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CLINICAL RESEARCH: CARDIAC RESYNCHRONIZATION THERAPY

Heart Failure Decompensation and All-Cause Mortality in Relation to Percent Biventricular Pacing in Patients With Heart Failure

Is a Goal of 100% Biventricular Pacing Necessary?

Bruce A. Koplan, MD, MPH^_*,_*, Andrew J. Kaplan, MD, Stan Weiner, MD, Paul W. Jones, MS, Milan Seth, MS^|| and Shelly A. Christman, PhD

^_* Brigham and Women's Hospital, Boston, Massachusetts
Banner Heart Hospital, Mesa, Arizona
Tyler Cardiovascular Consultants, Tyler, Texas
Boston Scientific Corporation, St. Paul, Minnesota
^|| The Integra Group, Brooklyn Park, Minnesota

Manuscript received July 8, 2008; revised manuscript received September 8, 2008, accepted September 25, 2008.

^_* Reprint requests and correspondence: Dr. Bruce A. Koplan, Brigham and Women's Hospital, Cardiovascular Division, 75 Francis Street, Tower 3A, Boston, Massachusetts 02115 (Email: bkoplan{at}partners.org).

Objectives: The goal of this analysis was to determine the appropriate biventricular pacing target in patients with heart failure (HF).

Background: Cardiac resynchronization therapy (CRT) decreases the risk of death and HF hospitalization. However, the appropriate amount of biventricular pacing is ill-defined.

Methods: Mortality and HF hospitalization data from patients undergoing CRT in 2 trials (CRT RENEWAL [Cardiac Resynchronization Therapy Registry Evaluating Patient Response with RENEWAL Family Devices] and REFLEx [ENDOTAK RELIANCE G Evaluation of Handling and Electrical Performance Study]; n = 1,812) were analyzed in a post-hoc fashion. Subjects were grouped based on percent biventricular pacing quartiles with the use of Kaplan-Meier survival analysis.

Results: Subjects were age 72 ± 11 years; 72% were men and 67% had coronary artery disease. Subjects paced 93% to 100% (quartiles 2 to 4) had a 44% reduction in hazard of an event compared with subjects paced 0% to 92% (quartile 1; hazard ratio [HR]: 0.56, p < 0.00001). Subjects paced 98% to 99% (quartile 3) had similar outcomes as subjects paced 93% to 97% (quartile 2; HR: 0.97, p = 0.82). Subjects paced 100% (quartile 4) had similar outcomes as subjects paced 98% to 99% (HR: 0.78, p = 0.17). There was a significant interaction between a history of atrial arrhythmia and percent pacing. Subjects with a history of atrial arrhythmia were more likely to be paced 92% (p < 0.001).

Conclusions: For CRT patients in this retrospective analysis, the greatest magnitude of benefit was observed with >92% biventricular pacing.

Key Words: cardiac resynchronization • heart failure • pacing

Abbreviations and Acronyms   AF = atrial fibrillation   ATR = atrial tachycardia response   CRT = cardiac resynchronization therapy   HF = heart failure   HR = hazard ratio   IV = intravenous   NYHA = New York Heart Association   Q = quartile   VRR = ventricular rate regulation

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