Up to one third of patients with biventricular (BiV) cardiac resynchronization therapy (CRT) are non-responders.1 § Greater clinical response to CRT has been shown in patients given TriV CRT compared to BiV CRT as de novo device therapy. 2 This abstract investigates if upgrade to TriV CRT in non-responders to BiV CRT will improve long-term clinical outcom

Man, Sharon Hw

Mohamed, Jeilan

Ng, G. André

Siddiqui, Shoaib

English

eCommons@AKU

eCommons@AKUInternal Medicine, East Africa Medical College, East AfricaAugust 2015Does upgrade to tri-ventricular pacemaker improvelong-term clinical response in non-responders tobiventricular cardiac resynchronization therapy?Sharon Hw ManUniversity of LeicesterJeilan MohamedAga Khan University, jeilan.mohamed@aku.eduShoaib SiddiquiUniversity of LeicesterG. André NgUniversity of LeicesterFollow this and additional works at: http://ecommons.aku.edu/eastafrica_fhs_mc_intern_medPart of the Internal Medicine CommonsRecommended CitationMan, S. H., Mohamed, J., Siddiqui, S., Ng, G. A. (2015). Does upgrade to tri-ventricular pacemaker improve long-term clinicalresponse in non-responders to biventricular cardiac resynchronization therapy?. European Heart Journal, 36(56).Available at: http://ecommons.aku.edu/eastafrica_fhs_mc_intern_med/65Results §  20 patients were recruited between July 2009 and August 2010 (13 received upgrade to TriV CRT and 7 did not receive upgrade of their biventricular CRT).  §  Baseline characteristics (Table 1) were similar between the two groups except for the Minnesota Living with Heart Failure score (Trivent 62.0±25.0 vs Control 33.0±14.5, p=0.01). §  At 5 years, fewer patients in the upgrade to TriV group had worsened clinical response compared to the no upgrade group (38.5% vs 85.7%, p=0.04). §  At 5 years, the cumulative probability of survival was higher in the Upgrade to TriV group vs no upgrade group (Kaplan-Meier Method, Log-rank test, p=0.021). §  No difference was found in percentage improvement in LVEF or percentage reduction in LVESV between the 2 groups on echocardiography during follow up (no upgrade group: 19.0±21.2 months vs upgrade to TriV group: 25±17.9 months; p=0.55). §  1 wound infection, 2 failures to upgrade and 1 lead displacement were observed in the upgrade to TriV group.         Does upgrade to tri-ventricular pacemaker improve long-term clinical response in non-responders to biventricular cardiac resynchronization therapy?  Man SH, Jeilan M, Siddiqui S, Chu GS, Chin SH, Varanasi SS, Nicolson WB, Chin D, Ng GA  Department of Cardiovascular Sciences, University of Leicester, UK; NIHR Leicester Cardiovascular Biomedical Research Unit, Leicester, UK University Hospitals of Leicester NHS Trust, Leicester, UK Conclusion  §  Upgrade to tri-ventricular CRT in non-responders to biventricular CRT may potentially improve clinical response to CRT and long-term survival. §  The rate of procedural complications may reflect the risks associated with a complex upgrade procedure.  §  Mechanism of survival benefit from upgrade to tri-ventricular CRT is not explained by LV ejection fraction or LV end systolic volume.  §  These findings warrant further evaluation in a large randomized control trial.  SH Man is supported by a Boston Scientific Research Fellowship.  Purpose §  Up to one third of patients with biventricular (BiV) cardiac resynchronization therapy (CRT) are non-responders.1  §  Greater clinical response to CRT has been shown in patients given TriV CRT compared to BiV CRT as de novo device therapy. 2 This abstract investigates if upgrade to TriV CRT in non-responders to BiV CRT will improve long-term clinical outcome. Table 1. Baseline characteristics of non-responders to biventricular CRT: upgrade to TriV CRT vs no upgrade group. Continuous data expressed as mean ± SD or median and interquartile range for non-parametric data. *p<0.05.  References 1. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. The New England Journal of Medicine. 2004; 350 (21): 2140-50. 2. Lenarczyk R. et al. Mid-term outcomes of triple-site vs. conventional cardiac resynchronization therapy: A preliminary study. Int J Cardiol, 2008.  