greater benefit
with CRT-D in patients with wider QRS complex at
baseline (≥150 ms for native and ≥200 ms for paced).
LBBB morphology also seemed to derive greater benefit,
and there was a trend towards greater efficacy in women.
However, device-related hospitalisations were higher in the
CRT-D arm (20.0% versus 12.2%, p<0.001). Device- or
implantation-related complications were significantly
higher in the CRT-D arm, as compared with the ICD arm
at 30 days (13.3% versus 6.8%, p<0.001). The complica-
tions included haemothorax or pneumothorax, device-
pocket haematomas, device-pocket infections, and lead
displacement requiring intervention.
The results of the RAFT study clearly indicate that in
patients with NYHA class II/III (80% class II!), LV systolic
dysfunction (LVEF, <30%), and a wide QRS complex, the
addition of CRT to an ICD reduces all-cause mortality and
hospitalisation for congestive heart failure by about 25%.
On subgroup analysis, the results of the primary endpoint
seemed to be more outspoken in patients with a wider QRS
complex at baseline and those with LBBB morphology.
There was a significant increase (twofold!) in the risk of
device- or procedure-related complications at 30 days in the
CRT-D arm, including a higher risk of hospitalisation for
device-related causes. The higher complication rates in the
RAFT trial are similar to those noted by other CRT-D trials,
and careful attention to complications is therefore essential.
Further studies are needed to identify optimal LV lead
placement for maximal benefit and the cost-effectiveness of
extending CRT-D to mildly symptomatic patients. In an
accompanying editorial, Dr. Arthur Moss (Rochester, NY,
USA) stated, ‘we can say that recent findings documenting
the use of CRT in preventing heart failure in minimally
symptomatic patients are breathtaking’ [2].
Open Access This article is distributed under the terms of the
Creative Commons Attribution Noncommercial License which per-
mits any noncommercial use, distribution, and reproduction in any
medium, provided the original author(s) and source are credited.
References
1. Tang AS, Wells GA, Talajic M, et al. Cardiac-resynchronization
therapy for mild-to-moderate heart failure. N Engl J Med.
2010;363:2385–95.
2. Moss AJ. Preventing heart failure and improving survival [editorial].
N Engl J Med. 2010;363:2456–7.
104 Neth Heart J (2011) 19:103–104


Cardiac resynchronisation improves survival in mild heart failure!

Cardiac-resynchronization therapy for mild-to-moderate heart failure.

Preventing heart failure and improving survival [editorial].

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Cardiac resynchronisation improves survival in mild heart failure!

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