De novo implantation vs. upgrade cardiac resynchronization therapy: a systematic review and meta-analysis

Abstract

Patients with conventional pacemakers or implanted defibrillators are often considered for cardiac resynchronization therapy (CRT). Our aim was to summarize the available evidences regarding the clinical benefits of upgrade procedures. A systematic literature search was performed from studies published between 2006 and 2017 in order to compare the outcome of CRT upgrade vs. de novo implantations. Outcome data on all-cause mortality, heart failure events, New York Heart Association (NYHA) Class, QRS narrowing and echocardiographic parameters were analysed. A total of 16 reports were analysed comprising 489,568 CRT recipients, of whom 468,205 patients underwent de novo and 21,363 upgrade procedures. All-cause mortality was similar after CRT upgrade compared to de novo implantations (RR 1.19, 95% CI 0.88–1.60, p = 0.27). The risk of heart failure was also similar in both groups (RR 0.96, 95% CI 0.70–1.32, p = 0.81). There was no significant difference in clinical response after CRT upgrade compared to de novo implantations in terms of improvement in left ventricular ejection fraction (ΔEF de novo − 6.85% vs. upgrade − 9.35%; p = 0.235), NYHA class (ΔNYHA de novo − 0.74 vs. upgrade − 0.70; p = 0.737) and QRS narrowing (ΔQRS de novo − 9.6 ms vs. upgrade − 29.5 ms; p = 0.485). Our systematic review and meta-analysis of currently available studies reports that CRT upgrade is associated with similar risk for all-cause mortality compared to de novo resynchronization therapy. Benefits on reverse remodelling and functional capacity improved similarly in both groups suggesting that CRT upgrade may be safely and effectively offered in routine practice. Clinical Trial Registration: Prospero Database—CRD42016043747Electronic supplementary materialThe online version of this article (10.1007/s10741-017-9652-1) contains supplementary material, which is available to authorized users.

Upgrades from a previous device compared to de novo cardiac resynchronization therapy in the European Society of Cardiology CRT Survey II

“…But, in general, patients upgraded in this survey were in worse disease state regarding HF symptoms and had more AF, ischaemic HF, renal function impairment and were older, all of which contributed to HF development. In a recent meta‐analysis, there was no significant difference in clinical response or mortality after CRT upgrade compared to de novo implantations …”

Long term outcomes in patients with chronic right ventricular pacing upgraded to cardiac resynchronization therapy

“…Contrary to these findings, Vamos et al reported inferior outcomes of upgraded patients compared with de novo implants over a follow up of approximately 3 years . Koztin et al performed a systematic review of the evidence showing similar all‐cause mortality to de novo implants. This systematic review, however, included studies reporting in‐hospital outcomes in its analysis.…”

“…Over a mean follow up of 4.2 years, the authors reported that patients with paced upgrades had similar survival to patients with de novo implants. Contrary to these findings, Vamos et al reported inferior outcomes of upgraded patients compared with de novo implants over a follow up of approximately 3 years . Koztin et al performed a systematic review of the evidence showing similar all‐cause mortality to de novo implants.…”

Cardiac resynchronization therapy in the real world: need to upgrade outcome research

“…In this CRT Survey II, the patients were discharged after a median hospital stay of 3 days and the study plan did not include follow‐up data after discharge. A focus on longer follow‐up periods, up to 6 months–1 year, is necessary in order to capture the occurrence of post‐discharge major complications, most of which are reported in Figure , with the indication of the most vulnerable periods …”

“…Incidence and usual most vulnerable periods for complications of cardiac resynchronization implants or upgrades . CIED, cardiac implantable electronic device; CS‐diss, coronary sinus dissection; d, days; fup, follow‐up; mo, months; unsuc, unsuccessful; yr, years.…”