Adding Defibrillation Therapy to Cardiac Resynchronization on the Basis of the Myocardial Substrate

Barra, Sérgio; Bovéda, Serge; Providência, Rui; Sadoul, Nicolas; Duehmke, Rudolf; Reitan, Christian; Borgquist, Rasmus; Narayanan, Kumar; Hidden‐Lucet, Françoise; Klug, Didier; Defaye, Pascal; Gras, Daniel; Anselme, Frédéric; Leclercq, Christophe; Hermida, Jean-Sébastien; Deharo, Jean Claude; Looi, Khang‐Li; Chow, Anthony; Virdee, Munmohan; Fynn, Simon P.; Heuzey, Jean‐Yves Le; Marijon, Éloi; Agarwal, Sharad

doi:10.1016/j.jacc.2017.01.042

Cited by 62 publications

(47 citation statements)

References 41 publications

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“…No clinical trial has established that the addition of ICD to CRT (CRT-D) improves survival beyond CRT alone (CRT-P)15; findings confirmed by the CRT subgroup of the DANISH trial (645 patients, HR 0.91 and p=0.73 for CRT-D vs CRT-P) 12. An observational study of 5307 patients demonstrated that CRT-D was associated with lower mortality than CRT-P only among those with ischaemic cardiomyopathy, rather than DCM 16. This may reflect that patients with DCM usually respond better to CRT17 and echocardiographic response to CRT is associated with lower incidence of ventricular arrhythmia 18.…”

Section: Lvef: the Established Risk Stratification Methodsmentioning

confidence: 94%

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: Lvef: the Established Risk Stratification Methodsmentioning

confidence: 94%

Towards cardiac MRI based risk stratification in idiopathic dilated cardiomyopathy

Brown

Miller

Marco

et al. 2018

Heart

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“…Recent registry and observational data suggest that CRT alone may still be appropriate in the primary prevention setting in specific groups of patients,8 9 but this is an area of ongoing debate 6 8 9 19–21. Studies have strongly suggested that additional ICD likely reduces mortality in men and in ischaemic cardiomyopathy,8 while in other subgroups such as the elderly, women and patients with non-ischaemic DCM, the evidence for a putative additional benefit over and above CRT appears questionable 22. In these patients, the risk/benefit ratio may also depend on whether the addition of the ICD associates with increased risk of device-related comorbidity and complications.…”

Section: Discussionmentioning

confidence: 99%

Device complications with addition of defibrillation to cardiac resynchronisation therapy for primary prevention

Barra

Providência

Bovéda

et al. 2018

Heart

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(WC=291)Objective: In patients indicated for cardiac resynchronization therapy (CRT), the choice between a CRT-pacemaker (CRT-P) versus defibrillator (CRT-D) remains controversial and indications in this setting have not been well delineated. Apart from inappropriate therapies, which are inherent to the presence of a defibrillator, whether adding defibrillator to CRT in the primary prevention setting impacts risk of other acute and late device-related complications has not been well studied and may bear relevance for device selection. Methods:Observational multicentre European cohort study of 3,008 consecutive patients with ischaemic or non-ischaemic dilated cardiomyopathy and no history of sustained ventricular arrhythmias, undergoing CRT implantation with (CRT-D, n=1,785) or without (CRT-P, n=1,223) defibrillator. Using propensity score and competing risk analyses, we assessed the risk of significant device-related complications requiring surgical reintervention. Inappropriate shocks were not considered except those due to lead malfunction requiring lead revision.Results: Acute complications occurred in 148 patients (4.9%), without significant difference between groups, even after considering potential confounders (OR=1.20, 95% CI 0.72-2.00, p=0.47). During a mean follow-up of 41.4±29 months, late complications occurred in 475 patients, giving an annual incidence rate of 26 (95% CI 9-43) and 15 (95% CI 6-24) per 1,000 patient-years in CRT-D and CRT-P patients, respectively. CRT-D was independently associated with increased occurrence of late complications (HR=1.68, 95%CI 1.27-2.23, p=0.001). In particular, when compared to CRT-P, CRT-D was associated with an increased risk of device-related infection (HR 2.10, p=0.004). Acute complications did not predict overall late complications, but predicted device-related infection (HR 2.85, 95%CI 1.71-4.56, p<0.001). 4Conclusions: Compared to CRT-P, CRT-D is associated with a similar risk of periprocedural complications but increased risk of long-term complications, mainly infection. This needs to be considered in the decision of implanting CRT with or without a defibrillator.

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“…Observational studies have failed to demonstrate an additional benefit with CRT-D over CRT-P in NIDCM (3,4). In a propensity score analysis of over 5000 patients, Barra and colleagues found no difference in mortality when comparing NIDCM patients with CRT-D and those with CRT-P (hazard ratio: 0.92; 95% CI 0.73:1.16; p=0.49)(4).…”

Section: Fraction (Lvef) (Hf-ref) Has Been Questioned Following the Dmentioning

confidence: 99%

Selecting Patients With Nonischemic Dilated Cardiomyopathy for ICDs

Cleland

Halliday

Prasad

2017

Journal of the American College of Cardiology

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Adding Defibrillation Therapy to Cardiac Resynchronization on the Basis of the Myocardial Substrate

Abstract: Among patients with heart failure with indications for CRT, those with DCM may not benefit from additional primary prevention implantable cardioverter-defibrillator therapy, as opposed to those with ICM.

Cited by 62 publications

References 41 publications

Towards cardiac MRI based risk stratification in idiopathic dilated cardiomyopathy

Towards cardiac MRI based risk stratification in idiopathic dilated cardiomyopathy

Device complications with addition of defibrillation to cardiac resynchronisation therapy for primary prevention

Selecting Patients With Nonischemic Dilated Cardiomyopathy for ICDs

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