Cardiac Resynchronization Therapy Survey Research Articles

What determines who gets cardiac resynchronization therapy in Europe? A comparison between ESC-HF-LT registry, SwedeHF registry, and ESC-CRT Survey II.

Cardiac resynchronization therapy (CRT) is effective in heart failure with reduced ejection fraction (HFrEF) and dyssynchrony but isunderutilized. In a cohort study, we identified clinical, organizational, and level of care factors linked to CRT implantation. We included HFrEF patients fulfilling study criteria in the ESC-HF-Long Term Registry (ESC-HF-LT, n=1031), the Swedish Heart Failure Registry (SwedeHF) (n=5008), and the ESC-CRT Survey II (n=11088). In ESC-HF-LT, 36% had a CRT indication of which 47% had CRT, 53% had indication but no CRT, and the remaining 54% had no indication and no CRT. In SwedeHF, these percentages were 30, 25, 75, and 70%. Median age of patients with CRT indication and CRT present vs. absent was 68 vs. 65 years with 24% vs. 22% women in ESC-HF-LT, 76 vs. 74 years with 26% vs. 26% women in SwedeHF, and 70 years with 24% women in CRT Survey II (all had CRT). For ESC-HF-LT, independent predictors of having CRT were guideline-directed medical therapy (GDMT), atrial fibrillation (AF), prior HF hospitalization, and NYHA class. For SwedeHF, they were GDMT, age, AF, previous myocardial infarction, lower NYHA class, enrolment at university hospital, and follow-up at HF centre/Hospital. In SwedeHF, above median income and higher education level were also independently associated with having CRT. In the ESC-CRT Survey II (n=11088), all patients received CRT but with differences in the clinical characteristics between countries. CRT was used in a minority of eligible patients and more used in ESC-HF-LT than in SwedeHF.

CRT Survey II: a European Society of Cardiology (ESC) survey of cardiac resynchronization therapy—an Irish subset analysis

Cardiac resynchronization therapy (CRT) has been shown to reduce mortality and morbidity in symptomatic patients with reduced left ventricular systolic function < 35%, a left bundle branch block (LBBB) and a widened QRS complex. This paper compares Irish national CRT practices with the European data that was gathered in the same multi-centre CRT Survey II. Each recruiting centre completed an internet-based facilitating collection of information relating to health care resource utilization by each centre. A second form was completed for consecutive patients undergoing CRT implantation, to provide information on patient demographics, pre-implantation clinical evaluation and investigations, indication for implantation and the procedure as well as short-term complications and adverse events. A total of 85 patients from 2 centres were representative of the current Irish practice and compared with data obtained. This was 26.6% of all CRT implantations in Ireland during this period (total number 319, 88 CRT-P, 231 CRT-D). Of those receiving CRT device, mean age was 73years, 74.1% were male, with predominantly NYHA class III symptoms, and left ventricular ejection fraction < 35%. NT-pro-BNP level was substantially elevated in most patients. 56% were in sinus rhythm, 31% in atrial fibrillation with overall mean QRS duration of 166ms. Within Ireland, the majority of CRT implantation are adherent with ESC guidelines. It has also highlighted problems that are noted in other ESC member countries such as the underutilization of device therapy in women, lack of referrals from peripheral centres and further need for optimization of medical therapy before device implantation.

