Factors that Determined a Positive Response to Resynchronization Therapy in Patients With Chronic Heart Failure and Cardiac Dyssynchrony. One Center Experience

Aim. To evaluate the efficacy of cardiac resynchronization therapy (CRT) in patients with chronic heart failure (CHF) associated with cardiac dyssynchrony and to identify the factors that influence the CRT efficacy.

Material and methods. This retrospective study included 155 patients after implantation of CRT devices. The CRT devices with a built-in cardioverter-defibrillator (CRT-D) and without it (CRT-P) were implanted in 139 (89.7%) and 16 (10.3%) patients, respectively. The follow-up period was 52.37±35.94 months. Based on the study results, two groups of patients were formed depending on the presence of a clinical response to CRT, responders and non-responders. The factors that influenced the clinical response to CRT were studied. The effect of the baseline state of patients on the effect of therapy was assessed. The need for CRT optimization and a possibility of using electrocardiographic criteria for that purpose were studied. Modern devices and leads for CRT, their functional capabilities and their influence on the CRT efficacy were characterized. Statistical analysis was performed with an IBM SPSS Statistics 21.0 (Chicago, USA) package.

Results. CRT implantation with the left ventricular lead placement according to the traditional technique, through the coronary sinus, was successful in 130 (87.9%) patients. Difficulties with the left ventricular lead placement were noted in 13 (8.3%) patients when other techniques were used. After 6 months, a hemodynamic and clinical response was observed in 112 (72.2%) patients, and no positive response in 43 (27.8%). The increase in left ventricular ejection fraction in the responder group was more than 21.8±3.7%, which was associated with an improvement of the 6-minute walk test results. Th clinical response was significantly influenced by the possibility of stimulation from the basal parts of the heart; the use of more modern devices for CRT and quadripolar left ventricular leads; timely CRT optimization; and persistent dyssynchrony in non-responders. During the follow-up period, 34 (21.9%) patients died. The death rate in the non-responder group was significantly higher than in the responder group, 18 (41.3%) vs. 16 (14.3%), p=0.001. The main cause of death in the group of non-responders was CHF. Heart transplantation was performed in 3 (1.9%) patients.

Conclusion. CRT increases the life span and improves the quality of life in patients with CHF and cardiac dyssynchrony. There was a group of patients with no benefit from CRT in this study. Modern devices allow increasing the number of patients who benefit from CRT. Periodic optimization of CRT is necessary. When optimizing CRT, it is possible to use electrocardiographic criteria of effectiveness: duration of the QRS complex and changes in the position of the electrical axis of the heart.

1. Lebedev D.S., Mikhailov E.N., Neminuschiy N.M., Golukhova E.Z., Babokin V.E., Bereznitskaya V.V. et al. Ventricular arrhythmias. Ventricular tachycardias and sudden cardiac death. 2020 Clinical guidelines. Russian Journal of Cardiology. 2021;26(7):128–89. DOI: 10.15829/1560-4071-2021-4600

2. Tereshchenko S.N., Galyavich A.S., Uskach T.M., Ageev F.T., Arutyunov G.P., Begrambekova Yu.L. et al. 2020 Clinical practice guidelines for Chronic heart failure. Russian Journal of Cardiology. 2020;25(11):311– 74. DOI: 10.15829/1560-4071-2020-4083

3. Glikson M, Nielsen JC, Kronborg MB, Michowitz Y, Auricchio A, Barbash IM et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal. 2021;42(35):3427–520. DOI: 10.1093/eurheartj/ehab364

4. Chung MK, Patton KK, Lau C-P, Dal Forno ARJ, Al-Khatib SM, Arora V et al. 2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure. Heart Rhythm. 2023;20(9):e17–91. DOI: 10.1016/j.hrthm.2023.03.1538

5. Kashtanova S.Yu., Mironova N.A., Gupalo E.M., Gaman S.A., Malkina T.A., Tarasovskiy G.S. et al. Assessment of myocardial electrical dissynchrony by noninvasive activation mapping and its role in achieving the success of cardiac resynchronization. Kardiologiia. 2019;59(4S):21–32. DOI: 10.18087/cardio.2613

6. Sawhney NS, Waggoner AD, Garhwal S, Chawla MK, Osborn J, Faddis MN. Randomized prospective trial of atrioventricular delay programming for cardiac resynchronization therapy. Heart Rhythm. 2004;1(5):562–7. DOI: 10.1016/j.hrthm.2004.07.006

7. Brabham WW, Gold MR. The role of AV and VV optimization for CRT. Journal of Arrhythmia. 2013;29(3):153–61. DOI: 10.1016/j.joa.2013.02.001

8. Vernooy K, Verbeek XAAM, Cornelussen RNM, Dijkman B, Crijns HJGM, Arts T et al. Calculation of effective VV interval facilitates optimization of AV delay and VV interval in cardiac resynchronization therapy. Heart Rhythm. 2007;4(1):75–82. DOI: 10.1016/j.hrthm.2006.09.007

