Patients Undergoing Cardiac Resynchronization Therapy Implantation Research Articles

Obesity paradox in patients with reduced ejection fraction eligible for device implantation - an observational study.

Patients with obesity have an overall higher cardiovascular risk, at the same time obesity could be associated with a better outcome in a certain subgroup of patients, a phenomenon known as the obesity paradox. Data are scarce in candidates for cardiac resynchronization therapy (CRT). We aimed to investigate the association between body mass index (BMI) and all-cause mortality in patients eligible for CRT. Altogether 1,585 patients underwent cardiac resynchronization therapy between 2000-2020 and were categorized based on their BMI, 459 (29%) patients with normal weight (BMI<25kg/m2), 641 (40%) patients with overweight (BMI 25-<30kg/m2) and 485 (31%) with obesity (BMI≥30kg/m2). The primary endpoint was all-cause mortality, heart transplantation, and left ventricular assist device implantation. We assessed periprocedural complications and 6-month echocardiographic response. Normal-weight patients were older compared to patients with overweight or obesity (70years vs. 69years vs. 68years; P ‹0.001), respectively. Sex distribution, ischaemic aetiology, and CRT-D implantation rates were similar in the three patient groups. Diabetes mellitus (BMI<25kg/m2 26% vs. BMI 25-<30kg/m2 37% vs. BMI≥30kg/m2 48%; P ‹0.001) and hypertension (BMI<25kg/m2 71% vs. BMI 25-<30kg/m2 74% vs. BMI≥30kg/m2 82%; P ‹0.001) were more frequent in patients with overweight and obesity. During the mean follow-up time of 5.1years, 973 (61%) reached the primary endpoint, 66% in the BMI<25kg/m2 group, 61% in the BMI 25-<30kg/m2 group and 58% in the BMI≥30kg/m2 group (log-rank P‹0.05). Patients with obesity showed mortality benefit over normal-weight patients (HR 0.78; 95%CI 0.66-0.92; P=0.003). The obesity paradox was present in patients free from diabetes, atrial fibrillation, and ischemic events. Periprocedural complication rates did not differ in the three groups (BMI<25kg/m2 25% vs. BMI 25-<30kg/m2 28% vs. BMI≥30kg/m2 26%; P=0.48). Left ventricular ejection fraction improved significantly in all patient groups (BMI<25kg/m2 median -LVEF 7% vs. BMI 25-<30kg/m2 median -LVEF 7.5% vs. BMI≥30kg/m2 median -LVEF 6%; P<0.0001) with a similar proportion of developing reverse remodeling (BMI<25kg/m2 58% vs. BMI 25-<30kg/m2 61% vs. BMI≥30kg/m2 57%; P=0.48); P=0.75). The obesity paradox was present in our HF cohort at long-term, patients underwent CRT implantation with obesity and free of comorbidities showed mortality benefit compared to normal weight patients. Patients with obesity showed similar echocardiographic response and safety outcomes compared to normal weight patients.

Machine learning-based prediction of 1-year all-cause mortality in patients undergoing CRT implantation: validation of the SEMMELWEIS-CRT score in the European CRT Survey I dataset

Abstract Aims We aimed to externally validate the SEMMELWEIS-CRT score for predicting 1-year all-cause mortality in the European Cardiac Resynchronization Therapy (CRT) Survey I dataset—a large multi-centre cohort of patients undergoing CRT implantation. Methods and results The SEMMELWEIS-CRT score is a machine learning-based tool trained for predicting all-cause mortality in patients undergoing CRT implantation. This tool demonstrated impressive performance during internal validation but has not yet been validated externally. To this end, we applied it to the data of 1367 patients from the European CRT Survey I dataset. The SEMMELWEIS-CRT predicted 1-year mortality with an area under the receiver operating characteristic curve (AUC) of 0.729 (0.682–0.776), which concurred with the performance measured during internal validation [AUC: 0.768 (0.674–0.861), P = 0.466]. Moreover, the SEMMELWEIS-CRT score outperformed multiple conventional statistics-based risk scores, and we demonstrated that a higher predicted probability is not only associated with a higher risk of death [odds ratio (OR): 1.081 (1.061–1.101), P &amp;lt; 0.001] but also with an increased risk of hospitalizations for any cause [OR: 1.013 (1.002–1.025), P = 0.020] or for heart failure [OR: 1.033 (1.015–1.052), P &amp;lt; 0.001], a less than 5% improvement in left ventricular ejection fraction [OR: 1.033 (1.021–1.047), P &amp;lt; 0.001], and lack of improvement in New York Heart Association functional class compared with baseline [OR: 1.018 (1.006–1.029), P = 0.003]. Conclusion In the European CRT Survey I dataset, the SEMMELWEIS-CRT score predicted 1-year all-cause mortality with good discriminatory power, which confirms the generalizability and demonstrates the potential clinical utility of this machine learning-based risk stratification tool.

