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. 2011 Oct 31;13(1):68.
doi: 10.1186/1532-429X-13-68.

Right ventricular dysfunction is a predictor of non-response and clinical outcome following cardiac resynchronization therapy

Francisco Alpendurada  1 , Kaushik Guha, Rakesh Sharma, Tevfik F Ismail, Amy Clifford, Winston Banya, Raad H Mohiaddin, Dudley J Pennell, Martin R Cowie, Theresa McDonagh, Sanjay K Prasad
Affiliations

Right ventricular dysfunction is a predictor of non-response and clinical outcome following cardiac resynchronization therapy

Francisco Alpendurada et al. J Cardiovasc Magn Reson. .

Abstract

Background: Cardiac resynchronization therapy (CRT) is an established treatment in advanced heart failure (HF). However, an important subset does not derive a significant benefit. Despite an established predictive role in HF, the significance of right ventricular (RV) dysfunction in predicting clinical benefit from CRT remains unclear. We investigated the role of RV function, assessed by cardiovascular magnetic resonance (CMR), in predicting response to and major adverse clinical events in HF patients undergoing CRT.

Methods: Sixty consecutive patients were evaluated with CMR prior to CRT implantation in a tertiary cardiac centre. The primary end-point was a composite of death from any cause or unplanned hospitalization for a major cardiovascular event. The secondary end-point was response to therapy, defined as improvement in left ventricular ejection fraction ≥ 5% on echocardiography at one year.

Results: Eighteen patients (30%) met the primary end-point over a median follow-up period of 26 months, and 27 out of 56 patients (48%) were considered responders to CRT. On time-to-event analysis, only atrial fibrillation (HR 2.6, 95% CI 1.02-6.84, p = 0.047) and RV dysfunction, either by a reduced right ventricular ejection fraction-RVEF (HR 0.96, 95% CI 0.94-0.99, p = 0.006) or tricuspid annular plane systolic excursion-TAPSE (HR 0.88, 95% CI, 0.80-0.96, p = 0.006), were significant predictors of adverse events. On logistic regression analysis, preserved RVEF (OR 1.05, 95% CI 1.01-1.09, p = 0.01) and myocardial scar burden (OR 0.90, 95% CI 0.83-0.96, p = 0.004) were the sole independent predictors of response to CRT. Patients with marked RV dysfunction (RVEF < 30%) had a particularly low response rate (18.2%) to CRT.

Conclusions: Right ventricular function is an important predictor of both response to CRT and long-term clinical outcome. Routine assessment of the right ventricle should be considered in the evaluation of patients for CRT.

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Figures

Figure 1
Figure 1
Software used for ventricular volumes and mass measurements. Mid-ventricular short-axis (top) and four-chamber views (bottom) at end-diastole (left) and end-systole (right). Coloured areas represent the left and right ventricular cavities and myocardium. Ventricular volumes are generated from a short-axis stack after being confined by the mitral and tricuspid valve planes (red lines).
Figure 2
Figure 2
Four-chamber view in end-diastole (left panel) and end-systole (right panel). The tricuspid annular plane is marked as a white line in diastole and as a dashed line in systole. The red vector represents the tricuspid annular systolic excursion (TAPSE).
Figure 3
Figure 3
Kaplan-Meier estimates of the time to the primary end-point for RVEF (left panel) and TAPSE (right panel).
Figure 4
Figure 4
Frequency of primary events and response to CRT for different ranges of RVEF and TAPSE.
See this image and copyright information in PMC

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