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dt) Improvement Predicts Chronic Resynchronization Pacing Efficacy for Refractory Heart Failure in Congenital Heart
S60 Journal of Cardiac Failure Vol. 16 No. 8S August 2010 patients regarding anticipated survival after VT ablation. Methods: This retrospective study included consecutive patients with HF and reduced left ventricular ejection fraction (LVEF) # 40% who underwent ablation for recurrent VT between January 1999 and September 2008. Routine clinical echocardiography was performed prior to ablation. Clinical and echocardiographic data were analyzed in relation to survival. Results: Characteristics of the 355 patients were: mean age 63 years, 87% male, CAD in 68%, mean LVEF 25 6 8%, 92% with ICD. During a mean follow-up of 48 months after VT ablation, there were 138 deaths (39%). Annualized mortality was 10%. In a stepwise multivariate Cox regression analysis RV dysfunction (hazard ration [HR] 1.78) and tricuspid regurgitation (HR 5 1.77) were independent predictors of all-cause mortality. Actuarial survival at 5 years was significantly better among patients free from $ moderate RV dysfunction (68% vs. 41%, p ! 0.01; figure). In patients who had $ moderate RV dysfunction and also showed $ moderate tricuspid regurgitation and estimated systolic PA pressures O 40 mmHg, survival at 2 years was only 46% and at 5 years was 27%. The best survival was in pts without RV dysfunction, TR, or PA systolic pressure O 40: 82% and 72% at 2 and 5 years. RV function was a predictor regardless of HF etiology. Conclusions: Despite low LVEF, patients with recurrent VT who have good RV function have a favorable prognosis after VT ablation. RV dysfunction identifies a high-risk group for whom there is a need for additional intervention to improve survival.
190 Heart Failure Patients Admitted With Elevated Cardiac Troponin Post Implantable Cardioverter-Defibrillator Firing Carry the Highest Mortality Rates Emad F. Aziz1, Juan Pablo Cordova1, Balaji Pratap1, Manpreet Singh1, David Newman2, Dan Musat1, Eyal Herzog1; 1Cardiology, St. Luke’s-Roosevelt Hospital Center, New York, NY; 2Emergency Medicine, St. Luke’s-Roosevelt Hospital Center, New York, NY Background: The consequences of the electrical discharge over the myocardiumin patients with implantable cardioverter-defibrillator (ICD) is continuously debated and its implications are controversial Cardiac troponin T (cTnT) elevations have been reported to occur after discharges, the relation between cTnT elevation after ICD firing and patients co-morbidity is still to be established. We aim to evaluate the outcome of heart failure patients with elevated cTnT after ICD discharge to establish its utility as a prognostic factor. Methods: This is a retrospective observational study comprised of 155 patients (mean (SD) age 61 (15) years, 45 women) who were admitted to our institution after receiving spontaneous (n 5 57) ICD discharges were studied. cTnT was measured between 12 and 24 h after ICD discharge. The relationship between cTnT levels and all-cause mortality was assessed in univariate and multivariate analyses. Results: During a median followup period of 66 months, 38 (24%) patients died. Patients with a post-discharge cTnT level of O0.12 ng/ml had worse survival than those with cTnT !0.12 ng/ml. Using adjusted Cox multivariate analysis for older age, history of diabetes, heart failure exacerbation and hypertension raised cTnT remained the most significant predictor of mortality.
Conclusions: Elevation of cTnT after ICD discharge, particularly in patient admitted with heart failure, is a risk factor for mortality that is independent of other common clinical factors that predict survival in such patients.
