Outcomes of Cardiac Resynchronization Therapy With or Without Defibrillation in Patients With Nonischemic Cardiomyopathy

Leyva, Francisco; Zegard, Abbasin; Acquaye, E.; Gubran, Christopher; Taylor, Robin J.; Foley, Paul; Umar, Fraz; Patel, Kiran; Panting, Jonathan; Marshall, Howard; Qiu, Tianyi

doi:10.1016/j.jacc.2017.07.712

Cited by 74 publications

(43 citation statements)

References 26 publications

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“…A recent observational study including 252 patients with DCM and CRT found that CRT-D provided survival benefit over CRT-P only in those with LGE 29. Additionally, absence of LGE is associated with greater CRT response 30…”

Section: The Emerging Risk Stratification Method: Late Gadolinium Enhmentioning

confidence: 99%

Towards cardiac MRI based risk stratification in idiopathic dilated cardiomyopathy

Brown

Miller

Marco

et al. 2018

Heart

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Sudden cardiac death (SCD) secondary to arrhythmia remains a risk in those with dilated cardiomyopathy (DCM), an implantable cardiac defibrillator (ICD) is an effective strategy to prevent SCD. Current guidelines recommend selection for ICD based on ejection fraction (EF) less than 35%, however, most SCD occurs in those with EF>35%. Although meta-analysis has demonstrated a survival benefit for primary prevention ICD in DCM, no randomised trial has shown a significant reduction in overall mortality including the most recent ‘Danish Study to Assess the Efficacy of ICDs in Patients With Non-Ischemic Systolic Heat Failure on Mortality’ study. Clearly, a more sophisticated selection strategy is required. Cardiac MRI (CMR) is an ideal non-invasive imaging technique which allows calculation of EF as well as tissue characterisation with gadolinium contrast, parametric mapping and feature tracking. Late gadolinium enhancement detects mid-wall fibrosis in approximately 30% of those with DCM, three meta-analyses have demonstrated an association between fibrosis in DCM and SCD, and those without fibrosis are at low risk of SCD. T1 mapping and extracellular volume (ECV) calculation are methods of demonstrating diffuse fibrosis in the myocardium. Raised ECV and native T1 have been associated with worse outcomes but the relationship to SCD has not been well studied. Undoubtedly, more research is required but CMR has several tools which offer incremental value above EF to improve risk stratification and consequent outcomes and resource utilisation in those with DCM.

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Section: The Emerging Risk Stratification Method: Late Gadolinium Enhmentioning

confidence: 99%

Towards cardiac MRI based risk stratification in idiopathic dilated cardiomyopathy

Brown

Miller

Marco

et al. 2018

Heart

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“…Higher CFR also has been suggested to be predictive of CRT response 24 ; thus, sMBF may correlate with better response to CRT. Importantly, while some have suggested that CRT may reduce the need for ICDs in nonischemics, late gadolinium enhancement (LGE) on cardiac MR (CMR) may predict mortality even in patients who have been treated with CRT 25 . Similarly, in our study, lower sMBF was able to identify a high‐risk group despite our cohort's high rate of CRT (49%).…”

Section: Discussionmentioning

confidence: 53%

Positron emission tomography absolute stress myocardial blood flow for risk stratification in nonischemic cardiomyopathy

Middour

Rosenthal

Abi‐Samra

et al. 2020

Cardiovasc electrophysiol

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Introduction: Sudden cardiac death is a substantial cause of mortality in patients with cardiomyopathy, but evidence supporting implantable cardioverter-defibrillator (ICD) implantation is less robust in nonischemic cardiomyopathy (NICM) than in ischemic cardiomyopathy. Improved risk stratification is needed. We assessed whether absolute quantification of stress myocardial blood flow (sMBF) measured by positron emission tomography (PET) predicts ventricular arrhythmias (VA) and/or death in patients with NICM.Methods: In this pilot study, we prospectively followed patients with NICM (left ventricular ejection fraction ≤ 35%) and an ICD who underwent cardiac PET stress imaging with sMBF quantification. NICM was defined as the absence of angiographic obstructive coronary stenosis, significant relative perfusion defects on imaging, coronary revascularization, or acute coronary syndrome. Endpoints were appropriate device therapy for VA and all-cause mortality. Subgroup analysis was performed in patients who had no prior history of VA (ie, the primary prevention population). Results:We followed 37 patients (60 ± 14 years, 46% male) for 41 ± 23 months. The median sMBF was 1.56 mL/g/min (interquartile range: 1.00-1.82). Lower sMBF predicted VA, both in the whole population (hazard ratio [HR] for each 0.1 mL/g/min increase: 0.84, P = .015) and in the primary prevention subset (n = 27; HR for each 0.1 mL/g/min increase: 0.81, P = .049). Patients with sMBF below the median had significantly more VA than those above the median, both in the whole population (P = .004) and in the primary prevention subset (P = .046). Estimated 3-year VA rates in the whole population were 67% among low-flow patients vs 13% among high-flow patients, and 39% vs 8%, respectively, among primary-prevention patients. sMBF did not predict all-cause mortality.Abbreviations: ACEi/ARB, angiotensin converting enzyme inhibitor/angiotensin II receptor blocker; BMI, body mass index; BNP, brain natriuretic peptide; BP, blood pressure; BUN, blood urea