Re-classification of response to cardiac resynchronization therapy: the long-term effect of echocardiographic non-progression

Abstract Introduction Approximately one-third of patients undergoing cardiac resynchronization therapy (CRT) implantation fail to show echocardiographic improvement and are categorized as non-responders, despite of probable beneficial clinical response. Purpose We aimed to evaluate the long-term outcome of CRT patients by their echocardiographic response outsorting those with unchanged parameters. Methods Altogether 1019 patients undergoing CRT implantation between 2000-2020 in our center were analyzed retrospectively. Patients were grouped by their echocardiographic response defined as LVEF change upto12 months: super-responders ≥20% (n=113), responders 6-19% (n=448), non-progressors 0-5% (n=244), and progressors &amp;lt;0% (n=214). The primary endpoint was the composite of all-cause mortality, heart transplantation, or left ventricular assist device implantation. Results During the median follow-up time of 4.7 years 547 (54%) patients died, 35 (31%) super-responders, 223 (50%) responders, 133 (55%) non-progressors, and 156 (73%) progressors. The mean change in LVEF occurred as follows: super-responders 24.5% ± 4.1%, responders 11.5% ± 3.8%, non-progressors 2.8% ± 1.8%, and progressors -6.6% ± 4.5% (p&amp;lt;0.001). Univariate Cox regression analysis revealed that non-progressors had a similar outcome to responders (HR 1.17; 95%CI 0.94-1.45; p=0.15) and a superior outcome to progressors (HR 0.60; 95%CI 0.48-0.76; p&amp;lt;0.001), which was also confirmed by multivariate analysis: non-progressors vs. responders (HR 1.25; 95%CI 0.98-1.58; p=0.07) and non-progressors vs. progressors (HR 0.62; 95%CI 0.47-0.80; p&amp;lt;0.001). Conclusion In our current analysis, non-progressors had a superior outcome to progressors suggesting that CRT moderates the remodeling process. These findings indicate their selection and the re-classification of CRT response by echocardiographic changes.Survival by responseMean change in LVEF by response

Fragmented QRS complex as a predictor of all-cause mortality in patients undergoing cardiac resynchronization therapy

Abstract Introduction Heart failure with reduced left ventricle ejection fraction (HFrEF) is a prevalent entity with poor prognosis in the follow-up. Cardiac resynchronization therapy (CRT) in specific situations, have demonstrated to reduce all-cause mortality in this group of patients. However, these patients represent a highly heterogeneous group, so risk stratification is crucial in the approach of these patients. In the recent years, specific electrocardiographic findings such as fragmentation of the QRS complex (fQRS) have been reported as potential prognostic factors in different cardiac conditions, but the role in patients undergoing CRT is unclear. Purpose The aim of this study is to determine if the presence of pre-implantation fQRS in 12-lead surface electrocardiogram (ECG) predicts all-cause mortality in patients undergoing CRT implantation. Methods Consecutive patients undergoing CRT implantation (with or without defibrillator) were prospectively included from October 2009 to December 2022. Demographic, clinical, electrocardiographic and echocardiographic variables as well as outcomes in the follow-up period were recorded from electronic clinical records and telephone interview. Fragmentation of the QRS complex was defined by the presence of different RSR′ patterns including an additional R-wave (R′), notching of the R-wave and S-wave or the presence of more than 1R′ in two contiguous leads corresponding to a main coronary artery territory. Results Finally, 244 patients were included. Mean age at device implantation was 71.8 years (standard deviation, SD ±9.8 years), 79.5% were male and 40.2% were diabetic. Mean left ventricle ejection fraction (LVEF) at baseline was 24.9% and the aetiology was non-ischaemic in 50.8% of the patients and ischaemic in 49.2%. 40.2% had prior history of acute myocardial infarction. Pre-implantation fQRS was found in 58.6% of the patients and mostly in inferior leads. CRT with defibrillator implantation was performed in 71.4% of the patients. The median follow-up time was 27.4 months. At the end of this period, mean LVEF was 33.2% and 76.6% presented NYHA class I-II. 28.7% of the patients died during the follow-up. A multivariate survival study using Cox regression revealed that the only variables were associated with death from any cause were maintaining NYHA functional class III-IV, the aetiology of the LV systolic dysfunction and pre-implantation fQRS. Specifically, the presence of pre-implantation fQRS in the surface ECG was a powerful predictor for all-cause mortality (HR 2.62; 95% CI 1.40-4.91). Kaplan-Meier curves for all-cause mortality are presented in Figure 1. Conclusions According to our results pre-implantation fQRS in the surface ECG is a powerful independent predictor of all-cause mortality in patients undergoing CRT implantation. Consequently, these patients could benefit from stricter follow-up. However, further studies are required to support our results.Figure 1.Kaplan-Meier curves.

