Predictors for Restoration of Normal Left Ventricular Function in Response to Cardiac Resynchronization Therapy Measured at Time of Implantation

      There are no parameters predicting the individual probability of “full response” to cardiac resynchronization therapy (CRT). The aim of this work was to find prognostic factors of full clinical and echocardiographic responses (i.e., ≥50% left ventricular ejection fraction [LVEF] and New York Heart Association class I) after 1 year of CRT. This was a prospective follow-up study that involved 2 hospitals. Patients (n = 75) with advanced heart failure (64 ± 9 years of age, 87% men, LVEF 24 ± 7%) who received CRT were followed for 17 ± 9 months. Univariate and multivariate regression analyses were used to identify predictors of full CRT response. A nomogram predicting the individual probability of full CRT response during follow-up was calculated. There were 13 patients with restoration of normal LVEF versus 62 without (mean LVEF 56% ± 5% vs 31% ± 8%, respectively, p <0.001). Predictors of full response included cause of heart disease, baseline QRS width, and degree of QRS shortening in response to CRT. Patients with nonischemic heart disease, baseline QRS width ≤150 ms, and QRS shortening ≥40 ms in response to CRT had a >75% probability of restoration of normal LVEF. In conclusion, our nomogram using a combination of cause, baseline QRS width, and degree of QRS shortening in response to CRT allows assessment of individual probability of full response. This observation awaits further confirmation from larger series.
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        • Young J.B.
        • Abraham W.T.
        • Smith A.L.
        • Leon A.R.
        • Lieberman R.
        • Wilkoff B.
        • Canby R.C.
        • Schroeder J.S.
        • Liem L.B.
        • Hall S.
        • Wheelan K.
        • Multicenter InSync ICD Randomized Clinical Evaluation (MIRACLEICD) Trial Investigators
        Combined cardiac resynchronization and implantable cardioversion defibrillation in advanced chronic heart failure: the MIRACLE ICD trial.
        JAMA. 2003; 289: 2685-2694
        • Bristow M.R.
        • Saxon L.A.
        • Boehmer J.
        • Krueger S.
        • Kass D.A.
        • De Marco T.
        • Carson P.
        • DiCarlo L.
        • DeMets D.
        • White B.G.
        • DeVries D.W.
        • Feldman A.M.
        • Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure (COMPANION) Investigators
        Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure.
        N Engl J Med. 2004; 350: 2140-2150
        • Cleland J.G.
        • Daubert J.C.
        • Erdmann E.
        • Freemantle N.
        • Gras D.
        • Kappenberger L.
        • Tavazzi L.
        • Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators
        The effect of cardiac resynchronization on morbidity and mortality in heart failure.
        N Engl J Med. 2005; 352: 1539-1549
      1. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA III, Freedman RA, Gettes LS, Gillinov AM, Gregoratos G, Hammill SC, Hayes DL, Hlatky MA, Newby LK, Page RL, Schoenfeld MH, Silka MJ, Stevenson LW, Sweeney MO, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Faxon DP, Halperin JL, Hiratzka LF, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura RA, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA/HRS 2008 guidelines for device based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol;51:2085–2105.

        • Tang A.S.
        • Ross H.
        • Simpson C.S.
        • Mitchell L.B.
        • Dorian P.
        • Goeree R.
        • Hoffmaster B.
        • Arnold M.
        • Talajic M.
        • Canadian Heart Rhythm Society and the Canadian Cardiovascular Society
        Canadian Cardiovascular Society/Canadian Heart Rhythm Society position paper on implantable cardioverter defibrillator use in Canada.
        Can J Cardiol. 2005; 21: 11A-18A
        • Richardson P.
        • McKenna W.
        • Bristow M.
        • Maisch B.
        • Mautner B.
        • O'Connell J.
        • Olsen E.
        • Thiene G.
        • Goodwin J.
        • Gyarfas I.
        • Martin I.
        • Nordet P.
        Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the definition and classification of cardiomyopathies.
        Circulation. 1996; 93: 841-842
        • Daubert J.C.
