Prognostic value of renal function in patients with cardiac resynchronization therapy
Introduction
Chronic heart and renal failure are two common and serious disorders affecting the worldwide population [1], [2], [3], [4], [5]. Both disorders are growing problems and the epidemiological link between them was well established [4], [5]. Moreover, renal insufficiency is an independent prognostic factor in diastolic and systolic dysfunction [6], [7], [8]. It was estimated that 56% of patients with heart failure had creatinine clearance less than 60 ml/min and 1 ml/min decrease in creatinine clearance was associated with 1% increase in mortality [6].
Renal insufficiency and heart failure actively interact with each other pathophysiologically and often named as cardiorenal syndrome. It has been proposed that activation of renin-angiotensin system, nitric oxide-reactive oxygen species imbalance, active inflammation and sympathetic activation are the keys of cardiorenal interaction [9]. It is a general belief that improvement in LV systolic function and cardiac output should have favorable effect on renal function due to enhanced renal blood flow but data from clinical trial is lacking as patients with heart failure and significant renal insufficiency were always excluded, especially in those involving pharmacological therapy [10]. Cardiac resynchronization therapy (CRT) is a proven device-based treatment for patients with severe heart failure and ventricular dyssynchrony. It improves LV systolic function, exercise capacity, symptom, functional status and reduces hospitalization and mortality rates in patients remained symptomatic despite the optimal heart failure medical therapy [11], [12], [13], [14]. In this study, we examined (i) the relationship between LV reverse remodeling by CRT and progression of renal disease and (ii) the prognostic value of renal function in patients with severe systolic heart failure and pre-existing renal insufficiency after CRT.
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Patients
This is a retrospective study evaluating the impact of CRT on progression of renal disease and the prognostic value of renal function in these patients with severe heart failure. Eight-five consecutive patients (mean age 64 ± 12, 64 male) who received CRT were analyzed. Inclusion criteria included severe symptomatic heart failure with New York Heart Association (NYHA) functional class III or IV, with LV ejection fraction < 35% and QRS duration > 120 ms despite optimal medical therapy including ACE
Effect of CRT in the whole group
The changes in clinical, echocardiographic and biochemical parameters between baseline and 3 months in the 85 patients after CRT were shown in Table 1. The whole group had moderate degree of renal insufficiency at baseline. There were significant improvements in NYHA functional class, exercise capacity, symptoms, LV systolic function, and reduction in LV volumes, NT-proBNP level and mitral regurgitation after CRT. However, there was a significant decline in GFR of 4.7 ml/min/1.73 m2 in the
Discussion
Current study showed that successful LV reverse modeling in patients with systolic heart failure and renal insufficiency plays a key role in preserving the renal function irrespective of the degree of baseline renal insufficiency. On the other hand, there was a rapid decline in renal function in those who did not respond to CRT (without significant LV reverse remodeling). Moreover, changes in renal function at 3 months provide prognostic information in terms of long-term morbidity and mortality
Conclusion
LV reverse remodeling by CRT plays a key role in preserving the renal function in patients with severe heart failure and moderate renal insufficiency. Changes in GFR at 3 months after CRT provide long-term prognostic information to these patients. Those without significant reverse remodeling constitute a high risk group of patients with rapid decline in renal function and warrant more aggressive intervention.
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Usefulness of Sodium Bicarbonate for the Prevention of Contrast-Induced Nephropathy in Patients Undergoing Cardiac Resynchronization Therapy
2017, American Journal of CardiologyImpact of baseline renal function on all-cause mortality in patients who underwent cardiac resynchronization therapy: A systematic review and meta-analysis
2017, Journal of ArrhythmiaCitation Excerpt :Indeed, CRT improves LV systolic function, systemic hemodynamic status, and prerenal circulation [41]. In support of these speculations Fung et al. showed reverse remodeling of the left ventricle, defined as a reduction in LV end-systolic volume by 10%, after CRT [42]. Specifically, Fung et al. were among the first to identify a potential link between impaired renal function and poor clinical outcomes in patients who underwent CRT [42].
Impact of Renal Function on Survival After Cardiac Resynchronization Therapy
2017, American Journal of CardiologyPredictors of response to cardiac resynchronization therapy: A prospective cohort study
2017, Revista Portuguesa de CardiologiaCardiac resynchronization therapy: Past, present, and future
2015, Heart Failure ClinicsCitation Excerpt :The role for this approach remains to be assessed in a larger prospective randomized fashion. In addition to QRS duration and AF, several other factors have been shown to influence the efficacy of CRT, including medical comorbidities (chronic renal insufficiency),70,71 hemodynamic abnormalities (precapillary pulmonary hypertension),72 and abnormalities of LV substrate (nonrevascularized coronary artery disease, myocardial scar).73,74 There has also been a suggestion that women may benefit from CRT more so than men, particularly in patients with LBBB and even at a QRS duration less than 150 milliseconds.75,76