Long‐Term Outcomes of Cardiac Resynchronization Therapy Using Apical Versus Nonapical Left Ventricular Pacing

Q: What is the clinical evidence from this study?

Study design: Observational. Population: Systolic heart failure (n=1189). Intervention: Apical left ventricular lead position vs. Nonapical left ventricular lead position. Primary outcome: Cardiac mortality (adjusted HR 0.74, 95% CI 0.56-0.99).

Q: What does this research mean for the field?

An apical left ventricular lead position in cardiac resynchronization therapy is associated with lower cardiac mortality compared to a nonapical position. Novelty: ClaimNovelty.CONTRADICTORY. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

Francisco Leyva; Abbasin Zegard; Robin J. Taylor; Paul Foley; Fraz Umar; Kiran Patel; Jonathan Panting; Peter van Dam; Frits W. Prinzen; Howard Marshall; Tian Qiu

doi:10.1161/jaha.117.008508

August 21, 2018Journal of the American Heart AssociationOpen Access

Long‐Term Outcomes of Cardiac Resynchronization Therapy Using Apical Versus Nonapical Left Ventricular Pacing

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Key result

Apical LV lead position in CRT linked to ~26% lower cardiac mortality vs nonapical position.

adjusted HR 0.74
95% CI 0.56-0.99
n=1,189

Figures

Why the study?

Does an apical left ventricular lead position reduce cardiac mortality compared to a nonapical position in patients undergoing cardiac resynchronization therapy?

Study Design

Type

Observational (n=1,189)

Multicenter

Yes

Structured PICO

Does an apical left ventricular lead position reduce cardiac mortality compared to a nonapical position in patients undergoing cardiac resynchronization therapy?

P

Population

1,189 patients with systolic heart failure and a wide QRS duration undergoing cardiac resynchronization therapy, followed for a median of 6.0 years.

E

Exposure

Apical left ventricular (LV) lead position during cardiac resynchronization therapy (CRT).

C

Comparator

Nonapical (basal or midventricular) left ventricular (LV) lead position during cardiac resynchronization therapy (CRT).

O

Outcome

Cardiac mortality (including cardiac transplantation or implantation of a ventricular assist device).hard clinical

Main Result

Hazard Ratio: 0.74 (95% CI 0.56–0.99)

In patients receiving cardiac resynchronization therapy, an apical left ventricular lead position is associated with significantly lower long-term cardiac mortality compared to a nonapical position, primarily driven by reduced pump failure and sudden cardiac death.

Limitations

Retrospective observational design
Nonrandomized, meaning unobserved variables may have contributed to outcomes
Reasons for choosing LV pacing sites were not assessed
Fluoroscopy may not permit precise localization of lead position compared to advanced imaging techniques
Retrospective, observational, nonrandomized design
Unobserved variables may have contributed to outcomes

Implication

Apical LV lead positioning should not yet change CRT practice; challenges prior observational consensus favoring nonapical sites and requires randomized confirmation.

Abstract

Background Experimental evidence indicates that left ventricular ( LV ) apical pacing is hemodynamically superior to nonapical LV pacing. Some studies have shown that an LV apical lead position is unfavorable in cardiac resynchronization therapy. We sought to determine whether an apical LV lead position influences cardiac mortality after cardiac resynchronization therapy. Methods and Results In this retrospective observational study, the primary end point of cardiac mortality was assessed in relation to longitudinal (basal, midventricular, or apical) and circumferential (anterior, lateral, or posterior) LV lead positions, as well as right ventricular (apical or septal), assigned using fluoroscopy. Lead positions were assessed in 1189 patients undergoing cardiac resynchronization therapy implantation over 15 years. After a median follow-up of 6.0 years (interquartile range: 4.4-7.7 years), an apical LV lead position was associated with lower cardiac mortality than a nonapical position (adjusted hazard ratio: 0.74; 95% confidence interval, 0.56-0.99) after covariate adjustment. There were no differences in total mortality or heart failure hospitalization. Death from pump failure was lower with apical than nonapical positions (adjusted hazard ratio: 0.69; 95% confidence interval, 0.51-0.94). Compared with a basal position, an apical LV position was also associated with lower risk of sudden cardiac death (adjusted hazard ratio: 0.34; 95% confidence interval, 0.13-0.93). No differences emerged between circumferential LV lead positions or right ventricular positions with respect to any end point. Conclusions In recipients of cardiac resynchronization therapy, an apical LV lead position was associated with better long-term cardiac survival than a nonapical position. This effect was due to a lower risk of pump failure and sudden cardiac death.

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Cite This Study

Leyva et al. (2018) conducted an observational in Systolic heart failure (n=1,189). Apical left ventricular lead position vs. Nonapical left ventricular lead position was evaluated on Cardiac mortality (adjusted HR 0.74, 95% CI 0.56-0.99). An apical left ventricular lead position during cardiac resynchronization therapy was associated with a significantly lower risk of cardiac mortality compared to a nonapical position (adjusted HR 0.74).

synapsesocial.com/papers/6a1a1435196cd56b09eb2323 https://doi.org/10.1161/jaha.117.008508