Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom. Electronic address: http://www.doctorleyva.com.
Aston Medical Research Institute, Aston Medical School, Aston University, Birmingham, United Kingdom.
J Am Coll Cardiol. 2017 Sep 5;70(10):1216-1227. doi: 10.1016/j.jacc.2017.07.712.
Recent studies have cast doubt on the benefit of cardiac resynchronization therapy (CRT) with defibrillation (CRT-D) versus pacing (CRT-P) for patients with nonischemic cardiomyopathy (NICM). Left ventricular myocardial scar portends poor clinical outcomes.
The aim of this study was to determine whether CRT-D is superior to CRT-P in patients with NICM either with (+) or without (-) left ventricular midwall fibrosis (MWF), detected by cardiac magnetic resonance.
Clinical events were quantified in patients with NICM who were +MWF (n = 68) or -MWF (n = 184) who underwent cardiac magnetic resonance prior to CRT device implantation.
In the total study population, +MWF emerged as an independent predictor of total mortality (adjusted hazard ratio [aHR]: 2.31; 95% confidence interval [CI]: 1.45 to 3.68), total mortality or heart failure hospitalization (aHR: 2.02; 95% CI: 1.32 to 3.09), total mortality or hospitalization for major adverse cardiac events (aHR: 2.02; 95% CI: 1.32 to 3.07), death from pump failure (aHR: 1.95; 95% CI: 1.11 to 3.41), and sudden cardiac death (aHR: 3.75; 95% CI: 1.26 to 11.2) over a maximum follow-up period of 14 years (median 3.8 years [interquartile range: 2.0 to 6.1 years] for +MWF and 4.6 years [interquartile range: 2.4 to 8.3 years] for -MWF). In separate analyses of +MWF and -MWF, total mortality (aHR: 0.23; 95% CI: 0.07 to 0.75), total mortality or heart failure hospitalization (aHR: 0.32; 95% CI: 0.12 to 0.82), and total mortality or hospitalization for major adverse cardiac events (aHR: 0.30; 95% CI: 0.12 to 0.78) were lower after CRT-D than after CRT-P in +MWF but not in -MWF.
In patients with NICM, CRT-D was superior to CRT-P in +MWF but not -MWF. These findings have implications for the choice of device therapy in patients with NICM.
最近的研究对非缺血性心肌病（NICM）患者心脏再同步治疗（CRT）加除颤（CRT-D）与起搏（CRT-P）的益处提出了质疑。左心室心肌瘢痕预示着较差的临床结局。
本研究旨在确定心脏磁共振检测到左心室中层心肌纤维化（MWF）（+）或无（-）的 NICM 患者中，CRT-D 是否优于 CRT-P。
在 CRT 设备植入前接受心脏磁共振检查的 NICM 患者中，对具有（+）MWF（n=68）或（-）MWF（n=184）的患者进行临床事件量化。
在总研究人群中，+MWF 是总死亡率（校正后的危险比[aHR]：2.31；95%置信区间[CI]：1.45 至 3.68）、总死亡率或心力衰竭住院（aHR：2.02；95%CI：1.32 至 3.09）、总死亡率或主要不良心脏事件住院（aHR：2.02；95%CI：1.32 至 3.07）、泵衰竭所致死亡（aHR：1.95；95%CI：1.11 至 3.41）和心源性猝死（aHR：3.75；95%CI：1.26 至 11.2）的独立预测因素，随访时间最长为 14 年（中位数 3.8 年[四分位距：2.0 至 6.1 年]为+MWF，4.6 年[四分位距：2.4 至 8.3 年]为-MWF）。在对+MWF 和-MWF 的单独分析中，与 CRT-P 相比，CRT-D 后总死亡率（aHR：0.23；95%CI：0.07 至 0.75）、总死亡率或心力衰竭住院（aHR：0.32；95%CI：0.12 至 0.82）和总死亡率或主要不良心脏事件住院（aHR：0.30；95%CI：0.12 至 0.78）较低，但在-MWF 中没有差异。
在 NICM 患者中，CRT-D 优于 CRT-P 在+MWF 中，但不是在-MWF 中。这些发现对 NICM 患者选择器械治疗具有重要意义。
