Event-free survival following CRT with surgically implanted LV leads versus standard transvenous approach

Abstract

Background: While surgical epicardial lead placement is performed in a subset of cardiac resynchronization therapy patients, data comparing survival following surgical versus transvenous lead placement are limited. We hypothesized that surgical procedures would be associated with increased mortality risk.

Methods: Long-term event-free survival was assessed for 480 consecutive patients undergoing surgical (48) or percutaneous (432) left ventricle (LV) lead placement at our institution from January 2000 to September 2008.

Results: Baseline clinical and demographic characteristics were similar between groups. While there was no statistically significant difference in overall event-free survival (P = 0.13), when analysis was restricted to surgical patients with isolated surgical lead placement (n = 28), event-free survival was significantly lower in surgical patients (P = 0.015). There appeared to be an early risk (first approximately 3 months postimplantation) with surgical lead placement, primarily in LV lead-only patients. Event rates were significantly higher in LV lead-only surgical patients than in transvenous patients in the first 3 months (P = 0.006). In proportional hazards analysis comparing isolated surgical LV lead placement to transvenous lead placement, adjusted hazard ratios were 1.8 ([1.1,2.7] P = 0.02) and 1.3 ([1.0,1.7] P = 0.07) for the first 3 months and for the full duration of follow-up, respectively.

Conclusions: Isolated surgical LV lead placement appears to carry a small but significant upfront mortality cost, with risk extending beyond the immediate postoperative period. Long-term survival is similar, suggesting those surviving beyond this period of early risk derive the same benefit as coronary sinus lead recipients. Further work is needed to identify risk factors associated with early mortality following surgical lead placement.

Figure 1

(A) Survival (free from all-cause mortality) as a function to time post-CRT initiation for patients with TV-CS leads (solid line) and surgical LV leads (dotted line). Number of patients in each group, by year, shown below x-axis. (B) Time post-CRT initiation free from the composite end-point (Transplant, VAD, death), for patients with TV-CS leads (solid line) and surgical LV leads (dotted line). Number of patients in each group, by year, shown below x-axis.

Figure 1

(A) Survival (free from all-cause mortality) as a function to time post-CRT initiation for patients with TV-CS leads (solid line) and surgical LV leads (dotted line). Number of patients in each group, by year, shown below x-axis. (B) Time post-CRT initiation free from the composite end-point (Transplant, VAD, death), for patients with TV-CS leads (solid line) and surgical LV leads (dotted line). Number of patients in each group, by year, shown below x-axis.

Figure 2. Event-free survival for individual surgical groups

Time post-CRT initiation free from the composite end-point (Transplant, VAD, death), for patients who underwent LV-only surgery (black solid line) and LV lead placement at the time of bypass or valve (black dotted line). Patients with a TV-CS lead are shown in solid gray (matches Figure 1B solid line). Patients for whom TV-CS lead attempt failed, and who were not subsequently referred for surgical lead placement (i.e., no CRT performed) are also shown as a function of time after attempted CRT (gray dashed line). Number of patients at risk in each group, by year, is shown below x-axis.