Prognostic influence of left atrial strain in heart failure patients with intermediate ECG criteria for cardiac resynchronization therapy

Abstract Background Heart failure (HF) patients with left bundle branch block (LBBB) with QRS width ≥150ms is class I indication for cardiac resynchronization therapy (CRT), whereas it is still controversy to CRT response in HF with QRS width 120-149ms or non-LBBB as intermediate ECG criteria in routine echocardiography. Left atrial (LA) adverse remodeling is a prognostic marker in patients with heart failure. Nevertheless, the prognostic significance of LA strain (LAS) imaging in HF patients with intermediate ECG criteria is not well understood. Purpose The objective of this study was to determine the prognostic value of LA deformation analysis in patients undergoing CRT implantation who met the intermediate ECG criteria. Methods We studied 94 patients who were defined routine CRT indication by the clinical guidelines. LAS was calculated as the average strain using apical two- and four-chamber views. The predefined endpoint was death, hospitalization due to worsening HF for 5 years after CRT implantation. Results Of the 94 patients, LAS is feasible in 76 patients (81%) with aged 69 ± 11 years, 30±8% of LV ejection fraction. 46 patients (61%) fulfilled intermediate ECG criteria. The predefined endpoint occurred in 43 patients (57%). The median LAS was 15%. LAS below 15% were associated with a high probability of unfavorable outcomes over 5 years (Log-rank, p = 0.002). After adjusting for left ventricular ejection fraction, LAS remained significantly associated with poor outcomes (hazard ratio 0.92, 95% confidence interval 0.87-0.97, p&amp;lt;0.001). There is no difference in the probability of poor outcomes between LBBB with QRS width ≥150ms and intermediate ECG criteria. Patients with intermediate ECG criteria and LAS &amp;lt;15% had worse outcome than in those with LBBB with QRS width ≥150ms and in those with intermediate ECG criteria patients with LAS ≥15% (Log-rank: p = 0.046, p = 0.029, respectively). Conclusion Baseline LA functional deterioration by deformation analysis was significantly associated with poor outcome after CRT implantation regardless of the ECG criteria for CRT indication and has promise for clinical utility.

Abstract 17529: Controlling Nutritional Status (CONUT) Score Predicts Adverse Events in Patients With Chronic Heart Failure Following Cardiac Resynchronization Therapy

Introduction: Malnutrition and cachexia have been reported to be associated with poor outcomes in patients with chronic heart failure (CHF). Hypothesis: This study aimed to investigate the association between malnutrition determined by the Controlling Nutritional Status (CONUT) score and adverse events in patients with CHF after cardiac resynchronization therapy (CRT). Methods: This retrospective study evaluated 134 patients (90 male, mean age 70.6 ± 9.7 years; 31 (23%) old myocardial infarction, 57 (43%) dilated cardiomyopathy, 46 (34%) others) who underwent CRT implantation between 2004 and 2020 and were followed for at least one year after the operation (mean, 1070 ± 649 days). CONUT score was calculated in those patients before the CRT implantation. Patients with CONUT score of 0 - 4 (n = 106) were allocated to the preserved nutrition group, and those with CONUT score 5 - 12 (n = 28) were allocated to the malnutrition group. The primary endpoint was hospitalization for heart failure. The secondary endpoint was ventricular arrhythmias including both ventricular tachycardia and ventricular fibrillation, requiring anti-tachycardia pacing, cardioversion. Results: During the follow-up period, hospitalization for heart failure occurred in 55 patients (41%). Ventricular arrhythmias occurred in 31 patients (23%), and 15(48.6%) patients required cardioversion. Kaplan-Meier survival analysis showed a higher incidence of hospitalization for heart failure (log-rank 6.55; P = 0.011) and ventricular arrhythmias (log-rank 6.55; P = 0.011) in the malnutrition group. Cox proportional hazards regression analysis revealed that malnutrition group had a higher incidence of hospitalization for heart failure (hazard ratio 2.11; 95% CI:1.14 - 3.70, P = 0.018) and ventricular arrhythmias (hazard ratio 2.53; 95% CI:1.17 - 5.19, P = 0.020). Conclusions: Malnutrition determined by the CONUT score predicts adverse events in patients undergoing CRT implantation.

Long-term outcome of cardiac resynchronization therapy patients in the elderly

Heart failure (HF) is a leading cause of mortality and hospitalization in the elderly. However, data are scarce about their response to device treatment such as cardiac resynchronization therapy (CRT). We aimed to evaluate the age-related differences in the effectiveness of CRT, procedure-related complications, and long-term outcome. Between 2000 and 2020, 2656 patients undergoing CRT implantation were registered and analyzed retrospectively. Patients were divided into 3 groups according to their age: group I, < 65; group II, 65–75; and group III, > 75 years. The primary endpoint was the echocardiographic response defined as a relative increase > 15% in left ventricular ejection fraction (LVEF) within 6 months, and the secondary endpoint was the composite of all-cause mortality, heart transplantation, or left ventricular assist device implantation. Procedure-related complications were also assessed. After implantation, LVEF showed significant improvement both in the total cohort [28% (IQR 24/33) vs. 35% (IQR 28/40); p < 0.01)] and in each subgroup (27% vs. 34%; p < 0.01, 29% vs. 35%; p < 0.01, 30% vs. 35%; p < 0.01). Response rate was similar in the 3 groups (64% vs. 62% vs. 56%; p = 0.41). During the follow-up, 1574 (59%) patients died. Kaplan–Meier curves revealed a significantly lower survival rate in the older groups (log-rank p < 0.001). The cumulative complication rates were similar among the three age groups (27% vs. 28% vs. 24%; p = 0.15). Our results demonstrate that CRT is as effective and safe therapy in the elderly as for young ones. The present data suggest that patients with appropriate indications benefit from CRT in the long term, regardless of age.

Predicting the survival benefit of cardiac resynchronization therapy with defibrillator function for non-ischemic heart failure-Role of the Goldenberg risk score.