Cardiac Resynchronization Therapy (CRT) in Algeria, result of ESC CRT Survey II

Cardiac resynchronization therapy (CRT) is an effective treatment for heart failure (HF) in ischemic and non-ischemic cardiomyopathy (NIDM) with widened QRS interval, and only being used in Algeria since ten years later. Describe the current clinical practice regarding CRT in Algeria and compare each data point with the total cohort of patients included in ESC CRT Survey II. From 1st October 2015 to 31 December 2016, all patients admitted for CRT implantation were included, even if unsuccessful procedure; generator replacements or revisions of existing CRT devices were excluded. The ESC web-based e-CRF used for data collection was developed by Institut für Herzinfarktforschung Ludwigshafen (IHF), which also conducted data management and statistical analysis. Sixty-six patients (57.8 ± 10.2 years old, 2/3 male, 170 ± 23ms QRS width, 77, 3% non-ischemic cardiomyopathy) were recruited, of which 41% had heart failure hospitalization during past year with 3% being upgrades. Comorbidities reported were hypertension (34, 8%), valvular heart desease(12,1%), diabetes(31.8%), anemia (25,8%) chronic kidney disease (16,7%). The procedures were performed successfully in 90% (60/66) pts, mostly CRT-P in 56, 7% (34/60), and in 96, 7% use of multipolar leads placed in lateral position. The operator was mostly an electro physiologist (96, 7%, 58/60 pts). The main reason of procedure failure was unsuccessful LV lead placement. No death occurred; pneumothorax (3%) and coronary dissection (3%) were the most common complications. Patients discharged were treated with ACE inhibitor/ARB, 97% beta blocker, 90% MRA and 95, 5% loop diuretic. Experienced centers in Algeria report high success rate of CRT implants, mostly primo-CRT P implantation with use of multipolar leads, low complication rates. Patients mostly had non ischemic cardiomyopathy, and were less old with fewer co morbidities than ESC survey patients.

The European Society of Cardiology Cardiac Resynchronization Therapy Survey II: A comparison of cardiac resynchronization therapy implantation practice in Europe and France

The first European Cardiac Resynchronization Therapy (CRT) Survey, conducted in 2008-2009, showed considerable variations in guideline adherence and implantation practice. A second prospective survey (CRT Survey II) was then performed to describe contemporary clinical practice regarding CRT among 42 European countries. To compare the characteristics of French CRT recipients with the overall European population of CRT Survey II. Demographic and procedural data from French centres recruiting all consecutive patients undergoing either de novo CRT implantation or an upgrade to a CRT system were collected and compared with data from the European population. A total of 11,088 patients were enrolled in CRT Survey II, 754 of whom were recruited in France. French patients were older (44.7% aged≥75 years vs 31.1% in the European group), had less severe heart failure symptoms, a higher baseline left ventricular ejection fraction and fewer co-morbidities. Additionally, French patients had a shorter intrinsic QRS duration (19.1% had a QRS<130ms vs 12.3% in the European cohort). Successful implantation rates were similar, but procedural and fluoroscopy times were shorter in France. French patients were more likely to receive a CRT pacemaker than European patients overall. Of note, antibiotic prophylaxis was reported to be administered less frequently in France, and a higher rate of early device-related infection was observed. Importantly, French patients were less likely to receive optimal drugs for treating heart failure at hospital discharge. This study highlights contemporary clinical practice in France, and describes substantial differences in patient selection, implantation procedure and outcomes compared with the other European countries participating in CRT Survey II.

Sex-Related Procedural Aspects and Complications in CRT Survey II: A Multicenter European Experience in 11,088 Patients.

This study sought to compare sex difference for procedural aspects and complications in the European Society of Cardiology CRT Survey II, exploring whether adverse events were related to the type of CRT device implanted. Sex-related differences in procedural aspects and complications in patients undergoing cardiac resynchronization therapy (CRT) implantation has not been explored in a real-life population. A post-hoc analysis of procedural data and complications in different sexes and factors associated with events was performed from data collected in the European Society of Cardiology CRT Survey II. Of all patients (n= 11,088) included, 24.3% were women. The mean age (70 years of age) of male and female recipients was similar. Female patients more frequently had an idiopathic cardiomyopathy (67.4% vs. 44.1%) and fewer comorbidities, including atrial fibrillation (34.8% vs. 42.8%), diabetes (29.1% vs. 32.1%), chronic obstructive lung disease (10.3% vs. 12.6%), and renal failure (28.7% vs. 31.9%), compared with men. More women compared with men had a pacemaker (56.6% vs. 46.3%) and much less often an implantable cardioverter-defibrillator (CRT-D) (19.0% vs. 34.7%) implant. Periprocedural event rate was the highest in women with CRT with defibrillator (7.1% vs. 4.8% in men), followed by women with a CRT with pacing (5.5% vs. 4.4% in men). The higher periprocedural event rate in CRT-D women was attributable primarily to the occurrence of pneumothorax (1.4%), coronary sinus dissection (2.1%), and pericardial tamponade (0.3%). The rate of in-hospital major adverse events (6.0%) and complications necessitating reoperation (4.0%) was not different among sex and device type. Women are more likely to experience adverse procedure-related events during CRT implantation. Thus,preventive strategies should be employed to minimize complication rate.

