P578Multipoint pacing in cardiac resynchronization therapy - how to improve remodeling criteria and its impact in quality of life

Abstract

Background Despite the reduction in mortality and hospitalization rates, resynchronization therapy still has 30-40% of non-responders. Several studies are ongoing to evaluate if novel programming techniques such as multipoint pacing (MPP) increase the conversion rate of non-responder to responder to CRT. However, there is still lack of information about conversion to super-responders and the impact in quality of life of MPP. Purpose To evaluate the impact of MPP in conversion to super-responders and its impact in the quality of life of patients. Methods Randomized clinical trial of non-AF patients with indication for CRT and who implanted the Quartet™ quadripolar left ventricle (LV) lead. After implant, CRTs were programmed on biventricular pacing according to the latest activated area for 6 months. After a 6-month follow-up, patients were randomized in a 1:1 fashion to MPP ON or MPP OFF. MPP was programmed with the two widest spaced LV electrodes and with a LV1-LV2 to LV2-RV delay of 5ms. Patients were followed-up for 12 months with a 6-month evaluation of NTproBNP, echocardiographic remodeling criteria (LV end systolic volume (ESV) and LV ejection fraction), and quality of life (QoL) evaluated by EQ-5D, Minnesota Living with Heart Failure (MLWHF) questionnaire and 6-minute walk test (6MWT). Results 76 patients were included in this trial, 62 with a completed 12-month follow-up (average age 67.2 ± 10.2 years old, 32.3% female gender, dilated cardiomyopathy in 77.4%). Among these patients, 24 were randomized to MPP ON, 28 to MPP OFF. Six patients died and 4 were lost to follow-up. Baseline clinical and echocardiographic characteristics were similar between groups (p = NS). At 6 months, the overall response rate (reduction in ESV≥15%) was 75%. At twelve months, patients randomized to MPP ON had a super-response rate (reduction in ESV≥30%) higher than patients with MPP OFF (75% vs 39.3%, p = 0.01). Between 6-12 months, patients assigned to MPP ON had a higher reduction in ESV (93.4 ± 52.3mL to 82.1 ± 40.5mL, p = 0.04) and an improvement in LVEF (38.3 ± 9.8% to 45.1 ± 11.1%, p < 0.01) compared to patients with MPP OFF (92.2 ± 47.3mL to 95.4 ± 47.5mL, p = NS; 37.1 ± 12.0% to 40.2 ± 9.2%, p = NS). Additionally, QoL of patients with MPP ON improved during follow up (EQ-5D 78.3% to 86.3%, p < 0.01; MLWHF 12.1 to 6.6, p = 0.03, 6MWT 316m to 239m, p = NS; NTproBNP 1608 ± 2450pg/mL to 775 ± 914pg/mL, p = NS) and was unchanged in MPP OFF patients (76.6% to 74.2%; MLWHF 12.7 to 12.7; 6MWT 338m to 299m, NTproBNP 1112 ± 1442pg/mL to 1383 ± 2118pg/mL, for all p = NS). Conclusion In our population, patients with CRT programmed with MPP ON, when compared to MPP OFF, had an improvement in the super-response rate and in quality of life. These results may be consequence from a more favorable reverse remodeling due to MPP, with a higher reduction in the LV end systolic volume. Abstract Figure.

Multipoint pacing for cardiac resynchronisation therapy in patients with heart failure: A systematic review and meta‐analysis

“…In the sensitivity analysis, excluding the abstracts by Al Mussad and Ferreira, resulted in no differences in the odds ratios and significance of results with regards to the prespecified endpoints 20,22 (Table 4).…”

“…A total of 2 were observational registry analyses, of which 1 was prospective, and 1 was retrospective. A total of 5 were fully published results, 7–10,19 1 was an abstract, 20 and 1 was a full‐text preprint of an earlier published abstract 21,22 (Table 1). In total 1390 patients were included in the final analysis (669 undergoing MPP, and 721 undergoing conventional CRT).…”

“…MPP was effective in the nonrandomised analysis [OR: 5.33, 95% CI: [3.05–9.33], p < .001; I 2 = 0%] and not‐effective in the randomised analysis [OR: 1.86, 95% CI: [0.91–3.79], p = .086; I 2 = 71%]. 3 studies had an active run‐in of at least 3 months with conventional CRT before randomisation 9,10,20 of which 1 study by Leclercq et al, 10 only randomised CRT nonresponders after 6 months. Studies with an active run‐in demonstrated no significant difference in efficacy of MPP [OR: 1.86, 95% CI: [0.38–9.01], p = .442; I 2 = 84%) whereas those without an active run‐in did demonstrate MPP efficacy (OR: 3.50, 95% CI: [1.85–6.28], p < .001; I 2 = 37%).…”

“…A sub‐analysis was performed of studies depending on type of MPP programming (as defined above), in the participants randomised to MPP vs conventional CRT. Two studies compared MPP‐AS only, 20,22 and two compared a combined cohort of MPP programming (MPP‐Mixed), 9,10 to conventional CRT. Three studies did not specify degree of final programming separation (MPP‐Other) 7,8,19 .…”

“…The current meta‐analysis adds important new data on the role of MPP from a quadripolar lead in the improvement of outcomes of CRT response and represents a critical addition to the literature evaluating the efficacy of MPP. Since the publication of a previous metanalysis by Hu et al there have been two major randomised trials 9,10 and two further preliminary randomised studies of MPP efficacy published 20–22 . The prior meta‐analysis of Hu et al incorporated smaller, non‐randomised studies with a high risk of bias.…”