Primary prevention of sudden cardiac death (SCD) in non-ischemic heart failure (HF) patients remains a topic of debate at cardiac resynchronization therapy (CRT) implantation requiring individual risk assessment. Using the Goldenberg SCD risk score, we aimed to predict, which non-ischemic HF patients will benefit from the addition of an implantable cardioverter defibrillator (ICD) to CRT at long-term. Between 2000 and 2018 non-ischemic HF patients undergoing CRT implantation were collected into our retrospective registry. The Goldenberg risk score (GRS) was calculated by the presence of atrial fibrillation, New York Heat Association (NYHA) class > 2, age > 70 years, blood urea nitrogen > 26 mg/dl and QRS > 120 ms. The primary endpoint was all-cause mortality, heart transplantation or left ventricular assist device implantation. From 667 patients, 347 (52%) underwent cardiac resynchronization therapy-pacemaker (CRT-P), 320 (48%) cardiac resynchronization therapy-defibrillator (CRT-D) implantations. During the median follow up time of 4.3 years, 306 (46%) patients reached the primary endpoint (CRT-D 37% vs. CRT-P 63%; p < 0.001). CRT-D patients were younger (64 vs. 69 years; p < 0.001), infrequently females (26 vs. 39%; p < 0.001), and had a lower ejection fraction (27 vs. 29%; p < 0.01) compared to CRT-P patients. After GRS calculation, patients were dichotomized by low (< 3) and high (≥ 3) scores. CRT-D patients with low GRS showed a mortality benefit compared to CRT-P (HR 0.68; 95% CI 0.48-0.96; p = 0.03), high-risk patients did not (HR 0.84; 95% CI 0.62-1.13; p = 0.26). In our non-ischemic cohort, patients with low GRS showed a clear long-term mortality benefit by adding ICD to CRT, however, in high-risk patients no further benefit could be observed.

Left Bundle Branch Area Pacing versus Biventricular Pacing for Cardiac Resynchronization Therapy on Morbidity and Mortality.

Left bundle branch area pacing (LBBAP) has emerged as an alternative to biventricular pacing (BVP) for cardiac resynchronization therapy (CRT). We aimed to compare the morbidity and mortality associated with LBBAP versus BVP in patients undergoing CRT implantation. Consecutive patients who received CRT from two high-volume implantation centers were retrospectively recruited. The primary endpoint was a composite of all-cause death and heart failure hospitalization, and the secondary endpoint was all-cause death. A total of 491 patients receiving CRT (154 via LBBAP and 337 via BVP) were included, with a median follow-up of 31months. The primary endpoint was reached by 21 (13.6%) patients in the LBBAP group, as compared with 74 (22.0%) patients in the BVP group [hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.43-1.14, P = 0.15]. There were 10 (6.5%) deaths in the LBBAP group, as compared with 31 (9.2%) in the BVP group (HR 0.91, 95% CI 0.44-1.86, P = 0.79). No significant difference was observed in the risk of either the primary or secondary endpoint between LBBAP and BVP after multivariate Cox regression (HR 0.74, 95% CI 0.45-1.23, P = 0.24, and HR 0.77, 95% CI 0.36-1.67, P = 0.51, respectively) or propensity score matching (HR 0.72, 95% CI 0.41-1.29, P = 0.28, and HR 0.69, 95% CI 0.29-1.65, P = 0.40, respectively). LBBAP was associated with a comparable effect on morbidity and mortality relative to BVP in patients with indications for CRT.

Abstract 10950: Prognostic Utility of Left Atrio-Ventricular Deformation Analysis in Heart Failure Patients Underwent Cardiac Resynchronization Therapy

Introduction: Left atrial (LA) adverse remodeling is a prognostic marker in patients with heart failure. Although left ventricular (LV) deformation analysis by speckle tracking method has been shown as a useful predictive marker after cardiac resynchronization therapy (CRT), the prognostic impact of baseline left atrio-ventricular functional deterioration on the outcome of patients underwent CRT implantation. Hypothesis: We hypothesized that a combination of LV and LA deformation assessments by speckle-tracking strain is of additive prognostic value in patients with CRT. Methods: We retrospectively analyzed 71 participants who received CRT implantation in the clinical guidelines. Global longitudinal strain (GLS) was defined as averaged strain from 3 apical views. LA strain (LAS) was calculated as the average strain using apical two- and four-chamber views. The endpoint was composite outcome of death, hospitalization due to worsening HF for 5 years after CRT implantation. Results: Out of 71 patients aged 68 ± 11 years with 162±24ms of QRS duration and 30±8% of LV ejection fraction, 40 patients (56%) met the endpoint. The patients were stratified using median value of LAS (-15%) and GLS (-8%). LAS and GCS remained significantly associated with poor outcome after adjusting for LVEF (LAS hazard ratio, 0.92; p&lt;0.001; GLS hazard ratio, 1.15; p = 0.01). Kaplan-Meier analysis showed that the subgroup of patients with both lower median values of LAS and GLS had the worst outcomes over 5 years (Figure, Log-rank, p = 0.008). In the sequential Cox model, predictive value of baseline LV ejection fraction (χ2 = 4.9) was improved by the addition of GLS (χ2 = 9.2, p = 0.037), and further improved by the addition of LAS (χ2 = 15.8, p = 0.005). C-statistics also improved from 0.62 to 0.73. Conclusions: Baseline left atrio-ventricular functional deterioration by deformation analysis were significantly associated with poor outcome after CRT implantation.

