Not left ventricular lead position, but the extent of immediate asynchrony reduction predicts long-term response to cardiac resynchronization therapy

Abstract

Cardiac resynchronization therapy (CRT) is an effective treatment for a large subgroup of chronic heart failure patients. Various attempts to improve the high non-responder rate of 30 % by preoperative asynchrony assessment have failed. We hypothesized that superior response to CRT is correlated with greater acute reduction of asynchrony and that a concordant left ventricular (LV) lead is beneficial compared to a discordant lead. Hundred and eight consecutive CRT patients from our center were prospectively included. Clinical status and asynchrony parameters were assessed before, 1 day and 6 months after CRT implantation. Super-response was defined as an increase of the LV ejection fraction by ≥15 % and a decrease in LV end systolic volume (LVESV) by ≥30 %. When the criteria for super-response were not met, average response was given with a decrease of baseline LVESV ≥15 %. Sixty eight patients were classified as responders (63 %). Comparing super- (n = 19) and average (n = 49) responders, we found that greater acute reduction of LV asynchrony (change of asynchronous segments under CRT: -1.3 vs. -0.4, p < 0.05; decrease of LV intraventricular delay: -34 ms vs. -16 ms, p < 0.05) is associated with superior reverse remodeling after 6 months. Importantly, asynchrony parameters of super-, average and non-responders were almost identical at baseline. A concordant LV lead (n = 63) was not associated with improved LV reverse remodeling compared to a discordant lead (n = 28): LVEF: +8.6 % vs. +7.8 %, p = 0.91; LVESV: -30.5 ml vs. -23.8 mL, p = 0.84. A greater immediate reduction of LV asynchrony predicts superior response. Preoperative asynchrony parameters do not correlate with outcome. A concordant LV lead is not superior to a discordant lead.

Hemodynamic device-based optimization in cardiac resynchronization therapy: concordance with systematic echocardiographic assessment of AV and VV intervals

“…In fact, pooled data have demonstrated that one-third of patients undergoing CRT fail to experience symptomatic benefit, with only 60% exhibiting a favorable echocardiographic response 12,13 and approximately 20% being considered super-responders. 12 Comparable echocardiographic responder rates (decrease in LVESV $15%) of 63% and 60% were reported at 6-month follow-up by Poller et al 15 and Shetty et al, 16 respectively. In the present study, the rates of clinical responders with reverse remodeling were almost 80%, and the majority of responders were classified as super-responders.…”

Cardiac resynchronization therapy outcomes with left ventricular lead concordant with latest mechanical activation: A meta‐analysis

“…Of 3084 unique citations identified, a total of nine publications from eight unique studies met the selection criteria for this analysis (Figure 1). [6][7][8]11,13,16,17,20,21 Two publications from the Targeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization (TARGET) study were included, but considered as only one study for analyses. 7,13 Of the nine publications, four were secondary analyses of data from RCTs, four were prospective observational studies, and one combined patients from a RCT and a prospective observational study.…”

“…6 In a third study, SD for absolute change in LVEF was not provided and thus the SD at baseline and follow-up were assumed to be the same and the correlation was conservatively estimated at 0.5. 17 For LVESV, the mean (SD) of the relative change, expressed as a percentage, from baseline was reported. For two studies, the mean relative change in LVESV was estimated using the reported means at baseline and follow-up and the SD was calculated assuming a conservative correlation between baseline and follow-up of 0.5.…”

“…For two studies, the mean relative change in LVESV was estimated using the reported means at baseline and follow-up and the SD was calculated assuming a conservative correlation between baseline and follow-up of 0.5. 6,17 Meta-analyses were conducted for all outcomes of interest that were reported in three or more included studies. Meta-analyses were preformed using a DerSimonian-Laird random-effects model and conservatively used the Knapp-Hartung approach to adjust the standard errors of the estimated model coefficients.…”

Outcome of super-responders to cardiac resynchronization therapy defined by endpoint-derived parameters of left ventricular remodeling: a two-center retrospective study

“…A number of investigations attempted to identify super-responders focusing on various echocardiographic parameters of reverse remodeling. Yu et al [11], Ypenburg [6] and Poller [12] defined super-responder by an improvement in left ventricular end-systolic volume (LVESV), although different cut-offs were selected [6,11]. Another study group used vectorcardiography parameters to assess response to CRT [13].…”