Huang Hao, Deng Yu, Cheng Sijing, Yu Yu, Liu Xi, Niu Hongxia, Chen Xuhua, Cai Chi, Gu Min, Hua Wei
Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 100037 Beijing, China.
Rev Cardiovasc Med. 2023 Sep 22;24(9):269. doi: 10.31083/j.rcm2409269. eCollection 2023 Sep.
Left ventricular ejection fraction (LVEF) remains the basic reference for the prevention of sudden cardiac death (SCD) patients, while right ventricular (RV) abnormalities have now been associated with SCD risk. A modified benefit assessment tool incorporating RV function parameters in consideration of implantable cardioverter defibrillators (ICD) insertion should be taken into account.
We enrolled 954 chronic heart failure (CHF) patients (age 58.8 13.1 years; 79.0% male) with quantitative measurements of right ventricular outflow tract diameter (RVOTD) before ICD implantation and then divided them according to the median level of RVOTD. The predictive value of RVOTD in life-threatening ventricular tachycardia (VT)/ventricular fibrillation (VF) vs. non-arrhythmic mortality (defined as death without prior sustained VT/VF), was evaluated respectively. Based on RVOTD and other identified risk factors, a simple risk assessment tool, RVOTD-ICD benefit score, was developed.
A higher RVOTD level was significantly associated with an increased risk of VT/VF (per 1 standard deviation (SD) increase, hazard ratio [HR], 1.22; 95% confidence interval [CI], 1.11-1.33; = 0.002) but not non-arrhythmic mortality (per 1 SD increase, hazard ratio, 0.93; 95% CI, 0.66-1.33; = 0.709) after multivariable adjustment. Three benefit groups were created based on RVOTD-ICD benefit score, which was calculated from VT/VF score (younger age, higher RVOTD, diuretic use, prior non-sustainable VT, prior sustainable VT/VF) and non-arrhythmic mortality scores (older age, renin-angiotensin-aldosterone system inhibitors use, diabetes, higher left ventricular end-diastolic diameter, New York Heart Association III/IV, higher N-terminal pro-B-type natriuretic peptide levels). In the highest RVOTD-ICD benefit group, the 3-year risk of VT/VF was nearly 8-fold higher than the corresponding risk of non-arrhythmic mortality (39.2% vs. 4.8%, 0.001). On the contrary, the 3-year risk of VT/VF was similar to the risk of non-arrhythmic mortality (21.9% vs. 21.3%, = 0.405) in the lowest benefit group. RVOTD-ICD benefit score system yielded improvement in discrimination for VT/VF, non-arrhythmic mortality, and all-cause mortality than Multicenter Automatic Defibrillator Implantation Trial (MADIT)-ICD benefit score in this cohort.
Higher RVOTD was associated with significantly increased risk of sustained VT/VF in CHF patients. A simple risk assessment tool incorporating RVOTD (RVOTD-ICD benefit score) could be generalized to ICD populations, and optimize the decision-making process of ICD implantation.
左心室射血分数（LVEF）仍然是预防心源性猝死（SCD）患者的基本参考指标，而右心室（RV）异常现在已与SCD风险相关。应考虑一种纳入右心室功能参数的改良获益评估工具，以用于考虑植入式心脏复律除颤器（ICD）的植入。
我们纳入了954例慢性心力衰竭（CHF）患者（年龄58.8±13.1岁；79.0%为男性），在ICD植入前对右心室流出道直径（RVOTD）进行定量测量，然后根据RVOTD的中位数水平将他们分组。分别评估RVOTD对危及生命的室性心动过速（VT）/心室颤动（VF）与非心律失常性死亡（定义为无先前持续性VT/VF的死亡）的预测价值。基于RVOTD和其他已确定的危险因素，开发了一种简单的风险评估工具，即RVOTD-ICD获益评分。
在多变量调整后，较高的RVOTD水平与VT/VF风险增加显著相关（每增加1个标准差（SD），风险比[HR]为1.22；95%置信区间[CI]为1.11 - 1.33；P = 0.002），但与非心律失常性死亡无关（每增加1个SD，风险比为0.93；95% CI为0.66 - 1.33；P = 0.709）。根据RVOTD-ICD获益评分创建了三个获益组，该评分由VT/VF评分（年龄较小、RVOTD较高、使用利尿剂、先前非持续性VT、先前持续性VT/VF）和非心律失常性死亡评分（年龄较大、使用肾素 - 血管紧张素 - 醛固酮系统抑制剂、糖尿病、左心室舒张末期直径较大、纽约心脏协会III/IV级、N末端B型利钠肽前体水平较高）计算得出。在最高的RVOTD-ICD获益组中，VT/VF的3年风险比相应的非心律失常性死亡风险高近8倍（39.2%对4.8%，P < 0.001）。相反，在最低获益组中，VT/VF的3年风险与非心律失常性死亡风险相似（21.9%对21.3%，P = 0.405）。在该队列中，RVOTD-ICD获益评分系统在区分VT/VF、非心律失常性死亡和全因死亡方面比多中心自动除颤器植入试验（MADIT）-ICD获益评分有改善。
较高的RVOTD与CHF患者持续性VT/VF风险显著增加相关。一种纳入RVOTD的简单风险评估工具（RVOTD-ICD获益评分）可推广至ICD人群，并优化ICD植入的决策过程。