Why does CRT work better in women?

Abstract Introduction It has been recently postulated that cardiac resynchronization therapy (CRT) might have a higher efficacy in women, with a greater reverse cardiac remodeling in this population. The reasons for these differences are not yet completely understood. We aimed to detect sex differences in the degree of ventricular asynchrony (VA) and mitral regurgitation (MR) in patients undergoing CRT implantation. Methods We analyzed baseline characteristics of a prospective international clinical trial that compared CRT response rate in a HF population with a comparable distribution of men and women (BIOWOMEN). A total of 408 patients were analyzed. The degree of mitral regurgitation and intra and inter-ventricular asynchrony was assessed by independent echocardiographers in a core lab. Inter-ventricular asynchrony was defined as an interventricular mechanical delay greater than 40ms and intra-ventricular asynchrony as differences greater than 50ms among regional pre-ejection periods. Multivariable logistic regression was performed using commercial data analysis software. Results As expected, ventricular asynchrony was dependent on QRS duration and the presence of LBBB (p&amp;lt;0.01). Baseline QRS duration was significantly shorter in women than men (155.85±19.0 in women vs 160.4±21.6, p=0.02). However, for a similar QRS duration, there were no differences in asynchrony parameters between the two groups (p=0.43; Figure 1). Female sex was associated with a significantly higher proportion of mitral regurgitation for a given QRS duration, which was independent of the etiology (p=0.05). Conclusions In our analysis, for a given QRS duration there was not a higher degree of asynchrony in women with HF. However, female sex was associated with a significantly higher proportion of mitral regurgitation for a given QRS duration irrespective of baseline HF etiology. Further investigations are needed to establish a possible link between these findings and better CRT outcomes in women. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): BIOTRONIK SE &amp; Co. KG

Effect of single ventricular premature contractions on response to cardiac resynchronization therapy

BackgroundWe lack data on the effect of single premature ventricular contractions (PVCs) on the clinical and echocardiographic response after cardiac resynchronization therapy (CRT) device implantation. We aimed to assess the predictive value of PVCs at early, 1 month-follow up on echocardiographic response and all-cause mortality.MethodsIn our prospective, single-center study, 125 heart failure patients underwent CRT implantation based on the current guidelines. Echocardiographic reverse remodeling was defined as a ≥ 15% improvement in left ventricular ejection fraction (LVEF), end-systolic volume (LVESV), or left atrial volume (LAV) measured 6 months after CRT implantation. All-cause mortality was investigated by Wilcoxon analysis.ResultsThe median number of PVCs was 11,401 in those 67 patients who attended the 1-month follow-up. Regarding echocardiographic endpoints, patients with less PVCs develop significantly larger LAV reverse remodeling compared to those with high number of PVCs. During the mean follow-up time of 2.1 years, 26 (21%) patients died. Patients with a higher number of PVCs than our median cut-off value showed a higher risk of early all-cause mortality (HR 0.97; 95% CI 0.38–2.48; P = 0.04). However, when patients were followed up to 9 years, its significance diminished (HR 0.78; 95% CI 0.42–1.46; P = 0.15).ConclusionsIn patients undergoing CRT implantation, lower number of PVCs predicted atrial remodeling and showed a trend for a better mortality outcome. Our results suggest the importance of the early assessment of PVCs in cardiac resynchronization therapy and warrant further investigations.

Prognostic value of the MELD-XI score in patients undergoing cardiac resynchronization therapy.

AimsMulti‐organ dysfunction was recently reported to be a common condition in patients with heart failure (HF). The Model for End‐stage Liver Disease eXcluding International normalized ratio (MELD‐XI) score reflects liver and kidney function. The prognostic relevance of this score has been reported in patients with a variety of cardiovascular diseases who are undergoing interventional therapies. However, the relationship between the severity of hepatorenal dysfunction assessed by the MELD‐XI score and the long‐term clinical outcomes of HF patients receiving cardiac resynchronization therapy (CRT) has not been evaluated.Methods and resultsClinical records of 283 patients who underwent CRT implantation between March 2003 and October 2020 were retrospectively evaluated (mean age 67 ± 12, 22.6% female). Blood samples were collected before CRT implantation. Patients were divided into three groups based on tertiles of the MELD‐XI score: first tertile (MELD‐XI = 9.44, n = 95), second tertile (9.44 < MELD‐XI < 13.4, n = 94), and third tertile (MELD‐XI ≥ 13.4, n = 94). The primary endpoint was all‐cause mortality. Compared with the other groups, the third tertile group exhibited significantly older age, higher prevalence of diabetes mellitus and hypertension, lower haemoglobin level, and higher N‐terminal pro‐brain natriuretic peptide level (all P < 0.05). The functional CRT response rate was also significantly lower in the third tertile group (P = 0.011). During a median follow‐up of 30 months (inter‐quartile range, 9–67), 105 patients (37.1%) died. Kaplan–Meier analysis revealed that patients with a higher MELD‐XI score had a greater risk of all‐cause mortality (log‐rank test: P < 0.001). Even after adjustment for clinically relevant factors and a conventional risk score, the MELD‐XI score was still associated with mortality (adjusted hazard ratio: 1.04, 95% confidence interval: 1.00–1.07, P = 0.014, and adjusted hazard ratio: 1.04, 95% confidence interval: 1.01–1.09, P = 0.005, respectively). A higher MELD‐XI score was associated with a greater risk of all‐cause mortality than a lower MELD‐XI score regardless of whether a pacemaker or defibrillator was implanted (log‐rank test: P = 0.010 and P < 0.001, respectively).ConclusionsImpaired hepatorenal function assessed by the MELD‐XI score was associated with older age, higher prevalence of multiple co‐morbidities, severity of HF, lower CRT response rates, and subsequent all‐cause mortality in HF patients undergoing CRT implantation. These results suggest that the MELD‐XI score can provide additional prognostic information and may be useful for improving risk stratification in this population.