        • Ritter P.
        • Le Breton H.
        • Gras D.
        • Leclercq C.
        • Lazarus A.
        • Mugica J.
        • Mabo P.
        • Cazeau S.
        Permanent left ventricular pacing with transvenous leads inserted into the coronary veins.
        Pacing Clin Electrophysiol. 1998; 21: 239-245
        • Harrel F.E.
        Regression Modelling Strategies.
        Springer, New York, NY2001
        • Banks J.
        in: Kotz S. Johnson N.L. Wiley, New York1985
        • Lubsen J.
        • Pool J.
        • Van der Does E.
        A practical device for the application of a diagnostic or prognostic function.
        Methods Inf Med. 1978; 17: 127-129
        • Yu C.M.
        • Fung J.W.H.
        • Zhang Q.
        • Sanderson J.E.
        Understanding nonresponders of cardiac resynchronization therapy—current and future perspectives.
        J Cardiovasc Electrophysiol. 2005; 16: 1117-1124
        • Bax J.J.
        • Marwick T.H.
        • Molhoek S.G.
        • Bleeker G.B.
        • van Erven L.
        • Boersma E.
        • Steendijk P.
        • van der Wall E.E.
        • Schalij M.J.
        Left ventricular dyssynchrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation.
        Am J Cardiol. 2003; 92: 1238-1240
        • Yu C.M.
        • Fung W.H.J.
        • Zhang Q.
        • Chan C.K.
        • Chan Y.S.
        • Lin H.
        • Kum L.C.
        • Kong S.L.
        • Zhang Y.
        • Sanderson J.E.
        Tissue Doppler imaging is superior to strain rate imaging and postsystolic shortening on the prediction of reverse remodeling in both ischemic and nonischemic heart failure after cardiac resynchronization therapy.
        Circulation. 2004; 110: 66-73
        • Penicka M.
        • Bartunek J.
        • De Bruyne B.
        • Vanderheyden M.
        • Goethals M.
        • De Zutter M.
        • Brugada P.
        • Geelen P.
        Improvement of left ventricular function after cardiac resynchronization therapy is predicted by tissue Doppler imaging echocardiography.
        Circulation. 2004; 109: 978-983
        • Yu C.M.
        • Zhang Q.
        • Fung J.W.
        • Chan H.C.
        • Chan Y.S.
        • Yip G.W.
        • Kong S.L.
        • Lin H.
        • Zhang Y.
        • Sanderson J.E.
        A novel tool to assess systolic asynchrony and identify responders of cardiac resynchronization therapy by tissue synchronization imaging.
        J Am Coll Cardiol. 2005; 45: 677-684
        • Chung E.S.
        • Leon A.R.
        • Tavazzi L.
        • Sun J.P.
        • Nihoyannopoulos P.
        • Merlino J.
        • Abraham W.T.
        • Ghio S.
        • Leclercq C.
        • Bax J.J.
        • Yu C.M.
        • Gorcsan III, J.
        • St John Sutton M.
        • De Sutter J.
        • Murillo J.
        Results of the Predictors of Response to CRT (PROSPECT) trial.
        Circulation. 2008; 117: 2608-2616
        • Gorcsan III, J.
        Role of echocardiography to determine candidacy for cardiac resynchronization therapy.
        Curr Opin Cardiol. 2008; 23: 16-22
        • Beshai J.F.
        • Grimm R.A.
        • Nagueh S.F.
        • Baker II, J.H.
        • Beau S.L.
        • Greenberg S.M.
        • Pires L.A.
        • Tchou P.J.
        • Rethin Q.
        • Study Investigators
        Cardiac-resynchronization therapy in heart failure with narrow QRS complexes.
        N Engl J Med. 2008; 357: 2461-2471
        • Castellant P.
        • Fatemi M.
        • Bertault-Valls V.
        • Etienne Y.
        • Blanc J.J.
        Cardiac resynchronization therapy: “nonresponders” and “hyperresponders.”.
