Long‐term outcome after upgrade to cardiac resynchronization therapy: A propensity score‐matched analysis

Abstract

AimCardiac resynchronization therapy (CRT) is a cornerstone in the management of chronic heart failure in patients with a broad or paced QRS. However, data on long‐term outcome after upgrade to CRT are scarce.Methods and resultsThis international, multicentre retrospective registry included 2275 patients who underwent a de novo or upgrade CRT implantation with a mean follow‐up of 3.6 ± 2.7 years. The primary composite endpoint included all‐cause mortality, heart transplantation, or ventricular assist device implantation. The secondary endpoint was first heart failure admission. Multivariable Cox regression and propensity score matching (PSM) analyses were performed. Patients who underwent CRT upgrade (n = 605, 26.6%) were less likely female (19.7% vs. 28.8%, p < 0.001), more often had ischeemic cardiomyopathy (49.8% vs. 40.2%, p < 0.001), and had worse renal function (median estimated glomerular filtration rate 50.3 ml/min/1.73 m2 [35.8–69.5] vs. 59.9 ml/min/1.73 m2 [43.0–76.5], p < 0.001). The incidence rate of the composite endpoint was 10.8%/year after CRT upgrade versus 7.1%/year for de novo implantations (p < 0.001). PSM for the primary endpoint resulted in 488 pairs. After propensity score matching, upgrade to CRT was associated with a higher chance to reach the composite endpoint (multivariable hazard ratio [HR] 1.35, 95% confidence interval [CI] 1.08–1.70), for both upgrade from pacemaker (multivariable HR 1.33, 95% CI 1.03–1.70) and implantable cardioverter‐defibrillator (ICD) (multivariable HR 1.40, 95% CI 1.01–1.95). PSM for the secondary endpoint resulted in 277 pairs. After PSM, upgrade to CRT was associated with a higher chance for heart failure admission (HR 1.74, 95% CI 1.26–2.41).ConclusionIn this retrospective analysis, the outcome of patients who underwent upgrades to CRT differed significantly from patients who underwent de novo CRT implantation, particularly for upgrades from ICD. Importantly, this difference in outcome does not imply a causal relation between therapy and outcome but rather a difference between two different patient populations.

De novo versus upgrade cardiac resynchronization therapy: A different patient population and outcome?

“…2 This was the first RCT on the field to investigate the efficacy on hard outcomes, which served as a true control group without an activated left ventricular lead versus biventricular pacing after a CRT upgrade. Previously, CRT upgrade patients were compared with de novo CRTs in meta-analyses 3 and observational studies, [4][5][6] but long-term outcome data were still limited and controversial.…”

“…retrospectively from a multicentre database. 5 The primary endpoint was all-cause mortality, heart transplantation or ventricular assist device implantation. During a mean follow-up of 3.6 ± 2.7 years, the incidence of the primary endpoint was significantly higher in the CRT upgrade group with 10.8%, having a 35% increased risk for mortality in these patients.…”

Landmark Evolutions in Time and Indication for Cardiac Resynchronization Therapy: Results from a Multicenter Retrospective Registry

“…All patients aged ≥18 years who had a CRT implantation in one of 3 participating tertiary care centers, University Hospital Zurich (Zurich, Switzerland), Ziekenhuis Oost-Limburg (Genk, Belgium), and University Hospitals Leuven (Leuven, Belgium), were included in a retrospective registry. The registry has been described previously [9]. In brief, indications for CRT implantation followed the latest literature or ESC guidelines available at the time [1,10].…”

“…Besides the age cut-off, the study by Darden et al only included patients who underwent de novo CRT-D implantations and the use of ACE inhibitors and angiotensin-receptor blockers was approximately 76%. Also, the study by Leyva et al did not include patients who underwent a CRT upgrade [9] and the data availability was at a different level of granularity (e.g., chronic kidney disease as a binary variable versus different chronic kidney disease stages in our study). On the other hand, we did not have detailed information available on the peri-or postprocedural complications, which may have had an influence given the increasing frailty of the patients.…”

“…Therefore, we aim to describe the evolution of patient characteristics, indications, and long-term outcomes in CRT patients over two decades of change and development, using a large, multicenter European CRT registry [9].…”