decreased EF and wide QRS. The objective of this study was to determine if these beneficial effects are seen in clinical practice. Methods: We studied all patients who received a first CRT device at St. Paul Heart Clinic with EF 35%, QRS R 120 ms and NYHA class III/IV HF during years 2003-2008 (Group 1). A subset of patients (Group 2) who met entrance criteria for the COMPANION CRT study, (hospitalization for HF in the year prior to CRT and not previously RV paced) were studied. Data were obtained just prior to CRT and at about 1 year post-CRT. ECHO’s were read blinded to condition. We compared these ‘‘real world’’ results to published results from the COMPANION study (Group 3). Results: Baseline characteristics are shown in the Table:
Number Age (yrs) Male sex (%) Ischemic etiology (%) NYHA class III (%) BP (mm Hg) QRS (ms) EF LVEDD (cm) LVESD (cm)
Introduction: Large multicenter studies have shown that CRT improves symptoms, LV size and function, hospitalization rate and mortality in patients with advanced HF,
Group 2
Group 3
593 77 71 60 88 118/69 156 27 6.1 5.2
214 75 67 62 83 117/68 151 25 6.2 5.4
1212 67 67 55 87 111/68 160 21 6.8
Assessment of clinical status showed 27.8% of the patients markedly improved, 36.8% mildly improved, 21.1% unchanged and 4.4% worsened. EF increased by 6.2% + /- 10.4. LVEDD decreased by 4mm +/- 8 and LVESD decreased by 5mm +/- 9. Kaplan Meier curves of survival demonstrated annual mortality in Groups 1-3 respectively of 4.8%, 6.0% and 12%. Annual mortality for the US population, mean age 77, is 3.7%. Annual mortality or CV hospitalization was 10.2%, 11.6%, 30% in the 3 groups respectively. Conclusions: CRT outcomes in a large clinical practice are as good or better than those reported in the COMPANION multicenter trial. These data suggest that the benefits observed in clinical trials can be observed in ‘‘real world’’ patients.
192 Acute Contractility (dP/dt) Improvement Predicts Chronic Resynchronization Pacing Efficacy for Refractory Heart Failure in Congenital Heart Peter P. Karpawich1, Harinder Singh1, Kathleen Zelin1; 1Pediatric Cardiology, Children’s Hospital Michigan, Wayne State University, Detroit, MI Background: Heart transplant for adults with medically refractory heart failure (HF) and congenital heart disease (CHD) may not be an option due to organ availability. Current criteria of patient (pt) selection for cardiac resynchronization pacing (CRT) including QRS duration are not applicable since many pts have preexisting pacemakers (PM) due to surgical heart block. CRT success has been defined as a 15% improvement in ejection fraction. However, due to CHD anatomy, ECHO estimation of contractility is suboptimal. As a result, overall predictors of efficacy of chronic CRT among CHD pts is limited. Purpose: Since CRT implant is expensive and often difficult in CHD we sought to better define which pts would benefit from CRT by pre-implant catheterization (cath) hemodynamics, including QRS duration, pressures and contractility indices (dP/dt). Methods: From 1999-2007, 17 CHD pts (9-31y, mean 21) with medically refractory HF (NYHA 2-4) considered for transplant underwent cath with comparative hemodynamic recordings following intrinsic sinus or paced rhythms with temporary biventricular pacing. Successful CRT response was defined as an improvement in dP/dt by 15% from baseline. Results: CHD was variable including repaired septal defects, transposition, tetralogy of Fallot, single ventricle, congenital AV block. Preexisting PM were in 15/17pts. Acute CRT pacing was effective in 10/17 (58%) pts (mean age 21y) with at least a 15% increase in dP/dt (mean 572 vs 761mmHg-sec (33%)). Following CRT, all these pts improved clinically (NYHA 1-2) and were removed from HT listing. Follow-up cath (1-11y later, mean 3.6) showed continued dP/dt improvement (mean 865). Neither QRS duration nor end diastolic pressures (EDP) showed any changes (Table). Of the 7 pts who did not show acute improvement (mean age 23y), the 2 youngest (9, 13y) had HT, 1 was lost to follow-up, 3 remain in NYHA 2-4 on the list and 1 removed from HT consideration due to other clinical issues. Conclusion: Current criteria for CRT do not apply to pts with CHD. Pre-CRT cath with direct contractility measurements help determine which pts should benefit from chronic CRT. Effective CRT provides positive cardiac remodeling with improved clinical well-being and delays the need for HT in CHD pts with HF.