Abstract 12159: Impact of Ischemic Heart Disease on Cardiac Resynchronization Therapy - Analysis From National Inpatient Sample

Introduction: Comparative outcomes of hospitalizations for Cardiac Resynchronization Therapy (CRT) implantation procedures with and without coexisting Ischemic Heart Diseases (IHD) have not been studied at national level databases. We attempted to assess outcomes and baseline characteristics in these hospitalizations based on the National Inpatient Sample (NIS). Hypothesis: Ischemic heart disease worsens inpatient outcomes in patients undergoing CRT implantation. Methods: We conducted a retrospective analysis of hospitalizations for CRT implantation from the National Inpatient Sample (NIS) between 2013 and 2014. ICD-9 Billing codes were used to identify the target population. The primary outcomes were inpatient mortality, and hospital length and cost of stay. Results: A total of 11057 cases were identified. IHD was listed as any diagnosis in 66% of these hospitalizations. The mean age was 72.5 and 66.9 years for CRT implantation with and without IHD, respectively. Hospitalizations without IHD were more likely to be female (44% vs. 25%; p=0.01). Patients in the CRT with IHD group had a higher comorbidity burden with a higher proportion of hypertension, chronic kidney disease, anemia, peripheral artery disease, and congestive heart failure (Table 1). Inpatient mortality was similar between both groups (OR 1.17, CI 0.75-1.81). The IHD cohort had higher rates of cardiac arrest (OR 1.30, CI 1.05-1.62), acute kidney injury (OR 1.21, CI 1.08-1.35), longer length and a higher cost of stay (Table 1). Conclusions: IHD is associated with higher costs, longer length of stay, and higher rates of cardiac arrest. However, the in-hospital mortality was not different between the two groups. Higher incidence of cardiac arrest in patients with CRT and IHD underlines the importance of ICD with CRT. The clinical implication is that the threshold of selecting a CRT-D device in patients eligible for CRT therapy should be lower in patients with IHD vis-à-vis patients without IHD.

Impact of atrial fibrillation and biventricular pacing percentage on long-term outcome in patients with heart failure treated with cardiac resynchronization therapy

Abstract Introduction A history of preoperative atrial fibrillation (AF) has been found to be associated with unfavorable outcomes, higher risks of non-response to cardiac resynchronization therapy (CRT) and loss of biventricular pacing (BivP). We aimed to assess the impact of AF and BivP on long-term outcomes in heart failure patients treated with CRT. Methods We retrospectively enrolled 227 patients undergoing CRT implantation between 2013 and 2020 according to the current guidelines. 118 patients were included in our analysis, from whom all data were available. Clinical, electrocardiographic and echocardiographic parameters were evaluated at baseline and 6 months after CRT. Response to CRT was defined as an increase in left ventricular ejection fraction (LVEF) &amp;gt;10%. We considered an effective delivery of BivP &amp;gt;98%. The primary endpoint was the composite endpoint of hospitalization due to HF or death for any cause. Results 118 patients were included (mean age 69±11 years, 66.1% males, 39.8% ischemic etiology; baseline LVEF was 27,6±6%). Patients were divided into AF (n=42; 35,6%) and sinus rhythm (SR (n=76); 18 patients had permanent AF. AF patients had higher index left atrial volume and left ventricular mass (p&amp;lt;0.001). Mean follow-up time was 43±18 months. BivP percentage was significantly superior in SR than in AF patients (98.1±2.1% vs 94.7±4.5%, p&amp;lt;0.001), with 75% of SR patients having BivP&amp;gt;98% vs 30,3% of AF patients (p&amp;lt;0.001). There were no differences in preoperative parameters between them. The response rate to CRT was higher in SR patients when compared to AF patients (63,2% vs 40,5%, p=0.021). Indeed, the variation of LVEF was higher in SR patients (12±10% vs 7±9%, p=0.012). During follow-up, there were significant differences between AF and SR patients in the primary endpoint (73,8% vs 42,6%, p&amp;lt;0.001), and mortality for any cause (26,2% vs 9,2% p=0.014; p&amp;lt;0.001). In a multivariate logistic regression analysis pre-procedural AF and BivP (%) were the only independent predictors of primary endpoint (HR 8.949, 95% CI 2.429 – 32.972, p=0.001; HR 0.719, 95% CI 0.526 – 0.982, p=0.038, respectively). Kaplan-Meier curves showed that event survival free was higher in SR patients when compared to AF (69±4 vs 24±3 months, p&amp;lt;0.001) Conclusion Pre - procedural AF and BivP are independent predictors of the occurrence of a primary endpoint of hospitalization due to HF or death for any cause in HF patients submitted to CRT. Funding Acknowledgement Type of funding sources: None.