Cardiac resynchronization in Poland - comparable procedural routines? Insights from CRT Survey II.

IntroductionCRT Survey II was initiated by the European Heart Rhythm Association and the Heart Failure Association, to explore everyday implantation practice of cardiac resynchronization therapy (CRT) devices in a broad spectrum of hospitals in European Society of Cardiology (ESC) member countries.AimTo compare Polish and European procedural practice.Material and methodsProcedural details of Polish patients collected in 37 Polish centres (n = 1241 – Poland group) were compared to the patients enrolled throughout Europe (n = 9847 – CRT II Survey group).ResultsThere were significant differences in: successful implantation (96.1% vs. 97.4%), type of device implanted (for CRT-D: 87% vs. 67.6%), implanting physician subspecialty (for electrophysiologist: 69.2% vs. 79.8%), type of location of procedure (for operating room: 19.4% vs. 8.9%), duration of procedure (117.8 ±44 vs. 97.5 ±46.1 min), left ventricle lead type (for multipolar lead: 50% vs. 57.9%), coronary sinus venogram with occlusion rate (41.4% vs. 47.9%) and peri-procedural complication rate (7.5% vs. 5.3%) between Poland and CRT II Survey groups, respectively.ConclusionsThis study provides important information describing current differences in Polish procedural routines in relation to ESC member countries. Heterogeneous CRT implantation practices across European countries still exist. However, it may be related to different clinical profile of patients qualified for CRT implantation in Poland as well as organization of care.

Atrial fibrillation and cardiac resynchronization therapy: how should rate be controlled?

Atrial fibrillation and cardiac resynchronization therapy: how should rate be controlled?

The European CRT Survey: 1 year (9–15 months) follow‐up results

The European CRT Survey is a joint initiative of the Heart Failure Association (HFA) and the European Heart Rhythm Association (EHRA) of the European Society of Cardiology evaluating the contemporary implantation practice of cardiac resynchronization therapy (CRT) in Europe. Patients who had a successful CRT implantation were enrolled from 141 centres in 13 countries between November 2008 and June 2009. Baseline demographics, clinical and implantation data were collected, with a follow-up of ∼1 year (9-15 months). The current report describes clinical outcomes including symptom severity, cardiovascular (CV) hospitalization, and survival. A total of 2438 patients were enrolled, and follow-up data were acquired from 2111 patients (87%). The population included important groups of patients poorly represented in randomized controlled trials, including very elderly patients and those with prior device implantation, atrial fibrillation, and/or QRS duration <120 ms. Investigators reported substantial improvement in New York Heart Association (NYHA) functional class at follow-up. Patient self-assessment indicated that 81% of the patients felt improved, 16% reported no change, and 4% reported deterioration. During follow-up, 207 (10%) patients died, 346 (16%) had a CV hospitalization, and 501 (24%) died or had CV hospitalization. Worse NYHA functional class, atrial fibrillation, ischaemic aetiology, and device type (CRT-P, i.e. CRT alone) were associated with poorer survival. Women had a better outcome, as did patients who had a CRT-D (with an implantable cardioverter defibrillator function) device. Outcomes including death and hospitalization in this European CRT survey were consistent with results from clinical trials of CRT. At 1 year follow-up, most patients who received a CRT device considered their symptoms improved compared with their pre-implant assessment. Although prospective, this is an observational study of successful CRT implantations, and outcomes in subgroup analyses must be interpreted with appropriate conservatism.