Methods §  Prospective randomized controlled study of non-responders to optimized, biventricualr CRT-pacemakers or CRT-defibrillators (at least 6 months of biventricular CRT) with New York Heart Association (NYHA) class III symptoms and left ventricular ejection fraction of ≤35%. §  The study conformed to the Declaration of Helsinki of the World Medical Association.  §  Participants were randomized (2:1) to the upgrade to TriV CRT group or no upgrade group.  §  Primary outcome was clinical response to CRT. Each patient was assessed for the worst outcome among the following categories of worsened clinical response: death from any cause, hospitalisation for heart failure, worsening of symptoms perceived by patients and worsening of NYHA class perceived by health professionals. Subjects were included only in one subcategory.  §  Secondary outcomes were all-cause mortality and procedural complications. LV ejection fraction (LVEF) and LV end systolic volume (LVESV) were compared between the 2 groups on the last available echocardiogram during follow up.  §  Censor date was on 13th January 2015. Variable	   No	  upgrade	  	  (n=7)	  Upgrade	  to	  TriV	  CRT	  (n=13)	  P-­‐value	  (2-­‐tailed)	  Age	  (years)	  	   70.4±9.3	   64.5±11.9	   0.27	  Gender	  (male)	  (%)	   5	  (71.4)	   10	  (76.9)	   0.79	  	  Time	  since	  BiV	  CRT	  (months)	   21	  (IQ	  12-­‐32)	   18	  (IQ	  13-­‐45.5)	   0.70	  Ischaemic	  heart	  failure	  (%)	   4	  (57.1)	   8	  (61.5)	   0.85	  NYHA:	  Class	  III	  (%)	   7	  (100)	   13	  (100)	   1.0	  Atrial	  arrhythmias	  (%)	   3	  (42.9)	   1	  (7.7)	   0.06	  Intrinsic	  PR	  or	  AR	  interval	  (ms)	   250.0±26.9	   180±60	   0.09	  BiV	  QRS	  duraOon	  (ms)	  Intrinsic	  QRS	  duraOon	  (ms)	  158.2±24.0	  154.8±16.8	  153.5±14.5	  148.4±23.6	  0.61	  0.60	  Minnesota	  Living	  with	  Heart	  Failure	  score	   33.0±14.5	   62±25.0	   *0.01	  Heart	  failure	  medicaOon	  (%):	  -­‐Beta-­‐blocker	  -­‐ACEi	  or	  ARB	  -­‐Spironolactone	  -­‐DiureOcs	  	  5	  (71.4)	  6	  (85.7)	  3	  (42.9)	  6	  (85.7)	  	  11	  (84.6)	  13	  (100)	  8	  (61.5)	  13	  (100)	  0.48	  0.16	  0.42	  0.16	  Percentage	  BiV	  pacing	  (%)	   99	  (IQ94-­‐99)	   99.5	  (IQ94.8-­‐100)	   0.34	  Old	  LV	  lead	  in	  posterolateral	  or	  lateral	  CS	  branch	  (%)	   3	  (42.9)	   7	  (53.8)	   0.60	  LVEF	  (%)	   26.8±5.6	   27.1±6.2	   0.95	  LVESV	  (ml)	   125.1±60.0	   128.9±43.4	   0.91	  *p=0.043 P=0.87 Fig. 1. Four patients in the upgrade to TriV CRT group underwent non-contact mapping of the left ventricle (LV) with the EnSite 3000 Array catheter to study the LV activation time from BiV and TriV pacing in different CS branches prior to the upgrade. Fig. 1 A to 1D were obtained from the same patient. Fig. 1A: CXR prior to upgrade of BiV CRT. Fig. 1B: CS venogram showing the anteroseptal vein (yellow arrow). Fig. 1C: Fluoroscopy image showing the Ensite 3000 Array catheter for non-contact mapping of the LV (green arrow) and the pacing wire in a new site in the anteroseptal CS branch (blue arrow). Fig. 1D: CXR after upgrade of BiV to TriV CRT.  A B C D Fig. 2. Percentage improvement in LVEF on echocardiography at follow up in the no upgrade of BiV group Vs upgrade to TriV CRT group,  Fig. 3. Percentage reduction in LV end systolic volume (LVESV) on echocardiography at follow up in the no upgrade of BiV group Vs upgrade to TriV CRT group,  Fig. 5. Clinical response to CRT at 5 years in non-responders to CRT: upgrade to TriV CRT vs no upgrade. *p<0.05 Chi-squared test.  P=0.88 Fig. 4. Cumulative probability of survival at 5 years in non-responders to biventricular CRT: upgrade to tri-ventricular CRT (TRIVENT) group vs no upgrade (Control). Kaplan-Meier Method, Log-rank test, *p<0.05. View publication stats

Does upgrade to tri-ventricular pacemaker improve long-term clinical response in non-responders to biventricular cardiac resynchronization therapy?

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Does upgrade to tri-ventricular pacemaker improve long-term clinical response in non-responders to biventricular cardiac resynchronization therapy?

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