9. Brugada J, Brachmann J, Delnoy PP, Padeletti L, Reynolds D, Ritter P et al. Automatic Optimization of Cardiac Resynchronization Therapy Using SonR – Rationale and Design of the Clinical Trial of the SonRtip Lead and Automatic AV-VV Optimization Algorithm in the Paradym RF SonR CRT-D (RESPOND CRT) Trial. American Heart Journal. 2014;167(4):429–36. DOI: 10.1016/j.ahj.2013.12.007

10. Starling RC, Krum H, Bril S, Tsintzos SI, Rogers T, Hudnall JH et al. Impact of a Novel Adaptive Optimization Algorithm on 30-Day Readmissions. JACC: Heart Failure. 2015;3(7):565–72. DOI: 10.1016/j.jchf.2015.03.001

11. AlTurki A, Lima PY, Bernier ML, Garcia D, Vidal A, Toscani B et al. Optimization of Chronic Cardiac Resynchronization Therapy Using Fusion Pacing Algorithm Improves Echocardiographic Response. CJC Open. 2020;2(2):62–70. DOI: 10.1016/j.cjco.2019.12.005

12. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E et al. Cardiac Resynchronization in Chronic Heart Failure. New England Journal of Medicine. 2002;346(24):1845–53. DOI: 10.1056/NEJMoa013168

13. Cleland JGF, Daubert J-C, Erdmann E, Freemantle N, Gras D, Kappenberger L et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. The New England Journal of Medicine. 2005;352(15):1539–49. DOI: 10.1056/NEJMoa050496

14. Zareba W, Klein H, Cygankiewicz I, Hall WJ, McNitt S, Brown M et al. Effectiveness of cardiac resynchronization therapy by QRS morphology in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT). Circulation. 2011;123(10):1061–72. DOI: 10.1161/CIRCULATIONAHA.110.960898

15. Rohit MK, Krishnappa D. Incidence and predictors of super-response to cardiac resynchronization therapy. Indian Heart Journal. 2019;71(4):334–7. DOI: 10.1016/j.ihj.2019.09.007

16. Zand S, Sadeghian H, Kazemisaied A, Ashraf H, Lotfi‐Tokaldany M, Jalali A. Predicting factors of echocardiographic super‐response to cardiac resynchronization therapy. Journal of Clinical Ultrasound. 2023;51(3):388–93. DOI: 10.1002/jcu.23380

17. Postol A.S., Antipov G.N., Ivanchenko A.V., Lyashenko V.V., Kotov S.N., Shneider Yu.A. Morphology of the QRS complex as a criterion of effectiveness in optimizing device parameters for cardiac resynchronization therapy. Thoracic and cardiovascular surgery. 2022;64(3):315–9. DOI: 10.24022/0236-2791-2022-64-3-315-319

18. Gamble JHP, Herring N, Ginks M, Rajappan K, Bashir Y, Betts TR. Procedural Success of Left Ventricular Lead Placement for Cardiac Resynchronization Therapy. JACC: Clinical Electrophysiology. 2016;2(1):69– 77. DOI: 10.1016/j.jacep.2015.08.009

19. Sieniewicz BJ, Gould J, Porter B, Sidhu BS, Teall T, Webb J et al. Understanding non-response to cardiac resynchronisation therapy: common problems and potential solutions. Heart Failure Reviews. 2019;24(1):41– 54. DOI: 10.1007/s10741-018-9734-8

20. Leyva F, Zegard A, Qiu T, Acquaye E, Ferrante G, Walton J et al. Cardiac Resynchronization Therapy Using Quadripolar Versus Non‐Quadripolar Left Ventricular Leads Programmed to Biventricular Pacing With Single‐Site Left Ventricular Pacing: Impact on Survival and Heart Failure Hospitalization. Journal of the American Heart Association. 2017;6(10):e007026. DOI: 10.1161/JAHA.117.007026

21. Massacesi C, Ceriello L, Maturo F, Porreca A, Appignani M, Di Girolamo E. Cardiac resynchronization therapy with multipoint pacing via quadripolar lead versus traditional biventricular pacing: A systematic review and meta-analysis of clinical studies on hemodynamic, clinical, and prognostic parameters. Heart Rhythm O2. 2021;2(6 Part B):682–90. DOI: 10.1016/j.hroo.2021.09.012

22. Zavadovsky K.V., Saushkin V.V., Varlamova Yu.V., Mishkina A.I., Shipulin V.V., Lebedev D.I. et al. Mechanical Dyssynchrony for Prediction of the Cardiac Resynchronization Therapy Response in Patients with Dilated Cardiomyopathy. Kardiologiia. 2021;61(7):14–21. DOI: 10.18087/cardio.2021.7.n1420