Open Access

Upgrade of right ventricular pacing to cardiac resynchronization therapy in heart failure: a randomized trial

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Date: 26 August 2023
Journal: European Heart Journal , Volume 44 , Issue 40 , Pages 4259 - 4269
Topic: ARRHYTHMIAS AND DEVICE THERAPY, HEART FAILURE, Chronic Heart Failure, Device Therapy
Authors: B. Merkely , R. Hatala , J. Wranicz , G. Duray , C. Földesi , Z. Som , M. Németh , K. Goscinska-Bis , L. Gellér , E. Zima , I. Osztheimer , L. Molnár , J. Karády , G. Hindricks , I. Goldenberg , H. Klein , M. Szigeti , S. Solomon , V. Kutyifa , A. Kovács , A. Kosztin

ESC Journals

AbstractBackground and Aims

De novo implanted cardiac resynchronization therapy with defibrillator (CRT-D) reduces the risk of morbidity and mortality in patients with left bundle branch block, heart failure and reduced ejection fraction (HFrEF). However, among HFrEF patients with right ventricular pacing (RVP), the efficacy of CRT-D upgrade is uncertain.

Methods

In this multicentre, randomized, controlled trial, 360 symptomatic (New York Heart Association Classes II–IVa) HFrEF patients with a pacemaker or implantable cardioverter defibrillator (ICD), high RVP burden ≥ 20%, and a wide paced QRS complex duration ≥ 150 ms were randomly assigned to receive CRT-D upgrade (n = 215) or ICD (n = 145) in a 3:2 ratio. The primary outcome was the composite of all-cause mortality, heart failure hospitalization, or <15% reduction of left ventricular end-systolic volume assessed at 12 months. Secondary outcomes included all-cause mortality or heart failure hospitalization.

Results

Over a median follow-up of 12.4 months, the primary outcome occurred in 58/179 (32.4%) in the CRT-D arm vs. 101/128 (78.9%) in the ICD arm (odds ratio 0.11; 95% confidence interval 0.06–0.19; P < .001). All-cause mortality or heart failure hospitalization occurred in 22/215 (10%) in the CRT-D arm vs. 46/145 (32%) in the ICD arm (hazard ratio 0.27; 95% confidence interval 0.16–0.47; P < .001). The incidence of procedure- or device-related complications was similar between the two arms [CRT-D group 25/211 (12.3%) vs. ICD group 11/142 (7.8%)].

Conclusions

In pacemaker or ICD patients with significant RVP burden and reduced ejection fraction, upgrade to CRT-D compared with ICD therapy reduced the combined risk of all-cause mortality, heart failure hospitalization, or absence of reverse remodelling.

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About the contributors

Béla Merkely

Budapest (Semmelweis University Heart and Vascular Center)

Role: Author

Robert Hatala

Role: Author

Jerzy K Wranicz

Role: Author