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1、Deferred DFT testing at the time of cardiac resynchronization therapy is associated with poor long term outcomeGrace Lin, MD, Peter A. Brady, MD, David L. Hayes, MDMayo Clinic, Rochester, MN USABackgroundDefibrillation threshold (DFT) testing is commonly performed at the time of ICD implantationIn s
2、ome cases DFT testing may not be performed, or deferred to a later dateImpact of no or deferred DFT testing on outcome is unknownBackgroundNo or deferred DFT testing: Inadequate anticoagulationInadequate anticoagulationHemodynamicHemodynamic instability instabilityPhysician discretionPhysician discr
3、etionLikelihood of no or deferred DFT testing may be higher in patients undergoing cardiac resynchronization therapy (CRT)BackgroundPrevalence and reasons of no or deferred DFT testing in patients undergoing CRT are unknownOutcome of CRT patients who undergo DFT testing vs. those who do not is unkno
4、wnMethodsAll CRT-D implants from 1999-2004 at Mayo ClinicReview ofClinical recordOperative noteICD databaseClinical follow up via questionnaireMethodsDFT+DFT testing at implantDFT testing at implantDFT-DFT testing not at implantDFT testing not at implantDelayed DFTSubsequent DFT testingSubsequent DF
5、T testingDFT- neverNo subsequent DFT testingNo subsequent DFT testingDefinitionsResults277 CRT-D 277 CRT-D implantsimplants14 pts lost to 14 pts lost to follow upfollow up263 pts included263 pts included192 DFT+192 DFT+(tested)(tested)71 DFT 71 DFT (deferred)(deferred)Device Implants 1999-2004 Resul
6、tsDFT +DFT +DFT -DFT -p valuep valueAgeAge67 +/- 1167 +/- 1170 +/- 1270 +/- 120.070.07MaleMale166 (86%)166 (86%)62 (87%)62 (87%)1 1EFEF21% +/- 621% +/- 620% +/- 820% +/- 80.460.46Ischemic CMIschemic CM 136 (71%)136 (71%)57 (80%)57 (80%)0.120.12NICMNICM56 (29%)56 (29%)14 (20%)14 (20%)0.120.12Creatini
7、neCreatinine1.6 g/dL +/-1.6 g/dL +/-0.80.81.6 g/dL +/-1.6 g/dL +/-0.70.70.380.38Fluoroscopy Fluoroscopy TimeTime42.7 min +/-42.7 min +/-23.923.952.1 min +/- 52.1 min +/- 32.932.90.110.11Baseline CharacteristicsResultsReasons for DFT-Inadequate anticoagulationInadequate anticoagulation18 18 (25%)(25%
8、)Severe CAD/ CHFSevere CAD/ CHF13 13 (18%)(18%)Prolonged procedureProlonged procedure11 11 (15%)(15%)HypotensionHypotension8 8 (11%)(11%)Intractable VT/ VFIntractable VT/ VF5 5 (7%)(7%)Chronic RV (ICD) leadChronic RV (ICD) lead4 4 (6%)(6%)CS lead instabilityCS lead instability4 4 (6%)(6%)AAD loading
9、AAD loading2 2 (3%)(3%)ResultsReasons for DFT-Malignant hyperthermiaMalignant hyperthermia1 1 (1%)(1%)Unable to induce VFUnable to induce VF1 1 (1%)(1%)ApneaApnea1 1 (1%)(1%)Electrolyte abnormalitiesElectrolyte abnormalities1 1 (1%)(1%)LV pseudoaneurysmLV pseudoaneurysm1 1 (1%)(1%)SurvivalSurvivalSu
10、rvivalMonthsMonthsMonthsP0.04P0.04P0.04CP1207784-1Survival in DFT + vs. DFT- Death or TransplantationDeath or TransplantationDFT+DFT+DFT-DFT-Results71 DFT -37 subsequent DFT testing34 no subsequentDFT testingResultsDelayed Delayed DFTDFTDFT - neverDFT - neverp valuep valueAgeAge73 +/- 1173 +/- 1168
