Toth Anna Zsofia, Nagy Laszlo, Szabo Krisztina Maria, Racz Vivien, Kiss Alexandra, Sandorfi Gabor, Borbely Attila, Nagy Tibor Laszlo, Csanadi Zoltan
Department of Cardiology, Division of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
ESC Heart Fail. 2025 Aug;12(4):2780-2790. doi: 10.1002/ehf2.15274. Epub 2025 Mar 19.
Classifying patients as responders or non-responders to cardiac resynchronization therapy (CRT) has been recently challenged, suggesting that preventing heart failure (HF) progression may also provide survival benefits. We assessed a novel classification based on echocardiographic left ventricular (LV) reverse remodelling and the occurrence of acute HF hospitalization (HHF) or sustained ventricular arrhythmia (VA) within 1-year post-CRT.
Patients implanted with a CRT defibrillator (CRT-D) at our department between 2010 and 2020 were classified based on the change in LV ejection fraction (LVEF) within 1 year as responders (increase ≥ 10%), non-progressors (increase <10%) or progressors (decline). Patients in each category were further divided based on the occurrence or absence of an HHF/VA event within 1-year post-implantation. Long-term survival free of heart transplantation or LV assist device implantation was calculated for all six subgroups. Cohorts demonstrating no significant between-group differences were grouped together and reclassified as improved, stabilized or worsened. One hundred nineteen responders, 79 non-progressors and 69 progressors were identified based on the echocardiographic response. Long-term event-free survival was higher for responders as compared with non-progressors (hazard ratio [HR] 0.51, P = 0.002) or progressors (HR 0.34, P < 0.0001). Furthermore, non-progressors had better outcome than progressors (HR 0.63, P = 0.03). Long-term prognosis in patients was superior with versus without an HHF/VA event within each group of responders (HR 0.47, P = 0.03), non-progressors (HR 0.31, P = 0.0001) or progressors (HR 0.38, P = 0.0004). No survival difference was found between responders and non-progressors with no event (HR 0.69, P = 0.09), who were recategorized as improved. Long-term prognosis was also similar in responders with any event and in progressors with no event (HR 0.98, P = 0.88; stabilized), as well as in non-progressors and progressors with any event (HR 0.87, P = 0.63; worsened). Median survival rates demonstrated significant differences between the improved, stabilized and worsened groups (102.3, 62.0 and 24.4 months; HR 0.53, P = 0.006 between improved and stabilized; HR 0.41, P < 0.0001 between stabilized and worsened; HR 0.21, P < 0.0001 between improved and worsened cohorts, respectively).
Long-term survival can be predicted based on the change in LVEF and on the occurrence of an HHF/VA event within 1-year after CRT-D implantation. Stabilized patients have significantly better prognosis as compared with the worsened group. Patients with strikingly poor prognosis can be identified using this assessment method.
将患者分类为心脏再同步治疗（CRT）的反应者或无反应者最近受到了挑战，这表明预防心力衰竭（HF）进展也可能带来生存益处。我们评估了一种基于超声心动图左心室（LV）逆向重构以及CRT后1年内急性HF住院（HHF）或持续性室性心律失常（VA）发生情况的新分类方法。
2010年至2020年间在我们科室植入CRT除颤器（CRT-D）的患者，根据1年内左心室射血分数（LVEF）的变化分为反应者（增加≥10%）、无进展者（增加<10%）或进展者（下降）。每个类别中的患者再根据植入后1年内是否发生HHF/VA事件进一步划分。计算了所有六个亚组无心脏移植或LV辅助装置植入的长期生存率。将组间无显著差异的队列合并在一起，重新分类为改善、稳定或恶化。根据超声心动图反应确定了119名反应者、79名无进展者和69名进展者。与无进展者（风险比[HR]0.51，P = 0.002）或进展者（HR 0.34，P < 0.0001）相比，反应者的长期无事件生存率更高。此外，无进展者的结局优于进展者（HR 0.63，P = 0.03）。在每组反应者（HR 0.47，P = 0.03）、无进展者（HR 0.31，P = 0.0001）或进展者（HR 0.38，P = 0.0004）中，有HHF/VA事件的患者长期预后优于无该事件的患者。无事件的反应者和无进展者之间未发现生存差异（HR 0.69，P = 0.09），这些患者被重新分类为改善。有任何事件的反应者和无事件的进展者的长期预后也相似（HR 0.98，P = 0.88；稳定），以及有任何事件的无进展者和进展者（HR 0.87，P = 0.63；恶化）。改善、稳定和恶化组的中位生存率显示出显著差异（分别为102.3、62.0和24.4个月；改善和稳定组之间HR 0.53，P = 0.006；稳定和恶化组之间HR 0.41，P < 0.0001；改善和恶化队列之间HR 0.21，P < 0.0001）。
基于CRT-D植入后1年内LVEF的变化以及HHF/VA事件的发生情况，可以预测长期生存率。与恶化组相比，稳定患者的预后明显更好。使用这种评估方法可以识别出预后极差的患者。
