Upgrade and de novo cardiac resynchronization therapy: Impact of paced or intrinsic QRS morphology on outcomes and survival

Anita Wokhlu, Robert F. Rea, Samuel J Asirvatham, Tracy Webster, Kelly Brooke, David O. Hodge, Heather J. Wiste, YingXue Dong, David L. Hayes, Yong-Mei Cha

Research output: Contribution to journalArticle

51 Citations (Scopus)

Abstract

Background: Cardiac resynchronization therapy (CRT) improves outcomes in patients with left bundle branch block (LBBB), but the benefits of CRT in patients with other QRS morphologies or previous pacing are uncertain. Objective: The purpose of this study was to describe outcomes in patients with prior right ventricular pacing and non-LBBB morphologies. Methods: We studied 505 patients who underwent de novo CRT (n = 338) or CRT upgrade (n = 167). De novo patients were categorized by underlying QRS morphology: LBBB (67%), right bundle branch block (RBBB; 11%), intraventricular conduction delay (IVCD; 13%), and QRS <120 ms (9%). Upgrade patients were categorized by the percentage of previous ventricular pacing. Results: Patients were followed for death over a median of 2.6 years (interquartile range 1.6-4.0). New York Heart Association (NYHA) functional class and echocardiographic improvements were similar in de novo and upgrade patients. However, within the de novo group, NYHA improvements were less in patients with RBBB (0.3 ± 0.8; P = .014) or IVCD (0.2 ± 0.7; P = .001) than in those with LBBB (0.7 ± 0.8). These patients had less left ventricular functional improvement as well. Survival was comparable after de novo versus upgrade CRT (61% vs 63% at 4 years; P = .906). No clinical or survival differences were noted in upgrade patients based on the percentage of previous pacing. However, survival in de novo CRT recipients with RBBB (32%) was lower than in those with LBBB (66%; P <.001), and RBBB independently predicted death (hazard ratio 3.5, confidence interval 1.9-6.5; P <.001). Conclusion: RBBB and IVCD result in less clinical improvement or worsened survival after CRT. Additional selection criteria may be beneficial in identifying potential responders with RBBB, IVCD, or narrow QRS.

Original languageEnglish (US)
Pages (from-to)1439-1447
Number of pages9
JournalHeart Rhythm
Volume6
Issue number10
DOIs
StatePublished - Oct 2009

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Cardiac Resynchronization Therapy
Bundle-Branch Block
Survival
Patient Selection
Confidence Intervals

Keywords

  • Biventricular pacing
  • Cardiac resynchronization therapy
  • Left bundle branch block
  • QRS morphology
  • Right bundle branch block
  • Upgrade
  • Ventricular pacing

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Upgrade and de novo cardiac resynchronization therapy : Impact of paced or intrinsic QRS morphology on outcomes and survival. / Wokhlu, Anita; Rea, Robert F.; Asirvatham, Samuel J; Webster, Tracy; Brooke, Kelly; Hodge, David O.; Wiste, Heather J.; Dong, YingXue; Hayes, David L.; Cha, Yong-Mei.

In: Heart Rhythm, Vol. 6, No. 10, 10.2009, p. 1439-1447.

Research output: Contribution to journalArticle

Wokhlu, Anita ; Rea, Robert F. ; Asirvatham, Samuel J ; Webster, Tracy ; Brooke, Kelly ; Hodge, David O. ; Wiste, Heather J. ; Dong, YingXue ; Hayes, David L. ; Cha, Yong-Mei. / Upgrade and de novo cardiac resynchronization therapy : Impact of paced or intrinsic QRS morphology on outcomes and survival. In: Heart Rhythm. 2009 ; Vol. 6, No. 10. pp. 1439-1447.
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abstract = "Background: Cardiac resynchronization therapy (CRT) improves outcomes in patients with left bundle branch block (LBBB), but the benefits of CRT in patients with other QRS morphologies or previous pacing are uncertain. Objective: The purpose of this study was to describe outcomes in patients with prior right ventricular pacing and non-LBBB morphologies. Methods: We studied 505 patients who underwent de novo CRT (n = 338) or CRT upgrade (n = 167). De novo patients were categorized by underlying QRS morphology: LBBB (67{\%}), right bundle branch block (RBBB; 11{\%}), intraventricular conduction delay (IVCD; 13{\%}), and QRS <120 ms (9{\%}). Upgrade patients were categorized by the percentage of previous ventricular pacing. Results: Patients were followed for death over a median of 2.6 years (interquartile range 1.6-4.0). New York Heart Association (NYHA) functional class and echocardiographic improvements were similar in de novo and upgrade patients. However, within the de novo group, NYHA improvements were less in patients with RBBB (0.3 ± 0.8; P = .014) or IVCD (0.2 ± 0.7; P = .001) than in those with LBBB (0.7 ± 0.8). These patients had less left ventricular functional improvement as well. Survival was comparable after de novo versus upgrade CRT (61{\%} vs 63{\%} at 4 years; P = .906). No clinical or survival differences were noted in upgrade patients based on the percentage of previous pacing. However, survival in de novo CRT recipients with RBBB (32{\%}) was lower than in those with LBBB (66{\%}; P <.001), and RBBB independently predicted death (hazard ratio 3.5, confidence interval 1.9-6.5; P <.001). Conclusion: RBBB and IVCD result in less clinical improvement or worsened survival after CRT. Additional selection criteria may be beneficial in identifying potential responders with RBBB, IVCD, or narrow QRS.",
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T2 - Impact of paced or intrinsic QRS morphology on outcomes and survival