11、+/- 1368 +/- 130.030.03MaleMale31 (84%)31 (84%)31 (91%)31 (91%)0.010.01EFEF19% +/- 719% +/- 721% +/- 821% +/- 80.360.36Ischemic CMIschemic CM 28 (76%)28 (76%)29 (85%)29 (85%)0.010.01NICMNICM9 (24%)9 (24%)5 (15%)5 (15%)0.010.01CreatinineCreatinine1.8 g/dL +/- 1.8 g/dL +/- 0.80.81.4 g/dL +/- 1.4 g/dL
12、+/- 0.80.80.020.02Fluoroscopy Fluoroscopy TimeTime52.5 min +/- 52.5 min +/- 31.731.750.8 min +/- 50.8 min +/- 34.634.60.830.83Baseline Characteristics for subsequent DFT testingBaseline Characteristics for subsequent DFT testingResultsTiming of delayed DFT testing: Mean 3.4 months +/- 5.7 Range of 1
13、 day to 26 months 13 patients tested 1 week after implantationResultsReasons for Delayed DFTInadequate anticoagulationInadequate anticoagulation10 10 (27%)(27%)Prolonged procedureProlonged procedure8 8 (21%)(21%)HypotensionHypotension5 5 (14%)(14%)Intractable VT/ VFIntractable VT/ VF3 3 (8%)(8%)CS l
14、ead instabilityCS lead instability3 3 (8%)(8%)AAD loadingAAD loading2 2 (5%)(5%)Chronic RV leadChronic RV lead2 2 (5%)(5%)ResultsReasons for Delayed DFTUnable to induce VFUnable to induce VF1 1 (3%)(3%)Electrolyte abnormalitiesElectrolyte abnormalities1 1 (3%)(3%)ApneaApnea1 1 (3%)(3%)CHFCHF1 1 (3%)
15、(3%)ResultsReasons for DFT- neverPhysician deferredPhysician deferred22 22 (65%)(65%)Anticoagulation (unable)Anticoagulation (unable)5 5 (17%)(17%)Patient deferredPatient deferred3 3 (9%)(9%)Chronic RV (ICD) leadChronic RV (ICD) lead3 3 (9%)(9%)ResultsPhysician deferred Physician deferred (23)(23)Se
16、vere CAD (12)Severe CAD (12)Anticoagulation (3)Anticoagulation (3)Hypotension (3)Hypotension (3)Prolonged Prolonged procedure(3)procedure(3)Malignant Malignant hyperthermia (1)hyperthermia (1)LV LV pseudoaneurysm (1)pseudoaneurysm (1)SurvivalSurvivalSurvivalMonthsMonthsMonthsP0.001P0.001P0.001CP1207
17、784-3Survival Delayed DFT vs. DFT-Death or TransplantationDeath or TransplantationDelayed DFTDelayed DFTDFT- neverDFT- neverSurvivalSurvivalSurvivalMonthsMonthsMonthsp= 0.5p= 0.5p= 0.5CP1207784-2Delayed DFTDelayed DFTDFT +DFT +Survival DFT + vs. Delayed DFTDeath or TransplantationDeath or Transplant
18、ationConclusionsPrevalence of no or deferred DFT testing in this population of patients is high (28%)Survival of patients who undergo DFT testing, whether at the time of implant or later, is similar and is significantly better than patients who never undergo DFT testing ConclusionsPatients who do no
19、t undergo DFT testing Patients who do not undergo DFT testing at implant due to a reversible cause have at implant due to a reversible cause have similar outcomes to those who do similar outcomes to those who do undergo DFT testing at implantundergo DFT testing at implantImplanting physician discretion regarding Implanting physician discretion regarding DFT testing at implant is an important DFT testing at implant is an important determinant of outcomedeterminant of outcome
