Predictors of Long-Term Survival in Patients With Malignant Ventricular Arrhythmias

doi:10.1016/S0002-9149(97)00046-5

The American Journal of Cardiology

Volume 79, Issue 8, 15 April 1997, Pages 1054-1060

https://doi.org/10.1016/S0002-9149(97)00046-5 Get rights and content

Abstract

The study consisted of 369 patients (age 62 ± 13 years) who presented to our institution from April 1984 to April 1994 for malignant ventricular arrhythmias presenting as sustained ventricular tachycardia (VT) in 57% of patients, ventricular fibrillation in 25% of patients, and syncope due to VT in 17% of patients. Coronary artery disease was present in 74% of patients, cardiomyopathy in 19% of patients, and no evident heart disease in 7% of patients. Two hundred twenty-one patients were given drug therapy, 47 patients underwent arrhythmia surgery, and 75 patients had an implantable cardioverter-defibrillator (ICD). During a mean follow-up of 30 months (range 1 to 101), 66 patients (18%) died from a cardiac death of which 26 (39%) were sudden. Cox regression analysis was conducted utilizing a total of 19 variables (clinical and therapeutic) in the entire population and separately in patients with coronary artery disease and cardiomyopathy. The most significant variables (multivariate analysis) of survival from cardiac mortality in the entire population were: congestive heart failure (CHF) class (p = 0.0003), ejection fraction (p = 0.02), and the use of drug therapy (p = 0.03); in patients with coronary artery disease, CHF class (p = 0.0001) and ejection fraction (p = 0.0006); and in patients with cardiomyopathy, CHF class (p = 0.009) and sustained VT on Holter monitoring (p = 0.007). Kaplan-Meier survival rates from cardiac death were: significantly lower (p = 0.005) in patients with CHF class III and IV compared with CHF class I and II (25% vs 58%, p = 0.005) with drug therapy; marginally significant (47% vs 88%, p = 0.06) from 20 to 40 months in patients with an ICD; and nonsignificant in patients who underwent arrhythmia surgery (63% vs 71%). Patients with an ICD had a better expected survival (82%) than patients who had arrhythmia surgery (69%) and drug therapy (65%). Thus, in patients with malignant ventricular arrhythmias, CHF class was the most significant independent predictor of survival from cardiac mortality over all disease substrates, and therapy influenced survival depending on the CHF class. Patients in CHF class III and IV who underwent arrhythmia surgery or had an ICD had a better expected survival than those taking drug therapy, and the negative impact of antiarrhythmic therapy was most prominent in patients with CHF class III and IV.

Congestive heart failure class was the most significant predictor of survival in 369 patients with malignant ventricular arrhythmias over all disease substrates. Implantable cardioverter-defibrillator and arrhythmia surgery in contrast to antiarrythmic drug therapy was associated with a better long-term survival in patients with congestive heart failure.

Section snippets

Study Patients

The study consisted of 369 consecutive patients (age 62 ± 13 years) who presented to our institution from April 1984 to April 1994 for malignant ventricular arrhythmias. The clinical features of the patients are listed in Table 1. Patients underwent special noninvasive and invasive tests including 24-hour Holter monitoring, signal-averaged electrocardiography, radionuclide ventriculography, coronary angiography, and programmed electrical stimulation utilizing standard methods. The efficacy of

Results

A total of 66 patients (18%) died from a cardiac death; of these, only 26 (39%) were classified as sudden. The Kaplan-Meier survival curve for cardiac death for the entire population is shown in Fig. 1. The survival for a mean of 61 months was 69%. Of the variables tested in the regression analysis, the most significant univariate predictors (Table 2) of cardiac mortality were CHF class (p = 0.001), EF <30% (p <0.001), late potential-I (p <0.006), use of drug therapy (p = 0.03), and the

Discussion

Most previous studies15, 16 have shown that EF and inducibility of VT are powerful predictors of arrhythmic events; however, the role of CHF in the setting of current modalities of therapy has not been adequately addressed. This retrospective study found that CHF classification was the most powerful predictor of cardiac and sudden death mortality in the entire population of patients, most of whom had coronary artery disease. Of interest was our observation that the use of antiarrhythmic therapy

References (26)

P Kelly et al.
Surgical coronary revasculaziation in survivors of prehospital cardiac arrest: its effect on inducible ventricular arrhythmias and long term survival
J Am Coll Cardiol
(1990)
RA Winkle et al.
Long-term outcome with the automatic implantable cardioverter-defibrillator
J Am Coll Cardio
(1989)
D Newman et al.
Survival after inplantation of the cardioverter defibrillator
Am J Cardiol
(1992)
D Mehta et al.
Survival of implantable cardioverter-defibrillator recipients: role of left ventricular function and its relationship to device use
Am Heart J
(1992)
SG Kim et al.
Long term outcomes and modes of death of patients treated with nonthoractomy implantable defribillators
Am J Cardiol
(1995)
SL Lansman et al.
Coronary bypass with ejection fraction of 0.20 or less using centigrade cardioplegia: long-term follow up
Ann Thorac Surg
(1993)
CW Choue et al.
Comparison of defribillator therapy and other therapeutic modalities for sustained ventricular tachycardia or ventricular fibrillation associated with coronary artery disease
Am J Cardiol
(1994)
DR Holmes et al.
The effect of medical and surgical treatment on subsequent sudden cardiac death in patients with coronary artery disease. A report from the Coronary Artery Surgery Study
Circulation
(1986)
NR Every et al.
Influence of coronary bypass surgery on subsequent outcome of patients resuscitated from out of hospital cardiac arrest
J Am Coll Cardiol
(1992)
LL Mickleborough et al.
Late results of operation for ventricular tachycardia
Ann Thorac Surg
(1992)

Randomized antiarrhythmic drug therapy in survivors of cardiac arrest

Am J Cardiol

(1993)

RN Fogoros et al.