Clinical trials update from the European Society of Cardiology Meeting 2011: ARISTOTLE, SMART‐AV: QLV substudy, SHIFT: echocardiography and quality of life substudies, European CRT Survey, and Basic Science Update

This article provides information and a commentary on key trials relevant to the pathophysiology, prevention, and treatment of heart failure presented at the European Society of Cardiology meeting held in Paris, France in August 2011. Unpublished reports should be considered as preliminary, since analyses may change in the final publication. Results from ARISTOTLE suggest that apixaban is more effective than warfarin for the prevention of stroke in patients with atrial fibrillation. Electrical dyssynchrony, measured by the time from onset of electrical activity on the surface ECG to activation of myocardium by intrinsic conduction at the pacing site (QLV), was a strong and independent predictor of improvement in ventricular function after cardiac resynchronization therapy (CRT) in an observational analysis of a subgroup of patients from the SMART-AV study. Subgroup analyses from SHIFT suggest that heart rate reduction with ivabradine causes favourable left ventricular remodelling and improves quality of life in patients with symptomatic systolic heart failure and an increased heart rate. The European CRT Survey reported outcome data.

The European Cardiac Resynchronization Therapy Survey: comparison of outcomes between de novo cardiac resynchronization therapy implantations and upgrades

Cardiac resynchronization therapy (CRT) is an effective treatment for a subset of patients with chronic heart failure. Data on the benefit of CRT in heart failure patients with previous right ventricular pacemakers or standard defibrillators are sparse. The European (HFA, Heart Failure Association/EHRA, European Heart Rhythm Association) CRT Survey enrolled patients from 141 centres in 13 countries in Europe collecting baseline demographic, echocardiographic, clinical, and implant data, with follow-up at ∼1 year. The present analysis reports implantation data and 1 year outcomes regarding New York Heart Association (NYHA) class, global patient assessment, hospitalizations, complications, and mortality in patients undergoing de novo CRT implantations compared with those receiving an upgrade of a previously implanted device (pacemaker or implantable cardioverter-defibrillators). This analysis includes 2367 CRT implant procedures of which 692 (28%) were upgrades to CRT. Distribution of NYHA functional class and left ventricular function were similar between the groups. Procedural duration was also similar, although fluoroscopy time was shorter in the 'upgrades'. There was no difference in the frequency of peri-procedural complications. There were similar improvements in NYHA functional class and similar reduction in QRS duration, but more patients reported unchanged global assessment status in the upgraded group. Total and cause-specific mortality at 1 year was low and the same in both groups. More than one quarter of all CRT procedures are upgrades from existing systems, although this group has not been subject to randomized clinical trials. Our data suggest that there are no significant differences in clinical outcomes or complication rates between upgrades and de novo procedures. Clinical study no NCT 01185392.

Derzeitige klinische Praxis der kardialen Resynchronisationstherapie in Österreich – nationale Ergebnisse aus dem European CRT Survey

Cardiac resynchronization therapy (CRT) has become an established treatment modality in patients with chronic heart failure, reducing both mortality and morbidity. However, patient selection, implantation and follow-up require great clinical experience. Between 2008 and 2010, the European Society of Cardiology initiated the European CRT survey to describe the current practice and routines associated with CRT implantations in 13 countries. Data from 156 patients collected in 10 Austrian centres were analysed compared to the total 2438 patients enrolled. The survey data showed that general practice did not adhere to the present guidelines. More than one third (36%) of the patients had atrial fibrillation and more than one-fourth (29%) had had a device implanted previously. Altogether, 22% of the patients were in NYHA functional class I or II, and 18% had a LVEF > 35%. Approximately one-fourth of the patients were treated with CRT-P devices (Austria 23%, total 27%). In Austria a higher percentage of patients with non-ischemic cardiomyopathy was selected for CRT than in the other European countries (56% versus 40%, p < 0.0001). Less than a quarter of all patients were females. Different from the rest of Europe, only a minority of CRT implantations were performed by cardiologists in Austria (29% as compared to 89% throughout Europe; p < 0.0001).

