Advertisement

Response of right ventricular size to treatment with cardiac resynchronization therapy and the risk of ventricular tachyarrhythmias in MADIT-CRT

      Background

      Cardiac resynchronization therapy (CRT) is increasingly recognized for its ability to reduce ventricular tachyarrhythmias, possibly associated with left ventricular reverse remodeling, but the role of the right ventricle (RV) in this process has not been examined.

      Objective

      The purpose of this study was to investigate the relationship between ventricular tachyarrhythmias and change in RV dimensions in patients receiving CRT with a defibrillator (CRT-D).

      Methods

      Multivariate Cox proportional hazards regression modeling was used to assess the risk for fast (≥180 bpm) ventricular tachycardia/ventricular fibrillation (VT/VF) or death by baseline and follow-up RV size (defined as right ventricular end-diastolic area [RVEDA]) among 1495 patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT).

      Results

      Multivariate analysis showed that treatment with CRT-D was independently associated with a 27% (P = .003) reduction in the risk of VT/VF or death among patients with larger RVs (>first quartile RVEDA ≥13 mm2/m2) compared with implantable cardioverter-defibrillator (ICD)-only therapy, whereas in patients with smaller RVs there was no significant difference in the risk of VT/VF between the 2 treatment arms (hazard ratio = 1.00, P = .99). At 1-year follow-up, CRT-D patients displayed significantly greater reductions in RVEDA compared to ICD-only patients (P <.001), associated with a corresponding reduction in the risk of subsequent VT/VF or death (>first quartile reduction in RVEDA with CRT-D vs ICD-only: hazard ratio = 0.55, P <.001) independent of changes in left ventricular dimensions.

      Conclusion

      Our findings suggest that the RV may have an important role in determining the antiarrhythmic effect of CRT independent of the effect of the device on the left ventricle.

      Abbreviations:

      BSA (body surface area), CI (confidence interval), CRT (cardiac resynchronization therapy), CRT-D (cardiac resynchronization therapy defibrillator), HR (hazard ratio), ICD (implantable cardioverter-defibrillator), LV (left ventricle), MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy), NYHA (New York Heart Association), RV (right ventricle), RVEDA (right ventricular end-diastolic area), RVFAC (right ventricular fractional area change), VF (ventricular fibrillation), VT (ventricular tachycardia)

