Right ventricular dysfunction is a predictor of non-response and clinical outcome following cardiac resynchronization therapy

Abstract

BackgroundCardiac resynchronization therapy (CRT) is an established treatment in advanced heart failure (HF). However, an important subset does not derive a significant benefit. Despite an established predictive role in HF, the significance of right ventricular (RV) dysfunction in predicting clinical benefit from CRT remains unclear. We investigated the role of RV function, assessed by cardiovascular magnetic resonance (CMR), in predicting response to and major adverse clinical events in HF patients undergoing CRT.MethodsSixty consecutive patients were evaluated with CMR prior to CRT implantation in a tertiary cardiac centre. The primary end-point was a composite of death from any cause or unplanned hospitalization for a major cardiovascular event. The secondary end-point was response to therapy, defined as improvement in left ventricular ejection fraction ≥ 5% on echocardiography at one year.ResultsEighteen patients (30%) met the primary end-point over a median follow-up period of 26 months, and 27 out of 56 patients (48%) were considered responders to CRT. On time-to-event analysis, only atrial fibrillation (HR 2.6, 95% CI 1.02-6.84, p = 0.047) and RV dysfunction, either by a reduced right ventricular ejection fraction-RVEF (HR 0.96, 95% CI 0.94-0.99, p = 0.006) or tricuspid annular plane systolic excursion-TAPSE (HR 0.88, 95% CI, 0.80-0.96, p = 0.006), were significant predictors of adverse events. On logistic regression analysis, preserved RVEF (OR 1.05, 95% CI 1.01-1.09, p = 0.01) and myocardial scar burden (OR 0.90, 95% CI 0.83-0.96, p = 0.004) were the sole independent predictors of response to CRT. Patients with marked RV dysfunction (RVEF < 30%) had a particularly low response rate (18.2%) to CRT.ConclusionsRight ventricular function is an important predictor of both response to CRT and long-term clinical outcome. Routine assessment of the right ventricle should be considered in the evaluation of patients for CRT.

Echocardiographic Predictors of Reverse Remodeling After Cardiac Resynchronization Therapy and Subsequent Events

“…However, RV systolic dysfunction is a strong and independent predictor of adverse outcomes with HF 33-35 and poor response to CRT. [36][37][38] In this study, the presence of normal RV systolic function (assessed by RVFAC ≥35%) was strongly associated with LV reverse remodeling after CRT (HR, 14 …”

The right ventricle in patients with chronic heart failure and atrial fibrillation

“…Recent studies seem to give a contrary opinion on how CRT influences markedly depressed RV function. It was proven, that significantly weakened RV function predisposes to a lack of improvement after CRT in terms of NYHA class, 6-minute walking test distance and LVEF [25][26][27]. On the other hand, it was shown that CRT may lead to improvement of the RV function regardless of its volume and size [27].…”

A new score system for predicting response to cardiac resynchronization therapy

“…Impairment of RV systolic function has been consistently associated with worse outcomes in patients with advanced heart failure, independently of LV function [20]. Previous studies reported that RV dysfunction represented a strong predictor of lack of clinical response to CRT [21][22][23]. In the present study, we used TAPSE, a simple, less dependent on optimal image quality and reproducible method to assess RV function and found that TAPSE was a strong variable to predict CRT response.…”