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Long-Term Outcomes in Patients With Ambulatory New York Heart Association Class III and IV Heart Failure Undergoing Cardiac Resynchronization Therapy

Published:October 14, 2014DOI:https://doi.org/10.1016/j.amjcard.2014.09.052

      Highlights

      • Patients with ambulatory New York Heart Association class IV heart failure were severely underrepresented in clinical trials of cardiac resynchronization therapy (CRT) despite strong recommendations in the current guidelines.
      • We examine long-term outcomes (survival free of left ventricular assist device or heart transplant) in patients with ambulatory class IV heart failure receiving CRT, presenting the longest known follow-up of these patients by a large margin.
      • The salient findings of this study are that although patients with ambulatory class IV heart failure who underwent CRT derive inferior long-term outcomes compared with class III patients after controlling for many variables, survival in such patients parallels that of class III patients rather than decreasing rapidly as could be expected.
      • Survival in ambulatory class IV patients receiving CRT at 5 years is a respectable 40%.
      Patients with ambulatory New York Heart Association (NYHA) class IV heart failure were significantly underrepresented in clinical trials of cardiac resynchronization therapy (CRT). The natural long-term trajectory of survival free of left ventricular assist device (LVAD) or heart transplant in patients with ambulatory class IV symptoms who underwent CRT has not been established. We extracted clinical data on 723 consecutive patients with NYHA class III or ambulatory class IV heart failure, left ventricular ejection fraction ≤35%, and a QRS duration ≥120 ms who underwent CRT from September 30, 2003, to August 6, 2007. Chart notes immediately before CRT were reviewed to confirm NYHA class status before CRT. Kaplan-Meier curves and a multivariate Cox proportional hazards model were constructed to determine long-term survival free of heart transplant and LVAD based on NYHA class status. Of the 723 patients, 52 had ambulatory class IV symptoms. Over a mean follow-up of 5.0 ± 2.5 years controlling for many possible confounders, ambulatory NYHA class IV status was independently associated with poor long-term outcomes. The 1-, 2-, 3-, 4-, and 5-year survival free of LVAD or heart transplant for class III versus ambulatory class IV patients was 92.0%, 84.0%, 75.0%, 68.1%, and 63.2% versus 75.0%, 61.5%, 52.0%, 45%, and 40.4%, respectively. Although patients with ambulatory class IV heart failure receiving CRT have inferior long-term outcomes compared with those with class III symptoms, survival in class IV patients continues to parallel class III patients over an extended follow-up. At 5 years, survival free of LVAD or heart transplant in ambulatory class IV patients receiving CRT is 40%.
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      References

        • Linde C.
        • Abraham W.T.
        • Gold M.R.
        • St John Sutton M.
        • Ghio S.
        • Daubert C.
        Randomized trial of cardiac resynchronization in mildly symptomatic heart failure patients and in asymptomatic patients with left ventricular dysfunction and previous heart failure symptoms.
        J Am Coll Cardiol. 2008; 52: 1834-1843
        • Moss A.J.
        • Hall W.J.
        • Cannom D.S.
        • Klein H.
        • Brown M.W.
        • Daubert J.P.
        • Estes 3rd, N.A.
        • Foster E.
        • Greenberg H.
        • Higgins S.L.
        • Pfeffer M.A.
        • Solomon S.D.
        • Wilber D.
        • Zareba W.
        • MADIT-CRT Trial Investigators
        Cardiac-resynchronization therapy for the prevention of heart-failure events.
        N Engl J Med. 2009; 361: 1329-1338
        • Tang A.S.
        • Wells G.A.
        • Talajic M.
        • Arnold M.O.
        • Sheldon R.
        • Connolly S.
        • Hohnloser S.H.
        • Nichol G.
        • Birnie D.H.
        • Sapp J.L.
        • Yee R.
        • Healey J.S.
        • Rouleau J.L.
        • Resynchronization-Defibrillation for Ambulatory Heart Failure Trial Investigators
        Cardiac-resynchronization therapy for mild-to-moderate heart failure.
        N Engl J Med. 2010; 363: 2385-2395
        • Epstein A.E.
        • DiMarco J.P.
        • Ellenbogen K.A.
        • Estes 3rd, N.A.
        • Freedman R.A.
        • Gettes L.S.
        • Gillinov A.M.
        • Gregoratos G.
        • Hammill S.C.
        • Hayes D.L.
        • Hlatky M.A.
        • Newby L.K.
        • Page R.L.
        • Schoenfeld M.H.
        • Silka M.J.
        • Stevenson L.W.
        • Sweeney M.O.
        • Tracy C.M.
        • Epstein A.E.
        • Darbar D.
        • DiMarco J.P.
        • Dunbar S.B.
        • Estes 3rd, N.A.
        • Ferguson Jr., T.B.
        • Hammill S.C.
        • Karasik P.E.
        • Link M.S.
        • Marine J.E.
        • Schoenfeld M.H.
        • Shanker A.J.
        • Silka M.J.
        • Stevenson L.W.
        • Stevenson W.G.
        • Varosy P.D.
        • American College of Cardiology Foundation
        • American Heart Association Task Force on Practice Guidelines; Heart Rhythm Society
        2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.
        J Am Coll Cardiol. 2013; 61: e6-e75
        • Lehmann M.H.
        • Aaronson K.D.
        CRT-D therapy in heart failure: how much do NYHA class IV patients benefit?.
        J Cardiovasc Electrophysiol. 2006; 17: 491-494
        • Lecoq G.
        • Leclercq C.
        • Leray E.
        • Crocq C.
        • Alonso C.
        • de Place C.
        • Mabo P.
        • Daubert C.
        Clinical and electrocardiographic predictors of a positive response to cardiac resynchronization therapy in advanced heart failure.
        Eur Heart J. 2005; 26: 1094-1100
        • Molohoek S.G.
        • Bax J.J.
        • Bleeker G.B.
        • Holman E.R.
        • van Erven L.
        • Bootsma M.
        • Boersma E.
        • Steendijk P.
        • van der Wall E.E.
        • Schalij M.J.
        Long-term follow-up of cardiac resynchronization therapy in patients with end-stage heart failure.
        J Cardiovasc Electrophysiol. 2005; 16: 701-707
        • Schubert A.
        • Muto C.
        • Maounis T.
        • Frank R.
        • Ella R.O.
        • Polauck A.
        • Padaletti L.
        • for the MASCOT Study Group
        One-year outcome after CRT implantation in NYHA class IV in comparison to NYHA class III patients.
        Clin Res Cardiol. 2013; 102: 505-511
        • Vidal B.
        • Delgado V.
        • Mont L.
        • Poyatos S.
        • Silva E.
        • Castel M.A.
        • Tolosana J.M.
        • Berruezo A.
        • Brugada J.
        • Sitges M.
        Decreased likelihood of response to cardiac resynchronization in patients with severe heart failure.
        Eur J Heart Fail. 2010; 12: 283-287
        • MERIT-HF Study Group
        Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomized Intervention Trial in Congestive Heart Failure(MERIT-HF).
        Lancet. 1999; 353: 2001-2007
        • Lindenfeld J.L.
        • Feldman A.M.
        • Saxon L.
        • Boehmer J.
        • Carson P.
        • Ghali J.K.
        • Anand I.
        • Singh S.
        • Steinberg J.S.
        • Jaski B.
        • DMarco T.
        • Mann D.
        • Yong P.
        • Galle E.
        • Ecklund F.
        • Bristow M.
        Effects of cardiac resynchronization therapy with or without a defibrillator on survival and hospitalizations in patients with New York Heart Association class IV heart failure.
        Circulation. 2007; 115: 204-212