Elsevier

JACC: Heart Failure

Volume 7, Issue 4, April 2019, Pages 281-290
JACC: Heart Failure

Mini-Focus Issue: Prognostic Measures in Heart Failure
Impact of Degree of Left Ventricular Remodeling on Clinical Outcomes From Cardiac Resynchronization Therapy

https://doi.org/10.1016/j.jchf.2018.11.004Get rights and content
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Abstract

Objectives

This study tested the hypothesis that the extent of left ventricular (LV) eccentric structural remodeling in heart failure with reduced ejection fraction (HFrEF) is directly associated with clinical event responses to cardiac resynchronization therapy (CRT).

Background

Whether the severity of LV structural remodeling influences CRT treatment effects is unknown.

Methods

COMPANION (Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure) trial data were analyzed retrospectively. Left ventricular internal dimensions at end diastole indexed by body surface area (LVEDDI) were measured pre-randomization by 2-dimensional echocardiography. LVEDDI values were stratified around the median value of 35 mm/m2, and CRT (including CRT-P [CRT with only pacing capability] and/or CRT-D [CRT with an implantable defibrillator]) treatment effects were assessed and compared by LVEDDI group. Patients assigned to these treatments were compared to those undergoing optimal pharmacologic therapy (OPT) for the outcomes of all-cause mortality (ACM) or ACM and heart-failure hospitalization (ACM/HFH).

Results

In the LVEDDI ≥35 mm/m2 group (n = 614), CRT vs. OPT was associated with a lower ACM/HFH hazard ratio (HR) (HR: 0.53; 95% confidence interval [CI]: 0.40 to 0.70; p <0.001), whereas in the LVEDDI <35 mm/m2 group, the CRT vs. OPT ACM/HFH hazard ratio was not statistically significant (HR: 0.80; 95% CI: 0.59 to 1.08; p = 0.15). For ACM alone, in the LVEDDI ≥35 mm/m2 group, the hazard ratio for CRT-P was 0.59 (95% CI: 0.39 to 0.90; p = 0.012) and for CRT-D 0.50 (95% CI: 0.32 to 0.77; p = 0.002). Neither of the CRT groups showed a statistically significant reduction in ACM in the LVEDDI <35 mm/m2 group.

Conclusions

Larger versus smaller LVEDDIs are associated with a reduction in ACM with CRT-P or CRT-D treatment, and with a more effective reduction in ACM/HFH for the combined CRT treatment groups.

Key Words

CRT
eccentric remodeling
left ventricular diastolic dimension

Abbreviations and Acronyms

ACH
all-cause hospitalization
ACM
all-cause mortality
CRT
cardiac resynchronization therapy
CRT-D
CRT with an implantable defibrillator
CRT-P
CRT with only pacing capability
HF
heart failure
HFH
heart failure hospitalization
HFrEF
HF with reduced LV ejection fraction
ICD
implantable cardioverter-defibrillator
IVCD
intraventricular conduction delay
LV
left ventricle
LVEDDI
left ventricular end diastolic dimension, determined by 2D echocardiography, indexed for body surface area
LVEF
left ventricular ejection fraction
LVESV
left ventricular end systolic volume
NYHA
New York Heart Association

Cited by (0)

Supported by Boston Scientific and by the Statistical Data Analysis Center, University of Wisconsin, Madison, Wisconsin. Analysis of data was supported by Statistical Data Analysis Center, University of Wisconsin. Dr. De Marco has received consulting fees from Boston Scientific; and is a speaker for Novartis. Dr. Lindenfield has consultant relationships with Abbott Lab, Edwards Life Science, Novartis, Boston Scientific, VWave, Relypsa, ResMed, CVRX, and Cardiotronix. Dr. Saxon is Executive Director, University of Southern California Center for Body Computing; and has received fees for consulting for Abbott Lab. Dr. Boehmer has received fees for consulting from Boston Scientific and Medtronic; and has received research support from Boston Scientific and Abbott Lab. Ms. Leigh is an employee of Boston Scientific. Mr. Yong is an employee of Boston Scientific. Dr. Bristow is a compensated Director of ARCA biopharma; and holds equity in ARCA biopharma. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Barry Greenberg, MD, served as Guest Editor for this article.