AU - Wokhlu, Anita

AU - Rea, Robert F.

AU - Asirvatham, Samuel J

AU - Webster, Tracy

AU - Brooke, Kelly

AU - Hodge, David O.

AU - Wiste, Heather J.

AU - Dong, YingXue

AU - Hayes, David L.

AU - Cha, Yong-Mei

PY - 2009/10

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N2 - Background: Cardiac resynchronization therapy (CRT) improves outcomes in patients with left bundle branch block (LBBB), but the benefits of CRT in patients with other QRS morphologies or previous pacing are uncertain. Objective: The purpose of this study was to describe outcomes in patients with prior right ventricular pacing and non-LBBB morphologies. Methods: We studied 505 patients who underwent de novo CRT (n = 338) or CRT upgrade (n = 167). De novo patients were categorized by underlying QRS morphology: LBBB (67%), right bundle branch block (RBBB; 11%), intraventricular conduction delay (IVCD; 13%), and QRS <120 ms (9%). Upgrade patients were categorized by the percentage of previous ventricular pacing. Results: Patients were followed for death over a median of 2.6 years (interquartile range 1.6-4.0). New York Heart Association (NYHA) functional class and echocardiographic improvements were similar in de novo and upgrade patients. However, within the de novo group, NYHA improvements were less in patients with RBBB (0.3 ± 0.8; P = .014) or IVCD (0.2 ± 0.7; P = .001) than in those with LBBB (0.7 ± 0.8). These patients had less left ventricular functional improvement as well. Survival was comparable after de novo versus upgrade CRT (61% vs 63% at 4 years; P = .906). No clinical or survival differences were noted in upgrade patients based on the percentage of previous pacing. However, survival in de novo CRT recipients with RBBB (32%) was lower than in those with LBBB (66%; P <.001), and RBBB independently predicted death (hazard ratio 3.5, confidence interval 1.9-6.5; P <.001). Conclusion: RBBB and IVCD result in less clinical improvement or worsened survival after CRT. Additional selection criteria may be beneficial in identifying potential responders with RBBB, IVCD, or narrow QRS.

AB - Background: Cardiac resynchronization therapy (CRT) improves outcomes in patients with left bundle branch block (LBBB), but the benefits of CRT in patients with other QRS morphologies or previous pacing are uncertain. Objective: The purpose of this study was to describe outcomes in patients with prior right ventricular pacing and non-LBBB morphologies. Methods: We studied 505 patients who underwent de novo CRT (n = 338) or CRT upgrade (n = 167). De novo patients were categorized by underlying QRS morphology: LBBB (67%), right bundle branch block (RBBB; 11%), intraventricular conduction delay (IVCD; 13%), and QRS <120 ms (9%). Upgrade patients were categorized by the percentage of previous ventricular pacing. Results: Patients were followed for death over a median of 2.6 years (interquartile range 1.6-4.0). New York Heart Association (NYHA) functional class and echocardiographic improvements were similar in de novo and upgrade patients. However, within the de novo group, NYHA improvements were less in patients with RBBB (0.3 ± 0.8; P = .014) or IVCD (0.2 ± 0.7; P = .001) than in those with LBBB (0.7 ± 0.8). These patients had less left ventricular functional improvement as well. Survival was comparable after de novo versus upgrade CRT (61% vs 63% at 4 years; P = .906). No clinical or survival differences were noted in upgrade patients based on the percentage of previous pacing. However, survival in de novo CRT recipients with RBBB (32%) was lower than in those with LBBB (66%; P <.001), and RBBB independently predicted death (hazard ratio 3.5, confidence interval 1.9-6.5; P <.001). Conclusion: RBBB and IVCD result in less clinical improvement or worsened survival after CRT. Additional selection criteria may be beneficial in identifying potential responders with RBBB, IVCD, or narrow QRS.

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KW - Cardiac resynchronization therapy

KW - Left bundle branch block

KW - QRS morphology

KW - Right bundle branch block

KW - Upgrade

KW - Ventricular pacing

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