Biventricular pacemaker upgrade in previously paced heart failure patients--improvements in ventricular dyssynchrony.

BACKGROUND: Cardiac resynchronization therapy (CRT) reduces symptoms and mortality in patients with left bundle branch block (LBBB) and severe chronic heart failure. There are few data demonstrating the effects of CRT on contemporary dyssynchrony variables in patients with advanced heart failure who have been chronically paced from the right ventricle (RV). METHODS AND RESULTS: We reviewed baseline and follow-up clinical and echocardiographic data on patients receiving CRT in a single centre. Indices of global left ventricular (LV) function and dyssynchrony before and after CRT were measured. Patients were then divided into those receiving their first device (n = 39) and those receiving CRT as an upgrade to existing RV pacemakers (n = 32). Baseline demographic variables, indices of global LV function, symptomatic status, renal function, hemodynamics, and diuretic requirements were not different between previously paced patients and nonpaced patients. Mean length of RV pacing in the previously paced patients was 59 months (range 12-167 months). Patients in the previously paced group had a broader QRS complex than patients with intrinsic LBBB. Aortopulmonary delay of longer than 40 ms was present in 68% of all subjects, 67% had intraventricular septal and posterior wall motion delay longer than 130 ms, and 59% had an intraventricular delay as measured by tissue Doppler imaging of longer than 65 ms. There was no difference between paced and nonpaced patients for any of these measures of dyssynchrony. QRS duration was reduced to a greater extent in the previously paced patients than those with no previous device therapy. CRT led to important reductions in each dyssynchrony variable in both patients with previous RV pacing and those with intrinsic LBBB. The magnitude of these changes in measures of dyssynchrony was not different between the 2 groups. In all patients undergoing CRT, 50% had a reduction in furosemide dose at 3 months, 56% an improvement of at least 1 grade in New York Heart Association status, and 66% an improvement of at least 5% in LVEF. Divided by group, previously paced patients were no more or less likely than newly implanted patients to achieve one or more of these clinical outcomes. CONCLUSION: Our data suggest that patients with RV pacing and heart failure have similar dyssynchrony as patients with intrinsic LBBB. CRT leads to improvements in LV global function, dyssynchrony variables and symptoms in patients chronically paced from the RV that are similar to those observed in patients with LBBB without preexisting devices.

Contrast nephropathy post cardiac resynchronization therapy: an under-recognized complication with important morbidity.

OBJECTIVES: The aim of the study was to define the incidence of contrast nephropathy in patients undergoing cardiac resynchronization therapy (CRT). BACKGROUND: CRT is a promising new treatment for advanced heart failure. It is a technically demanding procedure with a recognized failure/complication rate. Contrast nephropathy is a well-recognized complication of coronary angiography/intervention, but has not been described following CRT. METHODS: We performed a retrospective chart review of patients who had undergone CRT at Mount Sinai Hospital, a tertiary referral center for heart failure management, to define the incidence of contrast nephropathy in patients undergoing CRT. Contrast nephropathy was defined as the occurrence of a 25% or greater increase in serum creatinine within 48 h after contrast administration. RESULTS: Sixty-eight patients underwent a total of seventy-three procedures between October 1st 2000 and December 31st 2003. Ten patients (14%) developed contrast nephropathy. Three of these patients (4%) required hemofiltration and one died. Patients with creatinine > or = 200 micromol/l (2.26 mg/dl) were more likely to develop contrast nephropathy than those with creatinine < 200 micromol/l (6/14 patients [43%] v 4/59 patients [7%], p<0.01). The mean length of hospital stay post-procedure in patients developing contrast nephropathy was 19+/-18 (SD) days versus 4+/-5 days for those patients with stable renal function (p<0.01). CONCLUSIONS: Contrast nephropathy is a frequent, but under-recognized complication of CRT with important morbidity/mortality. The extended hospital stay associated with contrast nephropathy has important clinical and health care implications. Patients and physicians need to be aware of this potential risk.