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      Comparison of Tricuspid Regurgitation Severity Between Cardiac Resynchronization Therapy Versus Right Ventricular Pacing in Patients With Chronic Obstructive Pulmonary Disease

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          Abstract

          Background

          Right ventricular (RV) lead placement can worsen tricuspid regurgitation (TR). TR is known to be associated with lower survival irrespective of left ventricular ejection fraction (LVEF) or pulmonary hypertension (PH). Patients with chronic obstructive pulmonary disease (COPD) often have PH and pre-existent TR with higher morbidity and mortality from worsening TR. Prior studies are lacking to indicate if cardiac resynchronization therapy (CRT) may be more beneficial in lessening TR in COPD patients. Therefore, we sought to study if patients with COPD will have less TR with CRT versus non-CRT devices.

          Methods

          We performed a retrospective, single-center analysis on 154 COPD patients (mean age = 71.69 ± 10.58, males = 54.14%) that required single-chamber (n = 27), dual-chamber (n = 90), or CRT (n = 37) devices. TR severity, LVEF and right ventricular systolic pressure (RVSP) were evaluated by two cardiologists in a blinded fashion. Analysis of variance (ANOVA) and Chi-square tests were applied for continuous and categorical variables respectively. The primary endpoint was a change in the severity of TR comparing pre-device versus post-device echocardiogram. Secondary endpoints included changes in LVEF and RVSP.

          Results

          COPD patients, who underwent a CRT device had a significantly lower incidence of worsening TR (16%) when compared to single- (37%) (P = 0.001) and dual-chamber devices (30%) (P = 0.02). The increase in RVSP was similar between the groups. There was an expected improvement in LVEF in the CRT group.

          Conclusions

          COPD patients receiving a CRT device were least likely to have worsening TR, compared to single- or dual-chamber devices. Since both COPD and progression in TR may result in poor outcomes, our study may suggest that an upfront strategy of CRT rather than a single- or dual-chamber device may be more beneficial in COPD patients, especially with pre-existent TR.

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          Most cited references31

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          Cardiac-resynchronization therapy for the prevention of heart-failure events.

          Arthur Moss, W Hall, David S Cannom … (2009)
          This trial was designed to determine whether cardiac-resynchronization therapy (CRT) with biventricular pacing would reduce the risk of death or heart-failure events in patients with mild cardiac symptoms, a reduced ejection fraction, and a wide QRS complex. During a 4.5-year period, we enrolled and followed 1820 patients with ischemic or nonischemic cardiomyopathy, an ejection fraction of 30% or less, a QRS duration of 130 msec or more, and New York Heart Association class I or II symptoms. Patients were randomly assigned in a 3:2 ratio to receive CRT plus an implantable cardioverter-defibrillator (ICD) (1089 patients) or an ICD alone (731 patients). The primary end point was death from any cause or a nonfatal heart-failure event (whichever came first). Heart-failure events were diagnosed by physicians who were aware of the treatment assignments, but they were adjudicated by a committee that was unaware of assignments. During an average follow-up of 2.4 years, the primary end point occurred in 187 of 1089 patients in the CRT-ICD group (17.2%) and 185 of 731 patients in the ICD-only group (25.3%) (hazard ratio in the CRT-ICD group, 0.66; 95% confidence interval [CI], 0.52 to 0.84; P=0.001). The benefit did not differ significantly between patients with ischemic cardiomyopathy and those with nonischemic cardiomyopathy. The superiority of CRT was driven by a 41% reduction in the risk of heart-failure events, a finding that was evident primarily in a prespecified subgroup of patients with a QRS duration of 150 msec or more. CRT was associated with a significant reduction in left ventricular volumes and improvement in the ejection fraction. There was no significant difference between the two groups in the overall risk of death, with a 3% annual mortality rate in each treatment group. Serious adverse events were infrequent in the two groups. CRT combined with ICD decreased the risk of heart-failure events in relatively asymptomatic patients with a low ejection fraction and wide QRS complex. (ClinicalTrials.gov number, NCT00180271.) 2009 Massachusetts Medical Society
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            Impact of tricuspid regurgitation on long-term survival.