10-year survival in patients undergoing cardiac resynchronization therapy

Abstract Background Advanced heart failure with reduced ejection fraction (HFrEF) is associated with poor prognosis. Cardiac resynchronization therapy (CRT) is an effective method of treatment for advanced HFrEF to reduce HF hospitalizations and mortality. Nonetheless, very long-term observation of HF patients undergoing CRT implantation is scarce. Aim To assess very long-term survival (≥10 years) and predictors of shorter survival (death within 10 years from CRT implantation). Methods We screened a large dataset of CRT population from a tertiary care university hospital comprising consecutive HF patients implanted with CRT from 2002 through 2019 to select those who were alive ≥10 years and those who died within 10 years since device implantation. We analyzed various patients' baseline, clinical and procedural characteristics and sought for predictors of mortality within 10 years from CRT implantation. Results Of 1059 CRT patients, 143 (13.5%) were alive ≥10 years since CRT implantation. On multivariable regression analysis the independent predictors for all-cause death up to 10 years from CRT implantation were as follows: age, HR 1.02, 95% CI 1.01–1.31; male sex, 1.27, 95% CI 1.01–1.60; primary prevention of sudden cardiac death (SCD), HR 0.72, 95% CI 0.58–0.89; ischemic cardiomyopathy, HR 1.41, 95% CI 1.76–1.70; NYHA class at implantation, HR 1.38, 95% CI 1.17–1.62; baseline left ventricle ejection fraction (EF), HR 0.97, 95% CI 0.96–0.98; severe mitral regurgitation, HR 1.38; 95% CI 1.08–1.75; baseline NT-proBNP concentration, HR 1.00, 95% CI 1.00–1.00; and creatinine level, HR 1.00, 95% CI 1.00–1.01. Conclusions In a real-life patient population with CRT only 13.5% survived over 10 years since device implantation. Independent predictors for death within 10 years since CRT implantation were older age, male sex, secondary prevention of SCD, ischemic and more advanced heart failure along with renal impairment. Funding Acknowledgement Type of funding sources: None.

Prognostic impact of heart mate risk score among elderly heart failure patients with non-responder for cardiac resynchronization therapy

Abstract Background For patients with severe heart failure (HF) who are not eligible for transplantation, there is destination therapy (DT) that uses a continuous flow left ventricular assist device (LVAD). Implantation of LVAD improves HF and can be expected to improve the prognosis of life. Elderly refractory HF patients with non-responders for cardiac resynchronization therapy (CRT) may benefit from LVAD as DT. In considering indications of LVAD as DT for the elderly in Japan, conditions such as a low risk of Heart Mate Risk Score (HMRS) have been raised. HMRS has been shown to correlate with mortality in the cohort of LVAD patients enrolled in the Heartmate II trials. Purpose Because elderly CRT non-responder refractory HF patients are not indicated for transplantation and may benefit from LVAD as DT in Japan, we aimed to investigate the HMRS and prognosis among elderly CRT non-responders. Methods Of 467 patients underwent CRT implantation between 2000 and 2015, 157 were aged 65–75 years old. Of which 59 patients who could be determined to be non-responders based on echocardiographic data were included in this study. The primary endpoint was all-cause mortality, the secondary was readmission for HF and appropriate implantable cardioverter defibrillator (ICD) therapy. Results The patients' mean age was 68 years, males were 71%. The mean serum creatinine value was 1.1 mg/dl, albumin was 3.8 mg/dl, and BNP was 383 pg/ml. The mean left ventricular ejection fraction (LVEF) was 26%. The subjects were divided into 3 groups according to HMRS. The average of HMRS was 2.2, the low-risk group included 17 (29%) patients, the medium was 22 (37%), and the high was 20 (34%). There was no significant difference in age, LVEF, BNP, and NYHA functional classification at the time of CRT implantation between three groups. In the low-risk group, creatinine and INR were significantly lower, and albumin was significantly higher compared to the high-risk group. BNP tended to be lower in the low-risk group, but there was no significant difference. The mortality rate by HMRS was 12% in the low-risk group, 36% in the medium-risk group, and 50% in the high-risk group. On the Kaplan-Meier analysis, the low-risk group had a significantly lower mortality rate than the high-risk group (Figure). Furthermore, focusing on HF readmission, the rate of readmission was 59% in the low-risk group, 86% in the medium -risk group, and 65% in the high-risk group, and there was no significant difference between three groups. There was also no significant difference in appropriate ICD therapy between three groups. Conclusion Approximately 30% of elderly non-responders of CRT are in the low-risk group by HMRS and their mortality was lower than that of the other two groups. These elderly CRT non-responder patients might be considered a candidate for DT in Japan. Funding Acknowledgement Type of funding sources: None.

