Mechanical abnormalities detected with conventional echocardiography are associated with response and midterm survival in CRT.

OBJECTIVES: Our aim was to identify "correctable abnormalities" using conventional grayscale and blood-pool Doppler echocardiography and evaluate their ability to predict both response and midterm survival. BACKGROUND: Identification of mechanical abnormalities that may be corrected with cardiac resynchronization therapy (CRT) is useful for predicting echocardiographic response at 1-year follow-up. METHODS: A total of 200 CRT patients were included. Clinical evaluation and echocardiography were performed before and after CRT to assess the presence of the mechanical abnormalities of interest (septal flash, abnormal ventricular filling, or exaggerated interventricular dependence). Response to CRT was defined as a reduction in left ventricular (LV) end-systolic volume (ESV) ≥15%. Four subgroups of extent of response were defined: LVESV reduction >26.68% (extensive remodeling); LVESV reduction 6.8% to 26.68% (slight remodeling); LVESV reduction <6.8% (no remodeling) and clinical response; and LVESV reduction <6.8% without clinical response or the occurrence of death or heart transplantation. Midterm cardiovascular survival was evaluated (mean follow-up 38 ± 19 months). RESULTS: The presence of a correctable abnormality was independently associated with a better rate (odds ratio: 0.03 [95% confidence interval (CI): 0.01 to 0.10], p < 0.001) and extent of response to CRT (n = 59 [96.7%] for the extensive remodeling subgroup vs. n = 53 [85.5%] for the slight remodeling subgroup vs. n = 19 [47.5%] for the no remodeling with clinical response subgroup vs. n = 17 [45.9%] for the no remodeling without clinical response subgroup, p = 0.0001), as well as with increased midterm survival (hazard ratio: 0.11 [95% CI: 0.2 to 0.6]). Other independent predictors included creatinine level and LV end-systolic diameter for response; New York Heart Association functional class IV, creatinine, LV end-systolic diameter, and transmurality index for extent of response; and New York Heart Association functional class IV for cardiovascular mortality. CONCLUSIONS: The presence of a correctable abnormality evaluated by conventional echocardiography is associated with LV reverse remodeling and better survival at midterm follow-up. Clinical characteristics and myocardial viability also have an influence.

EAARN score, a predictive score for mortality in patients receiving cardiac resynchronization therapy based on pre-implantation risk factors.

AIMS: The beneficial effects of CRT in patients with advanced heart failure, wide QRS, and low LVEF have been clearly established. Nevertheless, mortality remains high in some patients. The aims of our study were to identify the predictors of mortality in patients treated with CRT and to design a risk score for mortality. METHODS AND RESULTS: A cohort of 608 consecutive patients treated with CRT from 2000 to 2011 in our centre was prospectively analysed. Baseline clinical and echocardiography variables were analysed and mortality data were collected. During a mean follow-up of 36.2 ± 29.2 months, 174 patients died: 123/174 (71%) due to cardiovascular causes, 25/174 (14%) non-cardiac causes, and 26/174 (15%) unknown aetiology. In a multivariate analysis the predictors of mortality were NYHA class IV [hazard ratio (HR) 2.54, 95% confidence interval (CI) 1.7-3.7, P < 0.001], glomerular filtration rate (GFR) <60 mL/min/1.73 m2 (HR 1.61, 95% CI 1.14-2.30, P = 0.008), AF (HR 1.67, 95% CI 1.19-2.3, P = 0.01), age ≥70 years (HR 1.44, (95% CI 1.04-2.00, P = 0.02), and LVEF <22% (HR 1.83, 95% CI 1.33-2.52, P ≤ 0.001). The EAARN score (EF, Age, AF, Renal dysfunction, NYHA class IV) summarizes the predictors. Each additional predictor increased the mortality: one predictor, HR 3.28 (95% CI 1.37-7.8, P = 0.008); two, HR 5.23 (95% CI 2.24-12.10, P < 0.001); three, HR 9.63 (95% CI 4.1-22.60, P < 0.001); and four or more, HR 14.38 (95% CI 5.8-35.65, P < 0.001). CONCLUSION: The predictors of mortality have a significant add-on predictive effect on mortality. The EAARN score could be useful to stratify the prognosis of CRT patients.

Complete atrioventricular block does not reduce long-term mortality in patients with permanent atrial fibrillation treated with cardiac resynchronization therapy.

AIMS: A maximum percentage of ventricular pacing is mandatory to obtain a good response to CRT. Atrioventricular junction (AVJ) ablation has been recommended to attain this objective in patients with AF. THE AIMS OF OUR STUDY WERE: (i) to determine whether the presence of complete AVJ block (induced or spontaneous) improves survival in patients with permanent AF treated with CRT and (ii) to analyse the predictors of mortality in AF patients treated with CRT. METHODS AND RESULTS: From a series of 608 patients treated with CRT in our centre from 2000 to 2011, a cohort of 155 patients with permanent AF was analysed. Patients in AF were divided into two groups, AF + AVJ block [76 (49%)] and AF non-AVJ block [79 (51%)]. Mean follow-up was 30 months (interquartile range 13-51 months). During the follow-up, 62 patients died. Overall and cardiovascular mortality were similar between both groups: hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.51-1.39, P = 0.51 and HR 0.94, 95% CI 0.52-1.68, P = 0.82. Multivariate analysis identified three independent predictors of mortality: basal NYHA functional class IV (HR 2.25, 95% CI 1.12-4.22, P = 0.03), glomerular filtration rate (HR 0.98, 95% CI 0.96-0.99, P = 0.03), and LVEF (HR 0.94, 95% CI 0.89-0.99, P = 0.02). CONCLUSIONS: AVJ block did not improve survival for patients in AF treated with CRT. Basal NYHA functional class IV, poor renal function, and LVEF were the independent predictors of mortality.