The automatic implantable cardioverter-defibrillator in drug-refractory ventricular tacharrhythmias

Ann Intern Med

(1987)

PJ Tchou et al.

Automatic implantable cardioverter defibrillators and survival of patients with left ventricular dysfunctiuon and malignant ventricular arrhythmias

Ann Intern Med

(1988)

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Left ventricular (LV) ejection fraction (LVEF) is a simple measure of global systolic function that pervades the risk evaluation and management of many cardiovascular diseases. However, this parameter is limited not only by technical challenges, but also by pathophysiological entities where the ratio of stroke volume to LV cavity size is preserved. The assessment of global longitudinal strain (GLS) from speckle-tracking analysis of 2-dimensional echocardiography has become a clinically feasible alternative to LVEF for the measurement of myocardial function. Evidence gathered over the last decade has shown GLS to be more sensitive to left ventricular dysfunction (LVD) than LVEF and to provide additional prognostic information. The technology is validated, reproducible within an acceptable range, and widely available. GLS has been proposed as the test of choice in guidelines for monitoring of asymptomatic cardiotoxicity related to chemotherapy. It also has the potential to improve risk stratification, redefine criteria for disease classification, and determine treatment in asymptomatic LVD resulting from a variety of etiologies. GLS provides utility across the spectrum of heart failure (and LVEF) as well as in the evaluation of valvular heart disease. There is a strong case for incorporation of GLS into clinical decision making. This review appraises the evidence addressing the utility of GLS as a complementary metric to LVEF for incorporation into mainstream clinical practice.
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Personalized cardiac models have the potential in facilitating the achievement of this goal [16,17]. The role of left ventricular (LV) systolic dysfunction has attracted broad attention from both clinical and experimental researchers [18–23]. On the other hand, LV diastolic dysfunction has been relatively slow in gathering interest due to its complex role in the pathomechanism of HF [24,25].
The search for a parameter representing left ventricular relaxation from non-invasive and invasive diagnostic tools has been extensive, since heart failure (HF) with preserved ejection fraction (HF-pEF) is a global health problem. We explore here the feasibility using patient-specific cardiac computer modeling to capture diastolic parameters in patients suffering from different degrees of systolic HF. Fifty eight patients with idiopathic dilated cardiomyopathy have undergone thorough clinical evaluation, including cardiac magnetic resonance imaging (MRI), heart catheterization, echocardiography, and cardiac biomarker assessment. A previously-introduced framework for creating multi-scale patient-specific cardiac models has been applied on all these patients. Novel parameters, such as global stiffness factor and maximum left ventricular active stress, representing cardiac active and passive tissue properties have been computed for all patients. Invasive pressure measurements from heart catheterization were then used to evaluate ventricular relaxation using the time constant of isovolumic relaxation Tau (τ). Parameters from heart catheterization and the multi-scale model have been evaluated and compared to patient clinical presentation. The model parameter global stiffness factor, representing diastolic passive tissue properties, is correlated significantly across the patient population with τ. This study shows that multi-modal cardiac models can successfully capture diastolic (dys) function, a prerequisite for future clinical trials on HF-pEF.
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The LVADs and the biventricular assist devices have been used as potential therapeutic options for profound cardiac failure and ventricular arrhythmias [1]. In most cardiomyopathies, the elevated intracardiac pressures and myocardial wall tension tends to induce ventricular irritability that results in ventricular arrhythmias [3]. In theory, by effectively unloading the LV with concomitant relaxation of the RV wall, LVADs should be an ideal treatment of ventricular arrhythmias [4].
Refractory ventricular tachyarrythmias (VTs) are potentially life-threatening rhythms in patients with cardiomyopathies, particularly when they result in hemodynamic instability. Here we report two cases of patients with intractable ventricular tachyarrythmias that were unresponsive to anti-arrhythmic medications and repeated catheter ablation, and for whom concomitant cryoablation and left ventricular assist device implantation was successfully performed. Both patients tolerated the procedure well with no complications and were free from ventricular tachyarrythmias postoperatively. Concomitant surgical ventricular ablation at the time of left ventricular assist device surgery may be a reasonable approach for this subset of patients as it provides excellent visualization and the ability to ablate both epicardial and endocardial sites.
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Predictors of Long-Term Survival in Patients With Malignant Ventricular Arrhythmias

Abstract

Section snippets

Study Patients

Results

Discussion

J Am Coll Cardiol

J Am Coll Cardio

Am J Cardiol

Am Heart J

Am J Cardiol

Ann Thorac Surg

Am J Cardiol

The effect of medical and surgical treatment on subsequent sudden cardiac death in patients with coronary artery disease. A report from the Coronary Artery Surgery Study

Circulation

Influence of coronary bypass surgery on subsequent outcome of patients resuscitated from out of hospital cardiac arrest

J Am Coll Cardiol

Late results of operation for ventricular tachycardia

Ann Thorac Surg

Randomized antiarrhythmic drug therapy in survivors of cardiac arrest

Am J Cardiol

The automatic implantable cardioverter-defibrillator in drug-refractory ventricular tacharrhythmias

Ann Intern Med

Automatic implantable cardioverter defibrillators and survival of patients with left ventricular dysfunctiuon and malignant ventricular arrhythmias

Ann Intern Med