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  • br Conclusion Elevated levels of the myocardial damage

    2019-05-22


    Conclusion Elevated levels of the myocardial damage markers c-TNT and H-FABP were not found after ≤10J-DT (9J or 10J) in patients who underwent device implantation. Our findings confirm that minimally-invasive DT has an acceptable success rate. To prevent unnecessary myocardium damage, ≤10J-DT may be an ideal strategy; however, it should not be used in patients at high risk for a high defibrillation threshold.
    Conflict of interest
    Acknowledgments This work was supported, in part, by a grant-in-aid for Scientific Research (No. 25461039) from the Ministry of Education Culture, Sport, Science, and Technology of Japan. All authors declare no conflict of interest related to this study.
    Introduction Cardiac resynchronization therapy (CRT) is an effective option for the treatment of moderate to severe acetylcholinesterase inhibitor failure [1–6]. The COMPANION trial [2] found that CRT with a defibrillator (CRT-D) was superior to that with a pacemaker (CRT-P) in acetylcholinesterase inhibitor terms of survival rate. However, direct comparisons of the efficacy of these devices are limited [2,7,8]. In fact, treatment with CRT-P also reduced all-cause mortality during a longer follow-up period [3]. In addition, the populations in these prospective studies consisted of patients with less advanced age (average 67 years) [2,3], which may not always represent our daily medical practice. The major role of an implantable cardioverter-defibrillator (ICD) is to prevent sudden cardiac death due to ventricular tachycardia (VT) or fibrillation (VF). The MERIT-HF study reported that the incidence of sudden cardiac death in patients with NYHA class II–III was approximately 60%, whereas it was approximately 30% in patients with NYHA class IV [9]. A sub-analysis of the COMPANION trial concluded that CRT-P and CRT-D both had beneficial effects on mortality and morbidity in the severely ill population of NYHA class IV patients [10]. Moreover, the risk of sudden cardiac death decreased in association with aging, according to the Amiodarone Trialists MetAnalysis (ATMA) database of 6252 patients with structural heart disease [11]. The current guidelines from the European Society of Cardiology have proposed that the better candidates for CRT-D vs. CRT-P are patients with (1) stable heart failure, NYHA class II, (2) life expectancy more than 1 year, (3) ischemic heart disease, and (4) no comorbidities [12]. Therefore, the choice between CRT-D and CRT-P may largely depend on the physician׳s discretion, especially in patients without documented VT/VF who require CRT for primary prevention. The present study aimed to examine national trends in the use of CRT devices and to determine factors affecting the choice of CRT-D in heart failure patients, based on data from the Japan Cardiac Device Treatment Registry (JCDTR) [13–15].
    Materials and methods
    Results
    Discussion A subanalysis of the MADIT-CRT trial demonstrated that the factors associated with an LVEF improvement (LVEF>50%) by CRT were female sex, no previous myocardial infarction, left bundle branch block, baseline LVEF >30%, left ventricular end-systolic volume ≤170mL, and left atrial volume index ≤45mL/m2[16]. The patients with LVEF improvement had a low risk of VT/VF (approximately 3% at 2 years) and a favorable clinical course within 2.2 years of follow-up. QRS duration ≥150ms was also associated with a reduction in echocardiographic left ventricular end-diastolic volume in response to CRT-D [17]. A recent meta-analysis demonstrated that male sex and ischemic heart disease were significant moderator variables for a stronger benefit of CRT-D vs. CRT-P in primary prevention recipients [18]. Taken together, male patients with ischemic heart disease, lower LVEF, and less prolonged QRS are less likely to show a good response to CRT, thereby requiring ICD backup for primary prevention. In addition, detection of NSVT (at least 18 beats in duration and at least 188beats/min) indicated a 4.3-fold increase in the risk of appropriate ICD shocks in the heart failure patients enrolled for SCD-HeFT [19]. Therefore, our tendency to select CRT-D would be reasonable in terms of the identified factors such as male sex, lower LVEF, and a history of NSVT. However, we should be cautious in the interpretation of our results, because the present study did not evaluate the patients’ outcomes.