            Jayant Nath, Elyse Foster, Paul A Heidenreich (2004)
            The goal of this study was to examine mortality associated with tricuspid regurgitation (TR) after controlling for left ventricular ejection fraction (LVEF), right ventricular (RV) dilation and dysfunction, and pulmonary artery systolic pressure (PASP). Tricuspid regurgitation is a frequent echocardiographic finding; however, the association with prognosis is unclear. We retrospectively identified 5,223 patients (age 66.5 +/- 12.8 years; predominantly male) undergoing echocardiography at one of three Veterans Affairs Medical Center laboratories over a period of four years. Follow-up data were available for four years (mean 498 +/- 402 days). Kaplan-Meier and proportional hazards methods were used to compare differences in survival among TR grades. Mortality increased with increasing severity of TR. The one-year survival was 91.7% with no TR, 90.3% with mild TR, 78.9% with moderate TR, and 63.9% with severe TR. Moderate or greater TR was associated with increased mortality regardless of PASP (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.16 to 1.49 for PASP >40 mm Hg; HR 1.32, 95% CI 1.05 to 1.62 for PASP or =50%). When adjusted for age, LVEF, inferior vena cava size, and RV size and function, survival was worse for patients with moderate (HR 1.17, 95% CI 0.96 to 1.42) and severe TR (HR 1.31, 95% CI 1.05 to 1.66) than for those with no TR. We conclude that increasing TR severity is associated with worse survival in men regardless of LVEF or pulmonary artery pressure. Severe TR is associated with a poor prognosis, independent of age, biventricular systolic function, RV size, and dilation of the inferior vena cava.
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              Burden of Tricuspid Regurgitation in Patients Diagnosed in the Community Setting

              Yan Topilsky, Simon Maltais, Jose R. Medina Inojosa … (2018)
              This study sought to analyze patients with tricuspid regurgitation (TR) diagnosed in the community setting (Olmsted County) by Doppler echocardiography to define the prevalence, characteristics, and implications of clinically significant (greater or equal to moderate) TR.
              Article 0 comments Cited 206 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cardiol Res
                Journal ID (iso-abbrev): Cardiol Res
                Journal ID (publisher-id): Elmer Press
                Title: Cardiology Research
                Publisher: Elmer Press
                ISSN (Print): 1923-2829
                ISSN (Electronic): 1923-2837
                Publication date (Print): June 2022
                Publication date (Electronic): 16 June 2022
                Volume: 13
                Issue: 3
                Pages: 128-134
                Affiliations
                [a ]Department of Medicine, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA
                [b ]Heart Lung Vascular Institute, University of Tennessee Medical Center, Knoxville, TN, USA
                Author notes
                [c ]Corresponding Author: Raj Baljepally, Division of Cardiology, Heart Lung Vascular Institute, University of Tennessee Medical Center, Knoxville, TN 37920, USA. Email: RBaljepa@ 123456utmck.edu
                Article
                DOI: 10.14740/cr1365
                PMC ID: 9239508
                PubMed ID: 35836733
                SO-VID: 83f2595c-d3d4-4968-8578-901cf438c40b
                Copyright © Copyright 2022, Livesay et al.
                License:

                This article is distributed under the terms of the Creative Commons Attribution Non-Commercial 4.0 International License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 9 February 2022
                Date accepted : 28 April 2022
                Categories
                Subject: Original Article

                Keywords: tricuspid regurgitation,chronic obstructive pulmonary disease,cardiovascular implantable electronic device,cardiac resynchronization therapy,right ventricular pacing
                Data availability:
                Keywords: tricuspid regurgitation, chronic obstructive pulmonary disease, cardiovascular implantable electronic device, cardiac resynchronization therapy, right ventricular pacing

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