CRT-D Therapy in Patients with Decompensated NYHA Class-Four CHF

Abstract

Background. ACC-HRS Guidelines for Cardiac Resynchronization Therapy ICD implantation (CRT-D) do not include patients with advanced nonambulatory NYHA class-four CHF due to an expectation of limited survival. There is little data available from these large multicenter randomized studies to support or refute this claim. Purpose. We evaluated the outcomes of patients with advanced nonambulatory NYHA class-four CHF who received CRT-D devices as an attempt to improve the clinical status and promote hospital discharge. Methods. Sixteen (of our six hundred and seventy CRT-D patients) were classified as advanced nonambulatory NYHA Class four inotrope/vasodilator/diuretic-dependent patients. These patients were analyzed retrospectively for weaning success to oral medications, hospital discharge, hemodynamic stability, and survival over eighteen months. Results. Thirteen of sixteen patients were discharged to home within two weeks of implantation. The survival to hospital discharge, as well as at six, twelve, and eighteen months was positive (ninety-four percent, seventy-five percent, sixty-nine percent, sixty-nine percent, resp.). The groups showed significant improvements in systolic blood pressure, renal function, left ventricular ejection fraction, and CHF class. Conclusion. CRT-D in advanced nonambulatory NYHA four patients proved feasible and beneficial. These findings suggest that the strategy merits further study.

Cardiac Resynchronization Therapy Device Implantation in a Patient with Cardiogenic Shock under Percutaneous Mechanical Circulatory Support

“…A desirable, early hemodynamic effect of CRT immediately after the procedure 12) can facilitate weaning from pharmacological and mechanical support in end-stage HF. 5) As expected, echocardiography revealed rapidly improving LV synchrony and contractility after implantation of CRT, with stabilization of the blood pressure and HR. The patient was successfully weaned from ECMO.…”

“…There have been few selective studies and case reports investigating the usefulness of “rescue” CRT in patients with non-ambulatory New York Heart Association (NYHA) functional class IV HF or cardiogenic shock. 3) 4) 5) 6) 7) Most attempts, however, have been unsuccessful. For example, in a retrospective study by Mantziari et al 3) 24 patients underwent CRT implantation during hospitalization in the cardiac critical care unit.…”

“… 1) 2) However, uncertainty remains whether it is beneficial to implant CRT devices in patients with severe HF, especially those in cardiogenic shock or end-stage HF, since such patients have been excluded from most CRT trials. Few cases have been reported about CRT implantation in patients with acute decompensated HF being treated with vasopressors/inotropes, 3) 4) 5) 6) but patients in the intensive care unit requiring mechanical circulatory support were usually not considered as eligible for CRT or CRT-implantable cardioverter defibrillator (CRT-D) “salvage” therapy. In this report, we present a case of successful extracorporeal membrane oxygenation (ECMO) weaning in a cardiogenic shock patient after CRT-D implantation.…”

The effectiveness of cardiac resynchronization therapy for patients with New York Heart Association class IV non‐ambulatory heart failure

“…Previously, various small studies reported that CRT is an effective therapy in patients with NAHF [7,10–15]. These studies demonstrated favorable outcomes in patients treated with CRT, including the ability to wean patients from intravenous inotropes to oral drugs.…”