Farhangee Arsalan, Davies Mark J, Mesina Mihai, Morgan David Roger, Sieniewicz Benjamin J, Meyrick Robyn, Gaughan Katie, Mîndrilă Ion
Department of Cardiology, Milton Keynes University Hospital, Milton Keynes MK6 5LD, UK.
Department of Cardiology, Plymouth NHS Trust Foundation, Derriford Hospital, Plymouth PL6 8DH, UK.
J Clin Med. 2024 May 7;13(10):2755. doi: 10.3390/jcm13102755.
The efficacy of de novo cardiac resynchronisation therapy (CRT) in patients with heart failure (HF), left ventricular systolic dysfunction (LVSD), and a broad QRS morphology is well established. However, the optimal stage for upgrading patients with existing pacemakers (PPMs) or implantable cardioverter-defibrillators (ICDs) and HF with high-burden right ventricular (RV) pacing remains uncertain. Thus, this multicentre retrospective analysis compared patients with pre-existing PPMs or ICDs who underwent CRT upgrades to investigate the appropriate stage for CRT implantation in these patients and to assess the validity of treating both PPM and ICD recipients under the same recommendation level in the current guidelines. A total of 151 participants underwent analysis in this study, comprising 93 upgrades to cardiac resynchronisation therapy with pacemaker (CRT-P) and 58 upgrades to cardiac resynchronisation therapy with defibrillator (CRT-D) across three centres in the UK. The aim of the study was to investigate the safety and efficacy of upgrading to CRT from an existing conventional pacemaker or an ICD in the context of high-burden RV pacing. The analysis was conducted separately for each group, assessing changes in echocardiographic parameters, functional New York Heart Association (NYHA) class, and procedure-related complications. The PPM group had a higher percentage RVP burden compared to the ICD group. Post-upgrade, NYHA functional class and EF and LV volumes improved in both groups; however, the response to an upgrade from a pacemaker was greater compared to an upgrade from an ICD. Post-procedural complication risks were similar across the two subgroups but significantly higher compared to de novo implantation. Within the CRT-P subgroup, participants exhibited better responses than their CRT-D counterparts, evident both in echocardiographic improvements and clinical outcomes. Furthermore, patients with non-ischemic cardiomyopathy (NICM) were better responders than those with ischaemic cardiomyopathy. These findings suggest that international guidelines should consider approaching each subgroup separately in the future.
对于心力衰竭（HF）、左心室收缩功能障碍（LVSD）且QRS波形态增宽的患者，从头开始进行心脏再同步治疗（CRT）的疗效已得到充分证实。然而，对于现有起搏器（PPM）或植入式心脏复律除颤器（ICD）患者以及伴有高负担右心室（RV）起搏的HF患者，升级的最佳阶段仍不确定。因此，这项多中心回顾性分析比较了接受CRT升级的现有PPM或ICD患者，以研究这些患者进行CRT植入的合适阶段，并评估在当前指南相同推荐水平下治疗PPM和ICD接受者的有效性。本研究共纳入151名参与者进行分析，其中包括英国三个中心的93例升级为带起搏器的心脏再同步治疗（CRT-P）和58例升级为带除颤器的心脏再同步治疗（CRT-D）。该研究的目的是调查在高负担RV起搏情况下，从现有的传统起搏器或ICD升级到CRT的安全性和有效性。对每组分别进行分析，评估超声心动图参数、纽约心脏协会（NYHA）功能分级以及与手术相关并发症的变化。与ICD组相比，PPM组的RVP负担百分比更高。升级后，两组的NYHA功能分级、射血分数（EF）和左心室容积均有所改善；然而，与从ICD升级相比，从起搏器升级的反应更大。两个亚组的术后并发症风险相似，但与从头开始植入相比显著更高。在CRT-P亚组中，参与者的反应比CRT-D亚组更好，这在超声心动图改善和临床结果中均有体现。此外，非缺血性心肌病（NICM）患者的反应比缺血性心肌病患者更好。这些发现表明，国际指南未来应考虑对每个亚组分别进行处理。
