Cardiac resynchronization therapy in New York Heart Association class-IV patients dependent on intravenous drugs or invasive supportive treatments

Abstract

Aims: We sought to evaluate the effectiveness of cardiac resynchronization therapy (CRT) in far-advanced heart failure (FA-HF) patients with New York Heart Association (NYHA) class-IV status and dependency on intravenous drugs (IVDs) and/or invasive supportive treatments (ISTs).

Methods and results: Among 305 patients who underwent CRT implantation between October 2005 to December 2019, we identified 17 FA-HF patients with NYHA class-IV status and dependency on IVDs (inotropes, diuretics, vasopressors, or vasodilators) and/or ISTs (extracorporeal membranous oxygenator or continuous renal replacement therapy). All patients (median age = 68.7 years, non-ischaemic cardiomyopathy = 15) remained dependent on several IVDs (2.2 ± 1.3 per patient) and/or ISTs for 11.3 ± 7.8 days due to multiple tapering failure (4.3 ± 3.2 per patient) before CRT implantation. However, 14 (82%) patients were successfully weaned from IVDs/ISTs within 5.2 ± 5.3 days following CRT, and 12 (71%) stayed alive for more than 1 year free of ventricular assist device or heart transplantation with symptom improvement (≥1 NYHA class) and a reduced annual HF hospitalization rate (P = 0.002). Considerable improvements in ventricular systolic function (P = 0.004) and volumetric reverse remodelling (P = 0.007) were noticed during the long-term follow-up period (35 ± 15 months post-CRT). The ventricular assist device/heart transplantation/death-free survival rate post-CRT was 71% and 65% at 1 and 3 years, respectively.

Conclusions: Cardiac resynchronization therapy implantation may be a feasible treatment that can offer short-term and long-term clinical benefits for NYHA class-IV FA-HF patients who are dependent on IVDs/ISTs. When considering treatment options, CRT should not be prematurely excluded solely based on a patient's dependency on IVDs/ISTs without first attempting to identify favourable CRT response factors.

Keywords: Cardiac resynchronization therapy; Far-advanced heart failure; New York Heart Association class IV; Prognosis.