Clinical trials update from the European Society of Cardiology Meeting 2009: AAA, RELY, PROTECT, ACTIVE‐I, European CRT survey, German pre‐SCD II registry, and MADIT‐CRT

This article provides information and a commentary on trials relevant to the pathophysiology, prevention, and treatment of heart failure presented at the annual meeting of the European Society of Cardiology held in Barcelona in 2009. The AAA study does not support the routine use of aspirin for the prevention of vascular events in patients with asymptomatic atherosclerosis. RELY suggests that dabigatran may be more effective than warfarin for the prevention of stroke in patients with atrial fibrillation. Rolofylline was not superior to placebo in improving outcomes in patients with acute heart failure enrolled in the PROTECT study, but dyspnoea was improved. Data from ACTIVE-I suggest that irbesartan does not provide additional therapeutic benefit in patients with atrial fibrillation who are well controlled on current therapy. The European cardiac resynchronization therapy (CRT) survey provides interesting epidemiological data on current CRT device usage. The German pre-SCD II registry identified a low prevalence of patients with a reduced ejection fraction following myocardial infarction. Implantation of CRT-D rather than an implantable cardioverter defibrillator in patients with mild heart failure and QRS >/=130 ms reduced the risk of hospitalization for heart failure in MADIT-CRT; mortality was similarly low with each device.

The European cardiac resynchronization therapy survey

The European cardiac resynchronization therapy (CRT) survey is a joint initiative taken by the Heart Failure Association and the European Heart Rhythm Association of the European Society of Cardiology. The primary aim of this survey is to describe current European practice associated with CRT implantations. A total of 140 centres from 13 European countries contributed data from consecutive patients successfully implanted with a CRT device with or without an ICD between November 2008 and June 2009. The total number of patients enrolled was 2438. The median age of the patients was 70 years (IQR 62-76) and 31% were > or =75 years. It was found that 78% were in NYHA functional class III or IV and 22% in I or II. The mean ejection fraction was 27% +/- 8 and the mean QRS duration 157 ms +/- 32. The QRS duration was <120 ms in 9%. Atrial fibrillation was reported in 23%. It was found that 26% of patients had a previously implanted permanent pacemaker or ICD; 76% of procedures were performed by an electrophysiologist; 82% had an elective admission for implantation and the median duration of hospitalization was 3 days (IQR 2-7); and 73% received a CRT-D device which was more often implanted in men, younger patients, and with ischaemic aetiology. The mean QRS duration was reduced to 133 ms +/- 27 (P < 0.0001) at discharge. Peri-procedural complication rates were comparable to the rates reported in randomized trials. This CRT survey provides important information describing current European practice with regard to patient demographics, selection criteria, procedural routines, and status at discharge. These data should be useful for benchmarking individual patient management and national practice against wider experience.

Current practice of cardiac resynchronization therapy (CRT) in the real world: insights from the European CRT survey

Large randomized controlled trials have demonstrated that cardiac resynchronization therapy (CRT) improves morbidity and mortality in patients with moderate to severe heart failure [New York Heart Association (NYHA) functional class III–IV], reduced left ventricular ejection fraction (LVEF ≤35%), and a broad QRS complex >120 ms on optimal medical therapy.1–3 As a result, the impressive survival benefit as well as the improvement in heart failure symptoms and quality of life observed in these trials have spurred interest in extending resynchronization therapy to a larger number of heart failure patients. Indeed, several lines of evidence indicate that currently employed guidelines (mainly based on the selection criteria used in the aforementioned pivotal trials) may not be perfect at identifying patients most likely to benefit from CRT, with a significant proportion of patients being ‘non-responders’ based on clinical outcomes or echocardiographic remodelling.4 Conversely, results from various small studies imply that certain patient populations may benefit from CRT despite the fact that they do not fulfil the criteria of current CRT guidelines.5–7 In the absence of randomized trials, data from large-scale ‘real world’ surveys provide a unique opportunity to study both the current practice regarding the employment of a novel type of therapy as well as its efficacy and safety, including ‘off-label’ indications. The European CRT Survey, a joint initiative by the Heart Failure Association (HFA) and the European Heart Rhythm Association (EHRA) of the European Society of Cardiology (ESC), reports on the current European practice in the use of CRT.8 In order to provide this information, 2438 patients from 141 centres in 13 European countries who underwent successful implantation of a CRT device were followed from November 2008 until June 2009. In addition to providing a detailed description of …