Benjamin A Steinberg1,2, Scott Wehrenberg3, Kevin P Jackson4, David L Hayes5, Niraj Varma6, Brian D Powell7, John D Day8, Camille G Frazier-Mills4, Kenneth M Stein9, Paul W Jones10, Jonathan P Piccini4,11. 1. Electrophysiology Section, Duke University Medical Center, PO Box 17969, Durham, NC, 27715, USA. benjamin.steinberg@duke.edu. 2. Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA. benjamin.steinberg@duke.edu. 3. Boston Scientific, St. Paul, MN, USA. Scott.Wehrenberg@bsci.com. 4. Electrophysiology Section, Duke University Medical Center, PO Box 17969, Durham, NC, 27715, USA. 5. Division of Cardiovascular Disease, Mayo Clinic, Rochester, MN, USA. dhayes@mayo.edu. 6. Section of Electrophysiology and Pacing, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA. varman@ccf.org. 7. Division of Cardiovascular Disease, Sanger Heart & Vascular Institute, Charlotte, NC, USA. powell.brian17@gmail.com. 8. Division of Cardiovascular Disease, Intermountain Medical Center, Salt Lake City, UT, USA. johndaymd@gmail.com. 9. Boston Scientific, St. Paul, MN, USA. kenneth.stein@bsci.com. 10. Boston Scientific, St. Paul, MN, USA. Paul.Jones@bsci.com. 11. Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA.
Abstract
PURPOSE: Cardiac resynchronization therapy (CRT) improves outcomes in patients with heart failure, yet response rates are variable. We sought to determine whether physician-specified CRT programming was associated with improved outcomes. METHODS: Using data from the ALTITUDE remote follow-up cohort, we examined sensed atrioventricular (AV) and ventricular-to-ventricular (VV) programming and their associated outcomes in patients with de novo CRT from 2009-2010. Outcomes included arrhythmia burden, left ventricular (LV) pacing, and all-cause mortality at 4 years. RESULTS: We identified 5709 patients with de novo CRT devices; at the time of implant, 34% (n = 1959) had entirely nominal settings programmed, 40% (n = 2294) had only AV timing adjusted, 11% (n = 604) had only VV timing adjusted, and 15% (n = 852) had both AV and VV adjusted from nominal programming. Suboptimal LV pacing (<95%) during follow-up was similar across groups; however, the proportion with atrial fibrillation (AF) burden >5% was lowest in the AV-only adjusted group (17.9%) and highest in the nominal (27.7%) and VV-only adjusted (28.3%) groups. Adjusted all-cause mortality was significantly higher among patients with non-nominal AV delay >120 vs. <120 ms (adjusted heart rate (HR) 1.28, p = 0.008) but similar when using the 180-ms cutoff (adjusted HR 1.13 for >180 vs. ≤180 ms, p = 0.4). CONCLUSIONS: Nominal settings for de novo CRT implants are frequently altered, most commonly the AV delay. There is wide variability in reprogramming. Patients with nominal or AV-only adjustments appear to have favorable pacing and arrhythmia outcomes. Sensed AV delays less than 120 ms are associated with improved survival.
PURPOSE: Cardiac resynchronization therapy (CRT) improves outcomes in patients with heart failure, yet response rates are variable. We sought to determine whether physician-specified CRT programming was associated with improved outcomes. METHODS: Using data from the ALTITUDE remote follow-up cohort, we examined sensed atrioventricular (AV) and ventricular-to-ventricular (VV) programming and their associated outcomes in patients with de novo CRT from 2009-2010. Outcomes included arrhythmia burden, left ventricular (LV) pacing, and all-cause mortality at 4 years. RESULTS: We identified 5709 patients with de novo CRT devices; at the time of implant, 34% (n = 1959) had entirely nominal settings programmed, 40% (n = 2294) had only AV timing adjusted, 11% (n = 604) had only VV timing adjusted, and 15% (n = 852) had both AV and VV adjusted from nominal programming. Suboptimal LV pacing (<95%) during follow-up was similar across groups; however, the proportion with atrial fibrillation (AF) burden >5% was lowest in the AV-only adjusted group (17.9%) and highest in the nominal (27.7%) and VV-only adjusted (28.3%) groups. Adjusted all-cause mortality was significantly higher among patients with non-nominal AV delay >120 vs. <120 ms (adjusted heart rate (HR) 1.28, p = 0.008) but similar when using the 180-ms cutoff (adjusted HR 1.13 for >180 vs. ≤180 ms, p = 0.4). CONCLUSIONS: Nominal settings for de novo CRT implants are frequently altered, most commonly the AV delay. There is wide variability in reprogramming. Patients with nominal or AV-only adjustments appear to have favorable pacing and arrhythmia outcomes. Sensed AV delays less than 120 ms are associated with improved survival.
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