title: Progressive ventricular dysfunction among nonresponders to cardiac resynchronization therapy: baseline predictors and associated clinical outcomes.
abstract: BACKGROUND
  Cardiac resynchronization therapy (CRT) nonresponders have poor outcomes. The significance of progressive ventricular dysfunction among nonresponders remains unclear.
  
  
  OBJECTIVE
  We sought to define predictors of and clinical outcomes associated with progressive ventricular dysfunction despite CRT.
  
  
  METHODS
  We conducted an analysis of 328 patients undergoing CRT with defibrillator for standard indications. On the basis of 6-month echocardiograms, we classified patients as responders (those with a ≥5% increase in ejection fraction) and progressors (those with a ≥5% decrease in ejection fraction), and all others were defined as nonprogressors. Coprimary end points were 3-year (1) heart failure, left ventricular assist device (LVAD), transplantation, or death and (2) ventricular tachycardia (VT) or ventricular fibrillation (VF).
  
  
  RESULTS
  Multivariable predictors of progressive ventricular dysfunction were aldosterone antagonist use (hazard ratio [HR] 0.23; P = .008), prior valve surgery (HR 3.3; P = .005), and QRS duration (HR 0.98; P = .02). More favorable changes in ventricular function were associated with lower incidences of heart failure, LVAD, transplantation, or death (70% vs 54% vs 33%; P < .0001) and VT or VF (66% vs 38% vs 28%; P = .001) for progressors, nonprogressors, and responders, respectively. After multivariable adjustment, progressors remained at increased risk of heart failure, LVAD, transplantation, or death (HR 2.14; P = .0029) and VT or VF (HR 2.03; P = .046) as compared with nonprogressors. Responders were at decreased risk of heart failure, LVAD, transplantation, or death (HR 0.44; P < .0001) and VT or VF (0.51; P = .015) as compared with nonprogressors.
  
  
  CONCLUSIONS
  Patients with progressive deterioration in ventricular function despite CRT represent a high-risk group of nonresponders at increased risk of worsened clinical outcomes.
authors.affiliation: Division of Cardiology, Duke University Hospital, Durham, North Carolina.
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Friedman
authors.affiliation: Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Gaurav A
authors.initials: GA
authors.lastname: Upadhyay
authors.affiliation: Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Alefiyah
authors.initials: A
authors.lastname: Rajabali
authors.affiliation: Al-Sabah Arrhythmia Institute, Mount Sinai St. Lukes Roosevelt Hospital, New York, New York.
authors.forename: Robert K
authors.initials: RK
authors.lastname: Altman
authors.affiliation: Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Mary
authors.initials: M
authors.lastname: Orencole
authors.affiliation: Heart Failure and Cardiac Transplantation Unit, Massachusetts General Hospital, Boston Massachusetts.
authors.forename: Kimberly A
authors.initials: KA
authors.lastname: Parks
authors.affiliation: Heart Failure and Cardiac Transplantation Unit, Massachusetts General Hospital, Boston Massachusetts.
authors.forename: Stephanie A
authors.initials: SA
authors.lastname: Moore
authors.affiliation: Department of Cardiology, Hallym University Dongtan Sacred Hospital, Hwaseong, Republic of Korea.
authors.forename: Mi Young
authors.initials: MY
authors.lastname: Park
authors.affiliation: Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Picard
authors.affiliation: Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Jeremy N
authors.initials: JN
authors.lastname: Ruskin
authors.affiliation: Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
authors.forename: Jagmeet P
authors.initials: JP
authors.lastname: Singh
authors.affiliation: Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts. Electronic address: kheist@partners.org.
authors.forename: E Kevin
authors.initials: EK
authors.lastname: Heist
mesh_terms: D000368:Aged; D058406:Cardiac Resynchronization Therapy; D018450:Disease Progression; D004452:Echocardiography; D023381:Endpoint Determination; D005260:Female; D006801:Humans; D008297:Male; D017202:Myocardial Ischemia / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology; D011446:Prospective Studies; D012307:Risk Factors; D017211:Treatment Failure; D014693:Ventricular Fibrillation / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*
keywords: Biventricular pacing; Cardiac resynchronization therapy; Cardiomyopathy; Heart failure; Remodeling; Ventricular fibrillation; Ventricular tachycardia