Clinical Investigation
Applications of Echocardiography in Heart Failure
Clinical Significance of Global Wasted Work in Patients with Heart Failure Receiving Cardiac Resynchronization Therapy

https://doi.org/10.1016/j.echo.2021.06.008Get rights and content

Highlights

  • GWW < 200 mm Hg% is associated with increased risk for mortality in CRT candidates.

  • GWW < 200 mm Hg% is associated with a lower CRT response rate in CRT candidates.

  • GWW provided independent prognostic information in CRT candidates.

  • Patients with low preprocedural GWW should be carefully monitored after CRT.

Background

The relationship between myocardial work assessment using pressure-strain loops by echocardiography before cardiac resynchronization therapy (CRT) and response to CRT has been recently revealed. Among myocardial work parameters, the impact of left ventricular myocardial global wasted work (GWW) on response to CRT and outcome following CRT has been seldom studied. Hence, the authors evaluated the relationship between preprocedural GWW and outcome in a large prospective cohort of patients with heart failure (HF) and reduced ejection fraction receiving CRT.

Methods

The study included 249 patients with HF. Myocardial work indices including GWW were calculated using speckle-tracking strain two-dimensional echocardiography using pressure-strain loops. End points of the study were (1) response to CRT, defined as left ventricular reverse remodeling and/or absence of hospitalization for HF, and (2) all-cause death during follow-up.

Results

Median follow-up duration was 48 months (interquartile range, 43–54 months). Median preoperative GWW was 281 mm Hg% (interquartile range, 184–388 mm Hg%). Preoperative GWW was associated with CRT response (area under the curve, 0.74; P < .0001), and a 200 mm Hg% threshold discriminated CRT nonresponders from responders with 85% specificity and 50% sensitivity, even after adjustment for known predictors of CRT response (adjusted odds ratio, 4.03; 95% CI, 1.91–8.68; P < .001). After adjustment for established predictors of outcome in patients with HF with reduced ejection fraction receiving CRT, GWW < 200 mm Hg% remained associated with a relative increased risk for all-cause death compared with GWW ≥ 200 mm Hg% (adjusted hazard ratio, 2.0; 95% CI, 1.1–3.9; P = .0245). Adding GWW to a baseline model including known predictors of outcome in CRT resulted in an improvement of this model (χ2 to improve 4.85, P = .028). The relationship between GWW and CRT response and outcome was stronger in terms of size effect and statistical significance than for other myocardial work indices.

Conclusions

Low preoperative GWW (<200 mm Hg%) is associated with absence of CRT response in CRT candidates and with a relative increased risk for all-cause death. GWW appears to be a promising parameter to improve selection for CRT of patients with HF with reduced ejection fraction.

Section snippets

Study Population and Clinical Data

The population consisted of ambulatory patients with HFrEF referred to Groupement des Hôpitaux de l'Institut Catholique de Lille (Université Catholique de Lille), Hôpital Saint Philibert (Lomme, France), for CRT device implantation between 2010 and 2017. This study was a retrospective analysis of a prospective registry.18,19

CRT was indicated in patients with HFrEF and increased QRS duration. HFrEF was defined as the presence of HF (New York Heart Association functional class II, III, or

Baseline Patient Characteristics

The study population consisted of 249 patients with HF who underwent CRT. The mean age was 72 ± 11 years, and 159 patients (64%) were men (Table 1). Obstructive coronary artery disease was found in 96 patients (39%). Seventy patients (28%) had histories of atrial fibrillation. Among these 70 patients, 34 had paroxysmal atrial fibrillation and were in sinus rhythm at the time of index echocardiography. The remaining 36 patients had regular atrial fibrillation and controlled heart rates allowing

Discussion

The present data indicate that (1) low GWW is strongly associated with poor outcomes and absence of response to CRT in a cohort of patients with HF receiving CRT in clinical practice; (2) GWW provides additional prognostic information over established predictors of outcome; and (3) although immediate changes in GWW are strongly correlated with baseline GWW (i.e., the higher the baseline GWW, the greater the decrease in GWW following CRT), immediate changes in GWW do not provide meaningful

Conclusion

Preprocedural GWW assessed by PSLs is reproducible, and low GWW values are associated with poor long-term outcomes and a lower CRT response rate in patients with HFrEF receiving CRT. GWW < 200 mm Hg% provides independent prognostic information over established predictors of outcome in this population of patients with HFrEF. However, in the absence of randomized controlled studies, even if a majority of patients with preprocedural GWW < 200 mm Hg% seem to not derive benefit from CRT, these

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  • Cited by (0)

    Drs. Riolet and Menet contributed equally to the preparation of this report.

    This work was supported in part by a grant from the Groupement de Coopération Sanitaire G4 (FHU CARNAVAL).

    Conflicts of interest: None.

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