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CLINICAL RESEARCH: CARDIAC RESYNCHRONIZATION THERAPY

Persistent Hemodynamic Benefits of Cardiac Resynchronization Therapy With Disease Progression in Advanced Heart Failure

Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio

Manuscript received May 5, 2008; revised manuscript received August 29, 2008, accepted August 31, 2008.

^_* Reprint requests and correspondence: Dr. W. H. Wilson Tang, Section of Heart Failure and Cardiac Transplantation Medicine, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, Ohio 44195 (Email: tangw{at}ccf.org).

Objectives: Our aim was to determine the potential hemodynamic contributions of cardiac resynchronization therapy (CRT) in patients admitted for advanced decompensated heart failure.

Background: CRT restores synchrony of the heart resulting in hemodynamic support that can facilitate the reversal of left ventricular (LV) remodeling in some patients.

Methods: A total of 40 consecutive patients with advanced decompensated heart failure and CRT implanted >3 months, admitted due to hemodynamic derangements, underwent simultaneous comprehensive echocardiographic and invasive hemodynamic evaluation under different CRT settings.

Results: All patients (mean LV ejection fraction 22 ± 7%, LV end-diastolic volume 323 ± 140 ml, 40% ischemic) had experienced progressive cardiac remodeling despite adequate LV lead positions and continuous biventricular pacing. A significant worsening of hemodynamics was observed immediately when CRT was programmed OFF in the majority (88%) of patients (systolic blood pressure: 105 ± 12 mm Hg to 98 ± 13 mm Hg; pulmonary capillary wedge pressure: 17 ± 6 mm Hg to 21 ± 7 mm Hg; cardiac output: 4.6 ± 1.4 l/min·m² to 4.0 ± 1.1 l/min·m²; all p < 0.001). Worsening of hemodynamics coincided with reappearance of significant electrical (QRS width 161 ± 29 ms to 202 ± 39 ms, p < 0.001) and intraventricular mechanical dyssynchrony (15 ± 26 ms to 57 ± 41 ms, p < 0.001), together with a significant reduction in diastolic filling time (377 ± 138 ms to 300 ± 118 ms, p < 0.001).

Conclusions: Despite progressive cardiac remodeling and decompensation, chronic CRT continues to provide hemodynamic augmentation in the failing heart in most patients. Our data suggest that disease progression may not be explained by diminished beneficial hemodynamic contributions of successful resynchronization.

Key Words: heart failure • hemodynamics • pacing • remodeling

Abbreviations and Acronyms   AV = atrioventricular   CO = cardiac output   CRT = cardiac resynchronization therapy   CVP = central venous pressure   LV = left ventricle/ventricular   NYHA = New York Heart Association   PCWP = pulmonary capillary wedge pressure

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