Prognostic importance of postoperative QRS widening in patients with heart failure receiving cardiac resynchronization therapy
Résumé
BACKGROUND Landmark reports have suggested that patients with QRS widening immediately after cardiac resynchronization therapy (CRT) experienced less frequently reverse left ventricular remodeling during follow-up. OBJECTIVE We sought to investigate the relationship between postoperative QRS widening relative to baseline and mortality in a prospective cohort of heart failure patients receiving CRT. METHODS A 12-lead electrocardiogram was recorded for 237 heart failure patients (New York Heart Association class II to IV, left ventricular ejection fraction <= 35%, and QRS width >= 120 ms) before and immediately after CRT device implantation. The relationships between QRS widening, all-cause and cardiovascular mortality, and echocardiographic response to CRT were studied. RESULTS During a median follow-up of 24 months, 39 patients died. Fifty patients (21%) experienced QRS widening after CRT [QRS (+) group]. During follow-up, all-cause mortality was higher in QRS (+) patients than in QRS(-) patients (36-month survival free from death 81% +/- 7% vs 64% 16%; log rank, P = .029). After adjustment for important prognostic confounders, QRS(+) patients remained associated with an excess overall mortality (adjusted hazard ratio [HR] 2.67; 95% confidence interval 1.07-6.65; P = .035) and cardiovascular mortality (adjusted hazard ratio 3.63; 95% confidence interval 1.13-11.65; P = .03). QRS(+) patients were less frequent responders to CRT than were QRS(-) patients (20 [47%] vs 136 [83%]; P < .0001). CONCLUSION Postoperative QRS widening relative to baseline after CRT is associated with a considerable increased mortality risk during follow-up. Whether QRS narrowing should be achieved to optimize CRT placement, and thereby increase the rate of CRT responders and improve outcome, deserves further research.