191 Cardiac Resynchronization Therapy Outcomes in Clinical Practice: Comparison With the COMPANION Study Alan J. Bank1, Kevin V. Burns1, Ryan M. Gage1, Daniel B. Vatterott1, Mariam Sajady1, Spencer H. Kubo1; 1St. Paul Heart Clinic, St. Paul, MN
Group 1
Comparative Cath Values (mean 6 sem)
QRS (msec) EDP (mmHg) dP/dt (mmHg-sec)
Intrinsic pre CRT
Acute CRT
Chronic CRT
157 6 9 17 6 2 572 6 71
138 6 9 15 6 2 761 6 83
151 6 9 14 6 2 865 6 131*
*p ! 0.05 compared with intrinsic
190 Heart Failure Patients Admitted With Elevated Cardiac Troponin Post Implantable Cardioverter-Defibrillator Firing Carry the Highest Mortality Rates Emad F. Aziz1, Juan Pablo Cordova1, Balaji Pratap1, Manpreet Singh1, David Newman2, Dan Musat1, Eyal Herzog1; 1Cardiology, St. Luke’s-Roosevelt Hospital Center, New York, NY; 2Emergency Medicine, St. Luke’s-Roosevelt Hospital Center, New York, NY Background: The consequences of the electrical discharge over the myocardiumin patients with implantable cardioverter-defibrillator (ICD) is continuously debated and its implications are controversial Cardiac troponin T (cTnT) elevations have been reported to occur after discharges, the relation between cTnT elevation after ICD firing and patients co-morbidity is still to be established. We aim to evaluate the outcome of heart failure patients with elevated cTnT after ICD discharge to establish its utility as a prognostic factor. Methods: This is a retrospective observational study comprised of 155 patients (mean (SD) age 61 (15) years, 45 women) who were admitted to our institution after receiving spontaneous (n 5 57) ICD discharges were studied. cTnT was measured between 12 and 24 h after ICD discharge. The relationship between cTnT levels and all-cause mortality was assessed in univariate and multivariate analyses. Results: During a median followup period of 66 months, 38 (24%) patients died. Patients with a post-discharge cTnT level of O0.12 ng/ml had worse survival than those with cTnT !0.12 ng/ml. Using adjusted Cox multivariate analysis for older age, history of diabetes, heart failure exacerbation and hypertension raised cTnT remained the most significant predictor of mortality.
Conclusions: Elevation of cTnT after ICD discharge, particularly in patient admitted with heart failure, is a risk factor for mortality that is independent of other common clinical factors that predict survival in such patients.
decreased EF and wide QRS. The objective of this study was to determine if these beneficial effects are seen in clinical practice. Methods: We studied all patients who received a first CRT device at St. Paul Heart Clinic with EF 35%, QRS R 120 ms and NYHA class III/IV HF during years 2003-2008 (Group 1). A subset of patients (Group 2) who met entrance criteria for the COMPANION CRT study, (hospitalization for HF in the year prior to CRT and not previously RV paced) were studied. Data were obtained just prior to CRT and at about 1 year post-CRT. ECHO’s were read blinded to condition. We compared these ‘‘real world’’ results to published results from the COMPANION study (Group 3). Results: Baseline characteristics are shown in the Table:
Number Age (yrs) Male sex (%) Ischemic etiology (%) NYHA class III (%) BP (mm Hg) QRS (ms) EF LVEDD (cm) LVESD (cm)
Introduction: Large multicenter studies have shown that CRT improves symptoms, LV size and function, hospitalization rate and mortality in patients with advanced HF,
Group 2
Group 3
593 77 71 60 88 118/69 156 27 6.1 5.2
214 75 67 62 83 117/68 151 25 6.2 5.4
1212 67 67 55 87 111/68 160 21 6.8
Assessment of clinical status showed 27.8% of the patients markedly improved, 36.8% mildly improved, 21.1% unchanged and 4.4% worsened. EF increased by 6.2% + /- 10.4. LVEDD decreased by 4mm +/- 8 and LVESD decreased by 5mm +/- 9. Kaplan Meier curves of survival demonstrated annual mortality in Groups 1-3 respectively of 4.8%, 6.0% and 12%. Annual mortality for the US population, mean age 77, is 3.7%. Annual mortality or CV hospitalization was 10.2%, 11.6%, 30% in the 3 groups respectively. Conclusions: CRT outcomes in a large clinical practice are as good or better than those reported in the COMPANION multicenter trial. These data suggest that the benefits observed in clinical trials can be observed in ‘‘real world’’ patients.