B-AB23-02 IMPACT OF DIABETES MELLITUS ON CARDIAC RESYNCHRONIZATION THERAPY - ANALYSIS FROM NATIONAL INPATIENT SAMPLE

Diabetes mellitus (DM) is a frequent co-morbidity and a prognostic risk factor in patients with heart failure and reduced left ventricle ejection fraction. Comparative outcomes of hospitalizations for Cardiac Resynchronization Therapy (CRT) with and without coexisting DM have limited large scale data. We assessed baseline characteristics and outcomes of CRT implantation in patients with coexisting DM. A retrospective analysis was conducted of hospitalizations for CRT implantation from the National Inpatient Sample (NIS) between 2013 and 2014 using ICD 9 codes. A total of 11,057 hospitalizations for CRT implantation were identified. DM type I and II were listed as a secondary diagnosis in 39% of cases. The mean ages were 70.7 and 70.5 years (p 0.460) in hospitalizations with and without DM, respectively. Those without DM had a higher proportion of white race (78.9 vs. 73.1, p< 0.001). Patients with DM had a higher baseline comorbidity burden as shown in the figure, such as hypertension, ischemic heart disease, obesity, anemia, chronic kidney disease, chronic liver disease, peripheral arterial disease, and congestive heart failure. There was a statistically significant increased length of stay in hospitalizations with DM (6.6 vs 6.1 days, <0.01). Inpatient mortality (OR 1.15, CI 0.77-1.72) and cost of hospital stay (mean difference, $1,007) were not statistically different between the groups. DM is associated with increased length of hospital stay in patients with CRT implantation. Optimal management of diabetes mellitus in patients undergoing CRT implantation can help decrease length of hospital stay.

Short Term Predictors of Success after Cardiac Resynchronization Therapy

AbstractBackground: In patients with symptomatic Heart Failure (HF) and wide QRS duration, cardiac resynchronization therapy (CRT) causes reduction of morbidity and mortality. However, it's unclear which patient features predict short‐term response to this device therapy. Aim of the Work: The research aimed to study which cases characteristics could expect short-term clinical and echocardiographic response to CRT. Subjects and methods: This prospective cohort study involved 40 patients indicated for CRT device. The study was conducted in the cardiology departments, faculty of medicine, Zagazig University, and Police hospital at the period from October 2018 to October 2020. Clinical, laboratory, electrocardiographic, and echocardiographic assessments were performed pre and six months after implantation. Results: Forty patients undergoing CRT implantation were included among which, 30 (75%) patients were considered responders after six months. From the present study, the responders to CRT were more frequently to be females with younger age than non -responders. Non-ischemic HF, left bundle branch block (LBBB) morphology and New York Heart Association (NYHA) functional class III were significantly more frequent in responders. Furthermore, responders had significantly wider baseline QRS duration, smaller baseline LV diastolic and systolic dimension and volumes, greater ejection fraction, lower levels of brain natriuretic peptide (BNP), and more baseline intra-ventricular dyssynchrony. Conclusion: We concluded that pre-implantation independent Predictors of good CRT response are LBBB morphology, septal to posterior wall mechanical delay, wide QRS duration, interventricular mechanical delay, NYHA functional class III, and lower levels of BNP. Large scale study is recommended for further verification of study results.

Exploring sex-specific patterns of mortality predictors among patients undergoing cardiac resynchronization therapy: a machine learning approach

Abstract Background The relative importance of variables explaining sex differences in outcomes is scarcely explored in patients undergoing cardiac resynchronization therapy (CRT). Purpose We sought to implement and evaluate machine learning (ML) algorithms for the prediction of 1- and 3-year all-cause mortality in patients undergoing CRT implantation. We also aimed to assess the sex-specific differences and similarities in the predictors of mortality using ML approaches. Methods A retrospective registry of 2191 CRT patients (75% males) was used in the current analysis. ML models were implemented in 6 partially overlapping patient subsets (all patients, females or males with 1- or 3-year follow-up data available). Each cohort was randomly split into a training (80%) and a test set (20%). After hyperparameter tuning with 10-fold cross-validation in the training set, the best performing algorithm was also evaluated in the test set. Model discrimination was quantified using the area under the receiver-operating characteristic curves (AUC) and the associated 95% confidence intervals. The most important predictors were identified using the permutation feature importances method. Results Conditional inference random forest exhibited the best performance with AUCs of 0.728 [0.645–0.802] and 0.732 [0.681–0.784] for the prediction of 1- and 3-year mortality, respectively. Etiology of heart failure, NYHA class, left ventricular ejection fraction and QRS morphology had higher predictive power in females, whereas hemoglobin was less important than in males. The importance of atrial fibrillation and age increased, whereas the relevance of serum creatinine decreased from 1- to 3-year follow-up in both sexes. Conclusions Using advanced ML techniques in combination with easily obtainable clinical features, our models effectively predicted 1- and 3-year all-cause mortality in patients undergoing CRT implantation. The in-depth analysis of features has revealed marked sex differences in mortality predictors. These results support the use of ML-based approaches for the risk stratification of patients undergoing CRT implantation. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary