Effects of Upgrade Versus De Novo Cardiac Resynchronization Therapy on Clinical Response and Long-Term Survival

Abstract

Background— Benefits of cardiac resynchronization therapy (CRT) on morbidity and mortality in selected patients are well known. Although the number of upgrade procedures from single- or dual-chamber devices to CRT is increasing, there are only sparse data on the outcomes of upgrade procedures compared with de novo CRT. This study aimed to evaluate clinical response and survival in patients receiving de novo versus upgrade CRT defibrillator therapy. Methods and Results— Prospectively collected outcome data were compared in patients undergoing de novo or upgrade CRT defibrillator implantation at 3 implant centers in Germany and Hungary. Clinical response was defined as an improvement by at least one New York Heart Association (NYHA) functional class. CRT implantation was performed in 552 consecutive patients of whom 375 underwent a de novo and 177 an upgrade procedure. Upgrade patients were more often implanted for secondary prevention, suffered more often from atrial fibrillation, chronic kidney disease, diabetes mellitus, and dyslipidemia, and had more often a non-LBBB (left bundle branch block) wide QRS complex, and lower left ventricular ejection fraction. Upgrade procedures were associated with a lower response rate compared to the de novo group (57% versus 69%, P univariate=0.008, P multivariate=0.021). During the follow-up of 37±28 months, survival was worse after upgrade compared with de novo CRT defibrillator implantations (hazard ratio, 1.65; 95% confidence interval, 1.22–2.24; P =0.001) even after careful adjustment for important baseline variables (adjusted hazard ratio, 1.68; 95% confidence interval, 1.20–2.34; P =0.002) and after propensity-score matching (propensity-adjusted hazard ratio, 1.79; 95% confidence interval, 1.08–2.95; P =0.023). Conclusions— Both clinical response and long-term survival were less favorable in patients undergoing CRT upgrade compared to de novo implantations.

Mortality and Heart Failure After Upgrade to Cardiac Resynchronization Therapy

“…Similar results were reported by a few other studies 21,23,24,29,30 with similarly short follow-up periods (ranging from reporting at 290 days to 4 years) or upgrades solely from pacemaker devices. Vamos et al 28 conducted an observational prospective study with an average follow-up of 37 months and reported higher mortality in upgraded patients compared with patients with de novo CRT implants (HR, 1.79; 95% CI, 1.08-2.95; P ¼ 0.023), whereas Cheung et al 20 reported that CRT upgrades were independently associated with increased mortality (adjusted odds ratio, 1.91; 95% CI, 1.67-2.19; P < 0.001) compared with de novo CRT implants. Prior studies have reported similar HF rates between patients with de novo CRT vs CRT upgrades.…”

“…Several analyses have been conducted to date, but thus far, the available evidence has yielded conflicting results. [19][20][21][22][23][24][25][26][27][28][29][30] Bogale et al 19 investigated 692 patients with upgrades to CRT/CRT-D and 1675 patients with de novo CRT/CRT-D, with follow-up of approximately 1 year, and did not find significant differences in survival (P ¼ 0.57) between the 2 groups. Similar results were reported by a few other studies 21,23,24,29,30 with similarly short follow-up periods (ranging from reporting at 290 days to 4 years) or upgrades solely from pacemaker devices.…”

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

“…The authors concluded that survival in patients undergoing a CRT upgrade from chronic RVP was superior to those undergoing de novo CRT implantation with a native LBBB . Gage et al reported on a cohort of 190 paced upgrades to CRT . 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.…”

“…10 Gage et al 10 reported on a cohort of 190 paced upgrades to CRT. 11 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 11 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.…”