        Heart Rhythm. 2008; 5: 193-197
        • Castellant P.
        • Fatemi M.
        • Orhan E.
        • Etienne Y.
        • Blanc J.J.
        Patients with non-ischaemic dilated cardiomyopathy and hyper-responders to cardiac resynchronization therapy: characteristics and long-term evolution.
        Europace. 2009; 11: 350-355
        • Gasparini M.
        • Regoli F.
        • Ceriotti C.
        • Galimberti P.
        • Bragato R.
        • De Vita S.
        • Pini D.
        • Andreuzzi B.
        • Mangiavacchi M.
        • Klersy C.
        Remission of left ventricular systolic dysfunction and of heart failure symptoms after cardiac resynchronization therapy: Temporal pattern and clinical predictors.
        Am Heart J. 2008; 155: 507-514
        • António N.
        • Teixeira R.
        • Coelho L.
        • Lourenço C.
        • Monteiro P.
        • Ventura M.
        • Cristóvão J.
        • Elvas L.
        • Gonçalves L.
        • Providência L.A.
        Identification of “super-responders” to cardiac resynchronization therapy: the importance of symptom duration and left ventricular geometry.
        Europace. 2009; 11: 343-349
        • Reant P.
        • Zaroui A.
        • Donal E.
        • Mignot A.
        • Bordachar P.
        • Deplagne A.
        • Solnon A.
        • Ritter P.
        • Daubert J.C.
        • Clementy J.
        • Leclercq C.
        • Roudaut R.
        • Habib G.
        • Lafitte S.
        Identification and characterization of super-responders after cardiac resynchronization therapy.
        Am J Cardiol. 2010; 105: 1327-1335
        • Rickard J.
        • Kumbhani D.J.
        • Popovic Z.
        • Verhaert D.
        • Manne M.
        • Sraow D.
        • Baranowski B.
        • Martin D.O.
        • Lindsay B.D.
        • Grimm R.A.
        • Wilkoff B.L.
        • Tchou P.
        Characterization of super-response to cardiac resynchronization therapy.
        Heart Rhythm. 2010; 7: 885-889
        • Murkofsky R.L.
        • Dangas G.
        • Diamond J.A.
        • Mehta D.
        • Schaffer A.
        • Ambrose J.A.
        • Prolonged A.
        QRS duration on surface electrocardiogram is a specific indicator of left ventricular dysfunction.
        J Am Coll Cardiol. 1998; 32: 476-482
        • Tournoux F.
        • Donal E.
        • Leclercq C.
        • De Place C.
        • Crocq C.
        • Solnon A.
        • Cohen-Solal A.
        • Mabo P.
        • Daubert J.C.
        Concordance between mechanical and electrical dyssynchrony in heart failure patients: a function of the underlying cardiomyopathy?.
        J Cardiovasc Electrophysiol. 2007; 18: 1022-1027
        • Bleeker G.B.
        • Kaandorp T.A.
        • Lamb H.J.
        • Boersma E.
        • Steendijk P.
        • de Roos A.
        • van der Wall E.E.
        • Schalij M.J.
        • Bax J.J.
        Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy.
        Circulation. 2006; 113: 969-976
        • Concato J.
        • Peduzzi P.
        • Holford T.R.
        • Feinstein A.R.
        Importance of events per independent variable in proportional hazards analysis.
        J Clin Epidemiol. 1995; 48: 1495-1501
        • Vittinghoff E.
        • McCulloch C.E.
        Relaxing the rule of ten events per variable in logistic and Cox regression.
        Am J Epidemiol. 2007; 165: 710-718
        • Yu C.M.
        • Zhang Q.
        • Chan Y.S.
        • Chan C.K.
        • Yip G.W.
        • Kum L.C.
        • Wu E.B.
        • Lee P.W.
        • Lam Y.Y.
        • Chan S.
        • Fung J.W.
        Tissue Doppler velocity is superior to displacement and strain mapping in predicting left ventricular reverse remodelling response after cardiac resynchronisation therapy.
        Heart. 2006; 92: 1452-1456