P1241Five-year risk of death and readmission for heart failure after implantation of de novo and upgrade cardiac resynchronization therapy devices

Abstract

Abstract Background De novo implantation of cardiac resynchronization therapy devices with and without an implantable cardiac defibrillator (CRT-D and CRT-P, respectively) is associated with a reduced risk of death and re-admission for heart failure (HF). Whether upgrade to CRT-P/D from a brady pacemaker or an implantable cardiac defibrillator is associated with a similar long-term clinical benefit as de novo implantations is unknown. Purpose To compare risk of death and HF readmission in patients receiving a de novo versus upgraded CRT-P/D device. Methods From the Danish nationwide administrative registers, we identified all patients who had a CRT-D or CRT-P implanted from 2006 through 2016. Patients were excluded if they had endocarditis within 12 months before implantation. The patients were divided into groups based on whether implantation was an upgrade of a previous device or a de novo implantation. The primary endpoint was the composite of all-cause mortality and HF readmission. Risk of the primary endpoint was assessed with Kaplan Meier estimator and multivariable Cox regression models adjusted for age, sex, ischemic heart disease, diabetes and chronic obstructive pulmonary disease. Results The study population comprised 6,324 patients, median age 70 years [25th-75th percentile: 63–77], 22% women. In total, 3,635 patients had a CRT-D, of whom 749 (20.6%) were upgraded from an implantable cardioverter defibrillator device and 2,689 patients had a CRT-P, of whom 496 (18.4%) were upgraded from brady-pacemakers. For patients with CRT-D, five-year event-free survival probability was 35.3% for de novo and 20.4% for upgrades (log-rank p-value<0.001). For patients with CRT-P, five-year event-free survival probability was 38.4% for de novo and 33.7% for upgrades (log-rank p-value=0.29) (Figure 1). In the CRT-D group, upgrade was associated with an increased risk of the primary endpoint, hazard ratio (HR): 1.49 (95%-confidence interval (CI): 1.34–1.65, p<0.001). In the CRT-P group, no significant difference between upgrade and de novo was observed, HR: 1.02 (95%-CI: 0.89–1.18, p=0.72). Figure 1 Conclusions Upgrade to a CRT-P was associated with a similar long-term clinical outcome as de novo device implantation. This was in contrast to upgrade CRT-D, which was associated with a worse outcome than de novo implantation. To understand the factors underlying this increased risk, more studies are warranted.