Varun Sundaram MD, Kenneth C. Bilchick MD, Albert L. Waldo MD, PhD (Hon), Yogesh N. V. Reddy MD, Samuel J. Asirvatham MD, Judith A. Mackall MD, Anselma Intini MD, Brigid Wilson PhD, Daniel I. Simon MD, Jayakumar Sahadevan MD. Disclosures; None Cardiac Resynchronization Therapy may be detrimental in patients with a Very Wide QRSD > 180 ms (VWQRSD) and Right Bundle Branch Block Morphology: Analysis From the Medicare ICD Registry
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Varun Sundaram MD, Kenneth C. Bilchick MD, Albert L. Waldo MD, PhD (Hon), Yogesh N. V. Reddy MD, Samuel J. Asirvatham MD, Judith A. Mackall MD,
Anselma Intini MD, Brigid Wilson PhD, Daniel I. Simon MD, Jayakumar Sahadevan MD.
Disclosures; None
Cardiac Resynchronization Therapy may be detrimental in patients with a Very Wide QRSD > 180
ms (VWQRSD) and Right Bundle Branch Block Morphology: Analysis From the Medicare ICD
Registry
Background
• It has been shown from meta-analysis ofrandomized clinical trials that patients with apre-CRT QRS duration (QRSD) >150 ms benefitmore than QRSD of 120-149 ms
• However, the benefits in the group of patientswith a very wide QRSD ≥180 ms (VWQRSD) hasnot been well studied, as these patients wereunder-represented in CRT trials
Sipahi I et al, Am Heart J 2012;163(2):260-67Cleland JG et al, Eur Heart J 2013;32(46):3547-56
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Causes of wide QRS complex
Conduction block(LBBB, RBBB, IVCD)
Electrical uncoupling
Combination of both
• Isolated diffuse left ventricular electrical uncoupling of the workingmyocardium alone produces a QRSD of 120 +/- 10ms
• With true left bundle branch block (LBBB), the QRSD is in the range of140 +/- 16 ms, and with true right bundle branch block (RBBB), theQRSD is even less
• Any further widening of the QRSD beyond 140 ms +/- 16 ms is due to acombined effect of BBB and electrical uncoupling
In the presence of significant electrical uncoupling, the benefits of CRT may be negated by slow and dispersed
conduction during pacing
Potse M et al. Europace 2012;14: v33–v39Potse M et al. J Cardiovasc Transl Res 2012;5:146–58
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BBB like morphology
Electrical uncoupling True BBBCombination of bothBBB and electrical
uncoupling
QRS < 130 ms QRS 140 ms +/- 16 ms QRS > 180 ms?ECHO CRT trial. Frank Ruschitzka, et al, N Engl J Med 2013; 369:1395-1405
Role of Cardiac Resynchronization Therapy (CRT)
Methods
Final analysis N=14,902 patients(Received CRT-D between Jan 2005 and April 2006)
Classified into 3 groups
based on theirQRS interval
120-149 ms 150-179 ms > 180 ms
Outcomes
1. Death 2. Composite of death and heart failure
hospitalization (HFH)
• Included patients with a left ventricular ejection fraction (LVEF) ≤ 35% and evidence of electrical dyssynchrony, defined by a QRSD ≥120 ms from the Medicare ICD registry
• All patients included in the analysis survived at least three days after CRT-D implantation
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HYPOTHESISWhen stratified by BBB
morphology, patients witha VWQRSD (≥180 ms) had worse clinical outcomes
Age, mean +/SD yrs 72.4±10.7 73.3±10.4 73.8±10.4 <0.0001BBB Morphology
LBBB n (%) 3,928 (65.3%) 4,383 (73.3%) 2,019 (69.4%) <0.0001RBBB n (%) 705 (11.7%) 708 (11.8%) 218 (7.5%) <0.0001IVCD n (%) 1,377 (22.9%) 892 (14.9%) 672 (23.1%) <0.0001
LVEF mean +/-SD % 23.4±6.3 23.1±6.3 22.5±6.3 <0.0001SBP, mean +/- SD, mm Hg 126.7±23.2 127.0±22.1 124.8±21.1 0.002DBP, mean +/- SD, mm Hg 70.4±15.2 70.0±12.7 70.0±12.5 0.08Gender n (%)
Table 3: Multivariable HRs for Early/Intermediate Time Points – Death/HF hospitalization Outcome
Figure1: Adjusted hazard ratios/95% confidence intervals for death at 6 years in a Cox Proportional Hazard model
A (LBBB); 3 groups, p<0.0001 for QRS 120-149 ms v QRS 150-179ms,p=0.0009 for QRS 120-149 ms v QRS> 180 ms,p<0.0003 for QRS 150-179ms v QRS> 180 ms, overall log-rank p < 0.0001
B (RBBB); 3 groups, p=0.04 for QRS> 180 ms vs QRS 150-179ms, overall log-rank p = 0.07
C (IVCD); 3 groups, overall log-rank p =0.49
Figure 2 (A, B, C): Kaplan Meyer 6 year survival plots for freedom from death (within each BBB group)
Figure 2A: LBBB Figure 2B: RBBB Figure 2C: IVCD
Free
dom
from
dea
th
Time (yrs)
p<0.0001 for QRS 120-149 ms v QRS 150-179ms, p<0.0001 for QRS 120-149 ms v QRS> 180 ms, p=0.0003 for QRS 150-179ms v QRS> 180 ms, overall log-rank p < 0.0001
p=0.10 for QRS> 180 ms v QRS 150-179ms, overall log-rank p = 0.15
p=0.08 for QRS 120-149 ms v QRS 150-179ms, p=0.03 for QRS 120-149 ms v QRS> 180 ms, overall log-rank p =0.08
Figure 3 (A, B, C): Kaplan Meyer 6 year survival plots for freedom from death/HFH (within each BBB group)
Figure 3A: LBBB Figure 3B: RBBB Figure 3C: IVCD
Free
dom
from
dea
th /
HFH
Time (yrs)
Major findings
• In patients with RBBB, clinical outcomes withVWQRSD (≥180 ms) were worse when compared to aQRSD of 120 -149 ms and a QRSD of 150 -179 ms.There appears to be an incremental risk within thisgroup that increases with patients in the higher end ofthis range (QRSD > 210-249 ms).
• In patients with LBBB, clinical outcomes withVWQRSD (≥180 ms) were similar when compared toLBBB patients with QRSD of 150-179 ms.
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Limitations
• The Medicare ICD registry had a wide range ofpatient information, but certain importantpatient characteristics, such as biomarkers andright ventricular function, were missing
• No follow up ECGs or echocardiograms whichare markers of the remodeling effects of CRTimplantation
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In Conclusion…
VWQRSD prior to CRT implantation has complexlong-term effects on prognosis afterresynchronization, with a dependency on BBBmorphology.
In patients with RBBB, a VWQRSD is possibly amarker of advanced electrical remodeling andsuggests that CRT may be ineffective in restoringsynchronous contraction.
Outcomes were worst for the narrower QRSDgroup in LBBB, and the VWQRSD group inRBBB.