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“…When individual coronary arteries were analyzed, only the LCx was more commonly affected by significant CAD in HF patients with LVEF ≤ 35% when compared to controls (50.0% vs. 7.1%, p = 0.011). At the same time, when LGE was assessed in segments according to coronary artery distribution, there was a trend to more commonly observed LGE in segments supplied by the LAD in HF patients with LVEF ≤ 35% than in controls (68.2% vs. 35.7%, p = 0.056; Table 3).…”

Section: Comparison Of Hf Patients With Lvef Of 35% or Less And Contrmentioning

confidence: 88%

“…Previous studies have found a significant correlation between total scar burden and non-response to CRT, and have proposed a dose-response type relationship in these groups, which may predict this outcome [33,34]. A recent study including patients with dilated cardiomyopathy and CRT found that CRT-defibrillators provided a survival benefit over CRT-pacemakers only in patients with observed LGE [35]. Moreover, implantation of an LV lead over an area with transmural myocardial scarring may result in an ineffective CRT [10].…”

Section: Discussionmentioning

confidence: 99%

“…In patients for whom coronary angiography data were available (n = 36) there was a trend towards a higher prevalence of CAD in HF patients with LVEF ≤ 35% than the remainder of the patients (63.6% vs. 35.7%, p = 0.102; Table 3). When individual coronary arteries were analyzed, only the LCx was more commonly affected by significant CAD in HF patients with LVEF ≤ 35% when compared to controls (50.0% vs. 7.1%, p = 0.011).…”

Section: Comparison Of Hf Patients With Lvef Of 35% or Less And Contrmentioning

confidence: 99%

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Ischemic and non-ischemic patterns of late gadolinium enhancement in heart failure with reduced ejection fraction

et al. 2021

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Background: Late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) may reveal myocardial fibrosis which is associated with adverse clinical outcomes in patients undergoing implantable cardioverter-defibrillator (ICD) placement. At the same time, transmural LGE in the posterolateral wall is related to nonresponse to conventional cardiac resynchronization therapy (CRT). Herein, the aim was to assess the presence and determinants of LGE in CMR in heart failure (HF) with reduced ejection fraction. Methods: 67 patients were included (17.9% female, aged 45 [29-60] years), who underwentLGE-CMR and had left ventricular ejection fraction (LVEF) as determined by echocardiography. Results:In HF patients with LVEF ≤ 35% (n = 29), ischemic and non-ischemic patterns ofLGE were observed in 51.7% and 34.5% of patients, respectively. In controls (n = 38), these patterns were noted in 23.7% and 42.1% of patients, respectively. HF patients with LVEF ≤ 35% and transmural LGE in the posterolateral wall (31.0%) were characterized by older age, coronary artery disease (CAD) and previous myocardial infarction (MI) (61 ± 6 vs. 49 ± 16 years, p = 0.008, 100% vs. 40%, p = 0.003 and 78% vs. 25%, p = 0.014, respectively). In patients with LVEF ≤ 35%, LGE of any type, diagnosed in 86.2% of patients, was associated with CAD (68% vs. 0%, p = 0.02), while only trends were observed for its association with older age and previous MI (p = 0.08 and p = 0.12, respectively). Conclusions: Among HF patients with LVEF ≤ 35%, clinical factors including older age, CAD, and previous MI are associated with transmural LGE in the posterolateral wall, while CAD is associated with LGE. This data may have potential implications for planning ICD and CRT placement procedures. Key words: heart failure, late gadolinium enhancement, ischemic, cardiac magnetic resonance, transmural late gadolinium enhancement, cardiac resynchronization therapy, implantable cardioverter-defibrillator CONCLUSIONS Among HF patients with LVEF of 35% or less, clinical factors, including older age, CAD, and previous MI are associated with transmural LGE in the posterolateral wall, while CAD is associated with LGE. This data may have potential implications for planning ICD and CRT placement procedures.

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Outcomes of Cardiac Resynchronization Therapy With or Without Defibrillation in Patients With Nonischemic Cardiomyopathy

Abstract: In patients with NICM, CRT-D was superior to CRT-P in +MWF but not -MWF. These findings have implications for the choice of device therapy in patients with NICM.

Cited by 74 publications

References 26 publications

Towards cardiac MRI based risk stratification in idiopathic dilated cardiomyopathy

Towards cardiac MRI based risk stratification in idiopathic dilated cardiomyopathy

Positron emission tomography absolute stress myocardial blood flow for risk stratification in nonischemic cardiomyopathy

Ischemic and non-ischemic patterns of late gadolinium enhancement in heart failure with reduced ejection fraction

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