Marijon Eloi, Leclercq Christophe, Narayanan Kumar, Boveda Serge, Klug Didier, Lacaze-Gadonneix Jonathan, Defaye Pascal, Jacob Sophie, Piot Olivier, Deharo Jean-Claude, Perier Marie-Cecile, Mulak Genevieve, Hermida Jean-Sylvain, Milliez Paul, Gras Daniel, Cesari Olivier, Hidden-Lucet Françoise, Anselme Frederic, Chevalier Philippe, Maury Philippe, Sadoul Nicolas, Bordachar Pierre, Cazeau Serge, Chauvin Michel, Empana Jean-Philippe, Jouven Xavier, Daubert Jean-Claude, Le Heuzey Jean-Yves
Cardiology Department, European Georges Pompidou Hospital, Paris, France Paris Descartes University, Paris, France Paris Cardiovascular Research Centre, Paris, France.
Pontchaillou University Hospital and INSERM 1099, CIC-IT 804 Rennes, France.
Eur Heart J. 2015 Nov 1;36(41):2767-76. doi: 10.1093/eurheartj/ehv455. Epub 2015 Sep 1.
The choice of resynchronization therapy between with (CRT-D) and without (CRT-P) a defibrillator remains a contentious issue. Cause-of-death analysis among CRT-P, compared with CRT-D, patients could help evaluate the extent to which CRT-P patients would have additionally benefited from a defibrillator in a daily clinical practice.
A total of 1705 consecutive patients implanted with a CRT (CRT-P: 535 and CRT-D: 1170) between 2008 and 2010 were enrolled in CeRtiTuDe, a multicentric prospective follow-up cohort study, with specific adjudication for causes of death at 2 years. Patients with CRT-P compared with CRT-D were older (P < 0.0001), less often male (P < 0.0001), more symptomatic (P = 0.0005), with less coronary artery disease (P = 0.003), wider QRS (P = 0.002), more atrial fibrillation (P < 0.0001), and more co-morbidities (P = 0.04). At 2-year follow-up, the annual overall mortality rate was 83.80 [95% confidence interval (CI) 73.41-94.19] per 1000 person-years. The crude mortality rate among CRT-P patients was double compared with CRT-D (relative risk 2.01, 95% CI 1.56-2.58). In a Cox proportional hazards regression analysis, CRT-P remained associated with increased mortality (hazard ratio 1.54, 95% CI 1.07-2.21, P = 0.0209), although other potential confounders may persist. By cause-of-death analysis, 95% of the excess mortality among CRT-P subjects was related to an increase in non-sudden death.
When compared with CRT-D patients, excess mortality in CRT-P recipients was mainly due to non-sudden death. Our findings suggest that CRT-P patients, as currently selected in routine clinical practice, would not potentially benefit with the addition of a defibrillator.
在有除颤器（CRT-D）和无除颤器（CRT-P）的心脏再同步治疗之间进行选择仍然是一个有争议的问题。对CRT-P患者与CRT-D患者进行死因分析，有助于评估在日常临床实践中CRT-P患者额外使用除颤器可能带来的获益程度。
在2008年至2010年期间，共有1705例连续植入心脏再同步治疗设备的患者（CRT-P：535例，CRT-D：1170例）纳入了CeRtiTuDe研究，这是一项多中心前瞻性随访队列研究，对2年时的死因进行了专门判定。与CRT-D患者相比，CRT-P患者年龄更大（P<0.0001），男性比例更低（P<0.0001），症状更明显（P = 0.0005），冠心病更少（P = 0.003），QRS波更宽（P = 0.002），房颤更多（P<0.0001），合并症更多（P = 0.04）。在2年随访时，年总死亡率为每1000人年83.80例[95%置信区间（CI）73.41 - 94.19]。CRT-P患者的粗死亡率是CRT-D患者的两倍（相对风险2.01，95%CI 1.56 - 2.58）。在Cox比例风险回归分析中，CRT-P仍然与死亡率增加相关（风险比1.54，95%CI 1.07 - 2.21，P = 0.0209），尽管其他潜在混杂因素可能仍然存在。通过死因分析，CRT-P患者中95%的额外死亡率与非猝死增加有关。
与CRT-D患者相比，CRT-P接受者的额外死亡率主要归因于非猝死。我们的研究结果表明，按照目前常规临床实践中选择的CRT-P患者，增加除颤器可能不会带来潜在获益。
