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Abstract
Background: NICE guidelines recommend cardiac resynchronisation therapy in patients with severe left ventricular dysfunction (Ejection Fraction <35%) and broad QRS complexes. CRTD is recommended in NYHA 1 or 2 patients, CRTP or D in NYHA 3 and CRTP in NYHA class 4 patients. The commissioning arrangements in East Lancashire permit only CRTP but not ICD or CRTD devices to be implanted. All patients who undergo CRTP implantation in our centre is included in a local database. This allowed a unique cohort of patients to be assessed for improvement in left ventricular function beyond 35% and thereby beyond the NICE recommended guidelines for ICD/CRTD requirment.
Methods 177 of the 202 consecutive patients who underwent CRTP implant and had pre and post implant echocardiograms between February 2012 and August 2017 were assessed. The duration of follow up was between 6 months to 5 years. Echocardiograms were done pre implant and at 4–8 months post implant. 25 patients who did not have an echo either died before the echo could be repeated (18 patients) or were waiting for the follow up echo appointment.
Results 73% were male and the average age was 72 years.>80% were in NYHA class 3 with a significant proportion having had at least one admission in class 4 heart failure in the preceeding 12 months. 90 (50.8%) patients had ischaemic cardiomyopathy and 87 non-ischaemic. 32 patients were in permanent AF. The implant success rate in the whole cohort of 202 patients was >97%. The complication rate at 1 year follow up of the whole cohort was 4.5% (6 A lead displacement, 1 LV lead displacement, 1 infection requiring extraction and 1 small pneumothorax). There were 32 deaths during this follow up period but only 5 due to progressive cardiac failure and 1 sudden cardiac death. 16 deaths were due to definite non-cardiac causes but a definite cause was unclear in 10 patients. 1 patient had a resuscitated cardiac arrest and underwent an upgrade to a CRTD device in another centre. The average ejection fraction (EF) was 31% pre-implant. 92% had EF of <35% with 48% having EF of <25%. The average EF improved post implant to 37%. More impressively 78.5% (139 patients) had an EF of >35% in the post implant echo. 22.5% (38 patients) had EF <35% post implantation but only 2.3% (4 patients) had EF persisting below 25%.
Conclusion This unique data from a single centre performing solely CRTP implantation demonstrates impressive implant success rates and low complication rates despite annual volumes considered below current British Heart Rhythm Society guidelines. More impressively 4 of every 5 implanted patients (78.5%) had objective improvement in their ejection fraction to greater than 35% which would then no longer necessitate ICD requirement as per NICE recommendations.