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Shiga T.
        • Kasanuki H.
        Drug therapy for ventricular tachyarrhythmia in heart failure.
        Circ J. 2007; 71: A90-A96
        • Tracy C.M.
        • Epstein A.E.
        • Darbar D.
        • et al.
        2012 ACCF/AHA/HRS focused update of the 2008 guidelines for device-based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        J Am Coll Cardiol. 2012; 60: 1297-1313
        • Moss A.J.
        • Hall W.J.
        • Cannom D.S.
        • et al.
        Cardiac-resynchronization therapy for the prevention of heart-failure events.
        N Engl J Med. 2009; 361: 1329-1338
        • Medina-Ravell V.A.
        • Lankipalli R.S.
        • Yan G.X.
        • et al.
        Effect of epicardial or biventricular pacing to prolong QT interval and increase transmural dispersion of repolarization: does resynchronization therapy pose a risk for patients predisposed to long QT or torsade de pointes?.
        Circulation. 2003; 107: 740-746
        • Higgins S.L.
        • Yong P.
        • Sheck D.
        • et al.
        Biventricular pacing diminishes the need for implantable cardioverter defibrillator therapy. Ventak CHF Investigators.
        J Am Coll Cardiol. 2000; 36: 824-827
        • Arya A.
        • Haghjoo M.
        • Dehghani M.R.
        • et al.
        Effect of cardiac resynchronization therapy on the incidence of ventricular arrhythmias in patients with an implantable cardioverter-defibrillator.
        Heart Rhythm. 2005; 2: 1094-1098
        • Kies P.
        • Bax J.J.
        • Molhoek S.G.
        • et al.
        Effect of left ventricular remodeling after cardiac resynchronization therapy on frequency of ventricular arrhythmias.
        Am J Cardiol. 2004; 94: 130-132
        • Di Biase L.
        • Gasparini M.
        • Lunati M.
        • et al.
        Antiarrhythmic effect of reverse ventricular remodeling induced by cardiac resynchronization therapy: The InSync ICD (implantable cardioverter-defibrillator) Italian Registry.
        J Am Coll Cardiol. 2008; 52: 1442-1449
        • Barsheshet A.
        • Wang P.J.
        • Moss A.J.
        • et al.
        Reverse remodeling and the risk of ventricular tachyarrhythmias in the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy).
        J Am Coll Cardiol. 2011; 57: 2416-2423
        • Solomon S.D.
        • Foster E.
        • Bourgoun M.
        • et al.
        Effect of cardiac resynchronization therapy on reverse remodeling and relation to outcome: Multicenter Automatic Defibrillator Implantation Trial: Cardiac Resynchronization Therapy.
        Circulation. 2010; 122: 985-992
        • Aktas M.K.
        • Kim D.D.
        • McNitt S.
        • et al.
        Right ventricular dysfunction and the incidence of implantable cardioverter-defibrillator therapies.
        Pacing Clin Electrophysiol. 2009; 32: 1501-1508
        • Moss A.J.
        • Brown M.W.
        • Cannom D.S.
        • et al.
        Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT): design and clinical protocol.
        Ann Noninvasive Electrocardiol. 2005; 10: 34-43
        • Lang R.M.
        • Bierig M.
        • Devereux R.B.
        • et al.
        Recommendations for chamber quantification: a report from the American Society of Echocardiography's guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology.
        J Am Soc Echocardiogr. 2005; 18: 1440-1463
        • Di Salvo T.G.
        • Mathier M.
        • Semigran M.J.
        • Dec G.W.
        Preserved right ventricular ejection fraction predicts exercise capacity and survival in advanced heart failure.
        J Am Coll Cardiol. 1995; 25: 1143-1153
        • Meyer P.
        • Filippatos G.S.
        • Ahmed M.I.
        • et al.
        Effects of right ventricular ejection fraction on outcomes in chronic systolic heart failure.
        Circulation. 2010; 121: 252-258
        • Ghio S.
        • Gavazzi A.
        • Campana C.
        • et al.
        Independent and additive prognostic value of right ventricular systolic function and pulmonary artery pressure in patients with chronic heart failure.
        J Am Coll Cardiol. 2001; 37: 183-188
        • de Groote P.
        • Millaire A.
        • Foucher-Hossein C.
        • et al.
        Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure.
        J Am Coll Cardiol. 1998; 32: 948-954
        • Bourantas C.V.
        • Loh H.P.
        • Bragadeesh T.
        • et al.
        Relationship between right ventricular volumes measured by cardiac magnetic resonance imaging and prognosis in patients with chronic heart failure.
        Eur J Heart Fail. 2011; 13: 52-60
        • Mehta S.R.
        • Eikelboom J.W.
        • Natarajan M.K.
        • et al.
        Impact of right ventricular involvement on mortality and morbidity in patients with inferior myocardial infarction.
        J Am Coll Cardiol. 2001; 37: 37-43
        • Zornoff L.A.
        • Skali H.
        • Pfeffer M.A.
        • et al.
        Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction.
        J Am Coll Cardiol. 2002; 39: 1450-1455
        • Campbell P.
        • Takeuchi M.
        • Bourgoun M.
        • et al.
        Right ventricular function, pulmonary pressure estimation, and clinical outcomes in cardiac resynchronization therapy.
        Circ Heart Fail. 2013; 6: 435-442
        • Gottdiener J.S.
        • Bednarz J.
        • Devereux R.
        • et al.
        American Society of Echocardiography recommendations for use of echocardiography in clinical trials.
        J Am Soc Echocardiogr. 2004; 17: 1086-1119
        • Maury P.
        Why is the right ventricular outflow tract so arrhythmogenic? (... or is it really?...).
        Heart. 2011; 97: 1631-1633
        • Rudski L.G.
        • Lai W.W.
        • Afilalo J.
        • et al.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23 (quiz 786–788): 685-713