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Background: Cardiac resynchronization therapy (CRT) reduces mortality in congestive heart failure (CHF) especially in responders. However, there are non-responders to CRT. In case of failed coronary sinus approach minimally invasive surgical epicardial (SE) placement is treatment of choice. But there are still patients who end up with dual chamber pacing after failed CS approach.
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Helmut Mair, Sabine Daebritz, Ingo Kaczmarek, Bruno Reichart, Peter Lamm.
Cardiac Surgery, University of Munich, Munich, Germany.
Methods: Since 1999, 243 patients (66,3±8,2years) with impaired LV-function (EF: 24±9%), left-bundle-branch-block (QRS: 171±28ms) and CHF (NYHA >3,0) were referred to CRT. Of these, 17 patients received primarily surgical epicardial placement via mini-thoracotomy or thoracoscopy. Of the other 226 patients with primary CS-approach, 35 (15%) failed and were converted to surgical epicardial lead placement. LV-lead related complications were higher after CS-approach compared to SE (p<0.001). 14 (6%) patients had discontinued CS-attempt and only dual chamber pacing. Follow-up was 19±18months (1-68months), representing 371,7 patient-years.
Results: Follow-up was 94% (227 patients). 168 (74%) patients were responders, 45 (20%) non-responders. NYHA-class of responders improved to 2,0±0.5 (p<0.001), but not in the other two groups. QRS decreased in responders and non-responders (p<0.001) but didn’t differ between groups (p=0.45). 4 responders needed heart-transplantation versus 12 non-responders (p<0.001) and 5 responders versus 14 non-responders died of CHF (p<0.001). 6 dual chamber pacing patients died (p<0.001 compared to responders). Actuarial-survival of responders after 1, 2 and 5 years is 99%, 91% and 82% compared to 65%, 46% and 24% in non-responders (p<0.001) and dual chamber pacing 83%, 71% and 21% (p<0.001). LV-lead related complications were higher after CS-approach compared to SE (p<0.001).
Conclusion: CRT improves CHF significantly in long-term, but a close follow up is mandatory because of a subset of non-responders. In such cases early referral to heart-transplantation has to be considered. If CS-lead implantation fails surgical revision with mini-approach is treatment of choice. Dual chamber pacing in patients with CRT-criteria is unacceptable.
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