Incidence, Predictors, and Procedural Results of Upgrade to Resynchronization Therapy

Abstract

Background-The resynchronization-defibrillation for ambulatory heart failure trial (RAFT) study demonstrated that adding cardiac resynchronization therapy (CRT) in selected patients requiring de novo implantable cardiac defibrillators (ICD) reduced mortality as compared with ICD therapy alone, despite an increase in procedure-related adverse events. Data are lacking regarding the management of patients with ICD therapy who develop an indication for CRT upgrade. Methods and Results-Participating RAFT centers provided data regarding de novo CRT-D (CRT with ICD) implant, upgrade to CRT-D during RAFT (study upgrade), and upgrade within 6 months after presentation of study results (substudy). Substudy centers enrolled 1346 (74.9%) patients in RAFT, including 644 de novo, 80 study upgrade, and 60 substudy CRT attempts. The success rate (initial plus repeat attempts) was 95.2% for de novo versus 96.3% for study upgrade and 90.0% for substudy CRT attempts (P=0.402). Acute complications occurred among 26.2% of de novo versus 18.8% of study upgrade and 3.4% of substudy CRT implantation attempts (P<0.001). The most common complication was left ventricular lead dislodgement. The principal reasons for not yet attempting upgrade in the substudy were patient preference (31.9%), New York Heart Association Class I (17.0%), and a QRS <150 ms (13.1%). Conclusions-Among a broad group of implant physicians, CRT upgrades were performed in patients with an ICD in situ with no difference in implant success rate and a reduced acute complication rate as compared with a de novo CRT implant. Decisions to upgrade were influenced by predictors of benefit in subgroup analyses of the RAFT study and other trials. (Circ Arrhythm Electrophysiol. 2015;8:152-158.

A Novel Risk Model for Mortality and Hospitalization following Cardiac Resynchronization Therapy in Patients with Non-ischemic Cardiomyopathy: The Alpha-score

“…The LBBB was traditionally a strong predictor of electrical LV discordance in numerous large trials [7, [31][32][33][34]. Our results are consistent with the findings of the MADIT-CRT[7], RAFT [35], and REVERSERS [36] trials, which have been shown that non-LBBB patients have an increased rate of mortality due to CRT compared to those with LBBB. A meta-analysis of the major CRT trials also confirmed that a greater benefit from the devices was found when a LBBB morphology was present in patients who underwent CRT, which is strongly recommended for symptomatic HF patients in current guidelines.…”

Mortality and Heart Failure After Upgrade to Cardiac Resynchronization Therapy

“…[1][2][3] Despite the benefits of CRT, prior studies have mostly included patients with de novo CRT implants. 4 The Resynchronization in Ambulatory Heart Failure Trial (RAFT) was one of the only trials that included patients with chronic ventricular pacing. 5 Patients with existing cardiac implantable electronic devices (CIEDs), such as implantable cardioverter defibrillators (ICDs) or pacemakers, may also become eligible for CRT subsequent to their initial implant.…”

“…9 Data on long-term outcomes for patients with previous CIEDs who later become eligible for upgrade to CRT are scarce. 4,10 We sought to determine the risks and benefits of CRT upgrade in eligible patients compared with patients who undergo de novo CRT-D implantation.…”

Short-term outcome of cardiac resynchronization therapy – a comparison between newly implanted and chronically right ventricle-paced patients

“…However, from the technical point of view, a sub study of RAFT trial showed that CRT upgrades have comparable implant success rate and acute complication rate as de novo CRT implantations [30].…”