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CABG with epicardial CRT improves survival of patients with HF, dyssynchrony
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Long-term results of the RESCUE study suggest that in patients with HF and systolic dyssynchrony undergoing CABG, the addition of epicardial cardiac resynchronization therapy improves the mortality rate, according to study results published in the European Journal of Cardio-Thoracic Surgery.
Alexander Romanov, MD, of the State Research Institute of Circulation Pathology in Novosibirsk, Russia, and colleagues randomly assigned 178 patients with chronic ischemic heart disease and severe HF to CABG alone (n = 87) or CABG with epicardial CRT implantation (n = 91). Mean follow-up was 55 ± 10.7 months. There was some crossover between the groups, with 20 CABG patients (22.9%) requiring a CRT device with transvenous leads during follow-up. Two patients (2.2%) in the CABG with CRT group experienced paroxysms of ventricular tachycardia and required an upgraded device. The primary endpoint was all-cause mortality. The researchers also evaluated mode of death, adverse cardiac events and lead performance as secondary outcomes.
During long-term follow-up, there were 24 deaths (35.8%) in the CABG group and 17 deaths (15.3%) in the CABG with CRT group. Compared with CABG alone, CABG with CRT reduced the risk for all-cause mortality (HR = 0.43; 95% CI, 0.23-0.84) and cardiac death (HR = 0.39; 95% CI, 0.21-0.72). Eleven (12.6%) sudden deaths occurred in the CABG group compared with four (4.4%) in the CABG with CRT group (P = .048). The hospital readmission rate was smaller for patients who received CRT during CABG than it was for those assigned to CABG alone (9.9% vs. 28.7%; P = .001). Four of the epicardial lead implantations had to be replaced with transvenous electrodes.
Romanov and colleagues also observed a greater increase in left ventricular ejection fraction, compared with baseline, in CABG with CRT than in CABG alone (43 ± 2.2% vs. 29 ± 3.2%; P < .001). Decreases in left ventricular volume were only found in the CABG with CRT group. Patients with CRT also saw a greater reduction in the number of segments with dyssynchrony and the delay of systolic contraction in these segments (P < .001).
“These results might be intriguing, knowing that, according to numerous reports, ischemic etiology of HF is associated with worse outcome of CRT in terms of mortality and reverse remodeling. Factors contributing to poorer performance in ischemic patients include reduced extent of viable tissue (cardiomyocytes) and transmural scar in the region of the LV lead,” Romanov and colleagues wrote.
“Owing to the specific design of our investigation, the aforementioned problems were addressed by complete surgical coronary revascularization, which restored adequate coronary perfusion, and by careful selection of the optimal implantation site on the LV posterolateral wall to avoid scar and ensure excellent pacing parameters,” the researchers wrote. – by Tracey Romero
Disclosure: The researchers report no relevant financial disclosures.
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