The short-term and long-term effects of cardiac resynchronization therapy in heart failure patients
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Abstract:
Objective
To assess short-term and long-term effects of cardiac resynchronization therapy (CRT) in heart failure patients.
Methods
We continuously assessed forty-five end-stage heart failure patients. NYHA grade, left ventricular diastolic diameter (LVED), left ventricular ejection fraction (LVEF) and B-type natriuretic peptides (BNP) before cardiac resynchronization therapy and at six months, one year, two years after cardiac resynchronization therapy were evaluated.
Results
Compared to the results before cardiac resynchronization, six months, one year and two years after CRT, NYHA grade, LVEF, LVED, BNP improved significantly (all P 0.05).
Conclusions
CRT could improve the short-term and long-term myocardial function of hear failure patients.
Key words:
Cardiac resynchronization therapy; Myocardial function; B-type natriuretic peptidesProlongation
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C urrent guidelines recommend cardiac resynchronization therapy (CRT), previously known as biventricular pacing, in patients with left ventricular (LV) systolic dysfunction (ejection fraction [EF] Յ35%), QRS prolongation (Ն120 ms), and New York Heart Association (NYHA) class III or IV heart failure (HF). 1 These recommendations come after multiple prospective, randomized trials demonstrated the benefits of CRT in advanced HF that included Ͼ6000 subjects.These initial trials targeted secondary prevention in the highest-risk cohorts, which was similar to the development of many other cardiovascular therapies.Such examples include implantable cardioverter-defibrillator (ICD) therapy initially used only for cardiac arrest survivors or lipidlowering therapy restricted to use after myocardial infarction.Today a majority of patients receive these therapies as primary prevention.Thus, it is logical and not surprising that a therapy as successful as CRT would be evaluated in subjects with mild HF.][4][5] Taken together, these trials randomized 2430 subjects with NYHA class I or II HF to CRT or to no CRT.The results show beneficial effects of CRT very similar to those observed for severe HF cohorts.Specifically, this therapy improves functional status, reduces HF hospitalizations, and promotes reverse remodeling.The results from REVERSE and MADIT-CRT provide strong, new support to expand the use of CRT to all patients with HF and a wide QRS.
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BackgroundThe benefit of cardiac resynchronization therapy (CRT) among patients with mild heart failure (HF), reduced left ventricular (LV) function and wide QRS is well established. We studied the long-term stability of CRT.
Ventricular remodeling
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Objective:To observe the clinical efficacy of cardiac resynchronization(CRT)pacemaker on dilated cardiomyopathy(DCM)complicated with congestive heart failure(CHF).Methods:CRT pacemakers were implanted in 10 patients with NYHA class Ⅲ～Ⅳ and mean QRS duration ≥130 ms.Left ventricular systolic and diastolic functions were assessed before and one year after the procedure with echocardiography.Results:After implantation of CRT pacemakers,NYHA functional class and 6MHW were significantly improved.Left ventricular ejection fraction(LVEF)and diastolic filling were increased.QRS duration was shortened.Conclusion:CRT pacemaker has a significant beneficial effect on patients with dilated cardiomyopathy complicated with CHF.
Dilated Cardiomyopathy
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Sarcoidosis with cardiac involvement is a rare pathological condition, and therefore cardiac resynchronization therapy (CRT) for patients with cardiac sarcoidosis is even further rare. We aimed to clarify the clinical features of patients with cardiac sarcoidosis who received CRT.We retrospectively reviewed the clinical data on CRT at three cardiovascular centres to detect cardiac sarcoidosis patients. We identified 18 (8.9%) patients with cardiac sarcoidosis who met the inclusion criteria out of 202 with systolic heart failure who received CRT based on the guidelines. The majority of the patients were female [15 (83.3%)] and underwent an upgrade from a pacemaker or implantable cardioverter defibrillator [13 (72.2%)]. We found 1 (5.6%) cardiovascular death during the follow-up period (mean ± SD, 4.7 ± 3.0 years). Seven (38.9%) patients had a composite outcome of cardiovascular death or hospitalization from worsening heart failure within 5 years after the CRT. Twelve (66.7%) patients had a history of sustained ventricular arrhythmias or those occurring after the CRT. Among the overall patients, no significant improvement was found in either the end-systolic volume or left ventricular ejection fraction (LVEF) 6 months after the CRT. A worsening LVEF was, however, more likely to be seen in 5 (27.8%) patients with ventricular arrhythmias after the CRT than in those without (P = 0.04). An improved clinical composite score was seen in 10 (55.6%) patients.Cardiac sarcoidosis patients receiving CRT may have poor LV reverse remodelling and a high incidence of ventricular arrhythmias.
