Nemer David M, Patel Divyang R, Madden Ruth A, Wilkoff Bruce L, Rickard John W, Tarakji Khaldoun G, Varma Niraj, Hussein Ayman A, Wazni Oussama M, Kanj Mohamed, Baranowski Bryan, Cantillon Daniel J
Department of Cardiovascular Medicine, Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
Department of Cardiovascular Medicine, Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
JACC Clin Electrophysiol. 2021 Jan;7(1):62-72. doi: 10.1016/j.jacep.2020.07.022. Epub 2020 Oct 28.
This study compared rates of procedural success and complications between de novo cardiac resynchronization therapy (CRT) implantation versus upgrade, including characterization of technical challenges.
CRT upgrade is common, but data are limited on the incidence of procedural success and complications as compared to de novo implantation.
All patients who underwent a transvenous CRT procedure at a single institution between 2013 and 2018 were reviewed for procedure outcome, 90-day complications, reasons for unsuccessful left ventricular lead delivery, and the presence of venous occlusive disease (VOD) that required a modified implantation technique.
Among 1,496 patients, 947 (63%) underwent de novo implantation and 549 (37%) underwent device upgrade. Patients who received a device upgrade were older (70 ± 12 years vs. 68 ± 13 years; p < 0.01), with a male predominance (75% vs. 66%; p < 0.01) and greater prevalence of comorbidities. There was no difference in the rate of procedural success between de novo and upgrade CRT procedures (97% vs. 96%; p = 0.28) or 90-day complications (5.1% vs. 4.6%; p = 0.70). VOD was present in 23% of patients who received a device upgrade and was more common among patients with a dual-chamber versus a single-chamber device (26% vs. 9%; p < 0.001). Patients with and without VOD had a similar composite outcome of procedural failure or complication (8.0% vs. 7.8%; p = 1.0).
Rates of procedural success and complications were no different between de novo CRT implantations and upgrades. VOD frequently increased procedural complexity in upgrades, but alternative management strategies resulted in similar outcomes. Routine venography before CRT upgrade may aid in procedural planning and execution of these strategies.
本研究比较了初次心脏再同步治疗（CRT）植入与升级之间的手术成功率和并发症发生率，包括技术挑战的特征。
CRT升级很常见，但与初次植入相比，手术成功率和并发症发生率的数据有限。
回顾了2013年至2018年在单一机构接受经静脉CRT手术的所有患者的手术结果、90天并发症、左心室导线植入失败的原因以及需要改良植入技术的静脉闭塞性疾病（VOD）的存在情况。
在1496例患者中，947例（63%）接受了初次植入，549例（37%）接受了设备升级。接受设备升级的患者年龄较大（70±12岁对68±13岁；p<0.01），男性占主导（75%对66%；p<0.01），合并症患病率更高。初次和升级CRT手术的手术成功率（97%对96%；p=0.28）或90天并发症发生率（5.1%对4.6%；p=0.70）没有差异。23%接受设备升级的患者存在VOD，在双腔设备患者中比单腔设备患者更常见（26%对9%；p<0.001）。有和没有VOD的患者手术失败或并发症的综合结果相似（8.0%对7.8%；p=1.0）。
初次CRT植入和升级之间的手术成功率和并发症发生率没有差异。VOD经常增加升级手术的复杂性，但替代管理策略导致了相似的结果。CRT升级前的常规静脉造影可能有助于这些策略的手术规划和实施。