192 Acute Contractility (dP/dt) Improvement Predicts Chronic Resynchronization Pacing Efficacy for Refractory Heart Failure in Congenital Heart Peter P. Karpawich1, Harinder Singh1, Kathleen Zelin1; 1Pediatric Cardiology, Children’s Hospital Michigan, Wayne State University, Detroit, MI Background: Heart transplant for adults with medically refractory heart failure (HF) and congenital heart disease (CHD) may not be an option due to organ availability. Current criteria of patient (pt) selection for cardiac resynchronization pacing (CRT) including QRS duration are not applicable since many pts have preexisting pacemakers (PM) due to surgical heart block. CRT success has been defined as a 15% improvement in ejection fraction. However, due to CHD anatomy, ECHO estimation of contractility is suboptimal. As a result, overall predictors of efficacy of chronic CRT among CHD pts is limited. Purpose: Since CRT implant is expensive and often difficult in CHD we sought to better define which pts would benefit from CRT by pre-implant catheterization (cath) hemodynamics, including QRS duration, pressures and contractility indices (dP/dt). Methods: From 1999-2007, 17 CHD pts (9-31y, mean 21) with medically refractory HF (NYHA 2-4) considered for transplant underwent cath with comparative hemodynamic recordings following intrinsic sinus or paced rhythms with temporary biventricular pacing. Successful CRT response was defined as an improvement in dP/dt by 15% from baseline. Results: CHD was variable including repaired septal defects, transposition, tetralogy of Fallot, single ventricle, congenital AV block. Preexisting PM were in 15/17pts. Acute CRT pacing was effective in 10/17 (58%) pts (mean age 21y) with at least a 15% increase in dP/dt (mean 572 vs 761mmHg-sec (33%)). Following CRT, all these pts improved clinically (NYHA 1-2) and were removed from HT listing. Follow-up cath (1-11y later, mean 3.6) showed continued dP/dt improvement (mean 865). Neither QRS duration nor end diastolic pressures (EDP) showed any changes (Table). Of the 7 pts who did not show acute improvement (mean age 23y), the 2 youngest (9, 13y) had HT, 1 was lost to follow-up, 3 remain in NYHA 2-4 on the list and 1 removed from HT consideration due to other clinical issues. Conclusion: Current criteria for CRT do not apply to pts with CHD. Pre-CRT cath with direct contractility measurements help determine which pts should benefit from chronic CRT. Effective CRT provides positive cardiac remodeling with improved clinical well-being and delays the need for HT in CHD pts with HF.
191 Cardiac Resynchronization Therapy Outcomes in Clinical Practice: Comparison With the COMPANION Study Alan J. Bank1, Kevin V. Burns1, Ryan M. Gage1, Daniel B. Vatterott1, Mariam Sajady1, Spencer H. Kubo1; 1St. Paul Heart Clinic, St. Paul, MN
Group 1
Comparative Cath Values (mean 6 sem)
QRS (msec) EDP (mmHg) dP/dt (mmHg-sec)
Intrinsic pre CRT
Acute CRT
Chronic CRT
157 6 9 17 6 2 572 6 71
138 6 9 15 6 2 761 6 83
151 6 9 14 6 2 865 6 131*
*p ! 0.05 compared with intrinsic