Cardiac sarcoidosis
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Vascular surgery
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Cardiac resynchronization therapy (CRT) is a beneficial strategy to improve severe cardiac dysfunction in patients with congestive heart failure (CHF). The improvement of endothelial function in CHF patients treated with CRT is reflected in the mortality risk reduction. However the precise mechanisms of the relationship between CRT and vascular endothelial function have not been well discussed.Twenty-two severe consecutive CHF patients associated with dilated cardiomyopathy [New York Heart Association (NYHA) class 3.3 ± 0.5, left ventricular ejection fraction (LVEF) 24.4 ± 5.9%] were included in this study. We evaluated endothelial function, measured by reactive hyperemia peripheral arterial tonometry (RH-PAT), between optimal medical therapy alone group (medical therapy group: n = 10) and CRT group (n = 12) at the study enrolment and 12 weeks later. Furthermore we analyzed the association between the RH-PAT and cardiac function.Both therapies significantly and equally improved NYHA class, LVEF, end-diastolic left ventricular dimension and plasma levels of brain natriuretic peptide (BNP). CRT significantly increased RH-PAT index (medical therapy group: 1.5 ± 0.2 to 1.5 ± 0.3, p = 0.824; CRT group: 1.4 ± 0.2 to 1.7 ± 0.4, p = 0.003) and cardiac output (medical therapy group: 3.3 ± 1.1 to 3.5 ± 1.0, p = 0.600; CRT group: 2.7 ± 0.6 to 4.3 ± 1.5, p = 0.001), compared to the medical therapy group. There was significant positive correlation between the change in RH-PAT index and cardiac output (r = 0.600, p = 0.003).CRT significantly improved endothelial function through the improvement of cardiac output in CHF patients, compared to optimal medical therapy.
Brain natriuretic peptide
Ischemic Cardiomyopathy
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To quantitatively assess the effects of cardiac resynchronization therapy (CRT) in patients with advanced congestive heart failure by real-time 3-dimensional(3D) echocardiography (RT-3DE).Eighteen patients with advanced congestive heart failure underwent CRT with New York Heart association(NYHA) class III and IV and wide QRS complex (>120 ms) were included (17 dilated cardiomyopathy and 1 ischemic cardiomyopathy). Before CRT and 8 months after CRT, the clinical and RT-3DE parameters and outcome were analyzed.The biventricular pacemaker was successfully implanted in 17 patients (94.4%). Compared with before CRT, NYHA class of patients decreased by 1.5 class (P < 0.01), left ventricular ejection fraction increased by 25% (P < 0.01), left ventricular end systolic volume decreased by 38% (P < 0.01), left ventricular systolic dyssynchrony index (SDI) improved significantly (14.2% before CRT vs. 9.8% after CRT, P < 0.01 ) post CRT. Change in SDI and change in LVEF was positively correlated (r = 0.62, P < 0.01) . The procedure complications and outcome during and after CRT included coronary sinus dissection (n = 1), left ventricular lead dislodgement (n = 1), phrenic nerve stimulation (n = 1), sudden cardiac death (n = 1). Three non-response patients were complicated with atrial fibrillation, nonspecific intraventricular block and dilated cardiomyopathy with postero-lateral scar tissue.CRT could improve the cardiac function, correct the mechanical desynchronization and reverse left ventricular remodeling in patients with congestive heart failure, and SDI quantification by RT-3DE could predict increase of LVEF after CRT, however, there were complications related to the implantation procedure and possibilities of non-response.
Dilated Cardiomyopathy
Ischemic Cardiomyopathy
Ventricular dyssynchrony
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Heart failure pharmacotherapy including beta-blockers (BB), angiotensin converting enzyme inhibitors/Angiotensin II Receptor Blockers (ACEi/ARB), and aldosterone antagonists have resulted in dramatic improvements in the morbidity and mortality of patients with heart failure (HF) with a reduced ejection fraction. However, in many patients, medical management alone is insufficient to achieve adequate symptom control and HF associated morbidity and mortality remains high. In a subgroup of these patients with prolonged QRS duration, particularly with left bundle branch block (LBBB) morphology, cardiac resynchronization therapy (CRT) has demonstrated additional benefit. Currently CRT is indicated for patients with NYHA functional class II-IV heart failure, severe systolic dysfunction (left ventricular ejection fraction (LVEF) ≤35 %) and interventricular conduction delay. Over the last two decades it has become a key component of the staged treatment of HF (Jessup and Brozena N Engl J Med 348(20):2007–18, 2003).
Bundle branch block
Pharmacotherapy
Angiotensin Receptor Blockers
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