Cardiac resynchronization therapy in New York Heart Association class‐IV patients dependent on intravenous drugs or invasive supportive treatments

Abstract

Aims We sought to evaluate the effectiveness of cardiac resynchronization therapy (CRT) in far-advanced heart failure (FA-HF) patients with New York Heart Association (NYHA) class-IV status and dependency on intravenous drugs (IVDs) and/or invasive supportive treatments (ISTs). Methods and results Among 305 patients who underwent CRT implantation between October 2005 to December 2019, we identified 17 FA-HF patients with NYHA class-IV status and dependency on IVDs (inotropes, diuretics, vasopressors, or vasodilators) and/or ISTs (extracorporeal membranous oxygenator or continuous renal replacement therapy). All patients (median age = 68.7 years, non-ischaemic cardiomyopathy = 15) remained dependent on several IVDs (2.2 ± 1.3 per patient) and/or ISTs for 11.3 ± 7.8 days due to multiple tapering failure (4.3 ± 3.2 per patient) before CRT implantation. However, 14 (82%) patients were successfully weaned from IVDs/ISTs within 5.2 ± 5.3 days following CRT, and 12 (71%) stayed alive for more than 1 year free of ventricular assist device or heart transplantation with symptom improvement (≥1 NYHA class) and a reduced annual HF hospitalization rate (P = 0.002). Considerable improvements in ventricular systolic function (P = 0.004) and volumetric reverse remodelling (P = 0.007) were noticed during the long-term follow-up period (35 ± 15 months post-CRT). The ventricular assist device/heart transplantation/death-free survival rate post-CRT was 71% and 65% at 1 and 3 years, respectively. Conclusions Cardiac resynchronization therapy implantation may be a feasible treatment that can offer short-term and long-term clinical benefits for NYHA class-IV FA-HF patients who are dependent on IVDs/ISTs. When considering treatment options, CRT should not be prematurely excluded solely based on a patient's dependency on IVDs/ISTs without first attempting to identify favourable CRT response factors.

Heart failure: an update from the last years and a look at the near future

“…2,171 It may be a feasible treatment that can offer short-term and long-term clinical benefits for NYHA Class IV HF patients. 172 Nevertheless, up to two thirds of eligible patients are not referred for CRT. 173,174 A joint position statement from three ESC Associations, HFA, European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI), aimed at overcoming CRT under-utilization, improving patient selection, and implementing dedicated post-implant CRT care pathways.…”

“…Cardiac resynchronization therapy (CRT) improves cardiac function and symptoms and reduces morbidity and mortality in an appropriately selected group of HF patients 2,171 . It may be a feasible treatment that can offer short‐term and long‐term clinical benefits for NYHA Class IV HF patients 172 . Nevertheless, up to two thirds of eligible patients are not referred for CRT 173,174 .…”