递延密度泛函理论在心脏再同步治疗时间的测试与长期贫困的结果.ppt

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 USABackground•Defibrillation threshold (DFT) testing is commonly performed at the time of ICD implantation•In some cases DFT testing may not be performed, or deferred to a later date•Impact of no or deferred DFT testing on outcome is unknownBackground•No or deferred DFT testing: –Inadequate anticoagulationInadequate anticoagulation–HemodynamicHemodynamic instability instability–Physician discretionPhysician discretion•Likelihood of no or deferred DFT testing may be higher in patients undergoing cardiac resynchronization therapy (CRT)Background•Prevalence and reasons of no or deferred DFT testing in patients undergoing CRT are unknown•Outcome of CRT patients who undergo DFT testing vs. those who do not is unknownMethods•All CRT-D implants from 1999-2004 at Mayo Clinic•Review of–Clinical record–Operative note–ICD database•Clinical follow up via questionnaireMethods•DFT+–DFT testing at implantDFT testing at implant•DFT-–DFT testing not at implantDFT testing not at implant•Delayed DFT–Subsequent DFT testingSubsequent DFT testing•DFT- never–No subsequent DFT testingNo subsequent DFT testingDefinitionsResults277 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 ResultsDFT +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%)0.120.12CreatinineCreatinine1.6 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 CharacteristicsResultsReasons for DFT-Inadequate anticoagulationInadequate anticoagulation18 18 (25%)(25%)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 loadingAAD 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%)SurvivalSurvivalSurvivalMonthsMonthsMonthsP<0.04P<0.04P<0.04CP1207784-1Survival in DFT + vs. DFT- Death or TransplantationDeath or TransplantationDFT+DFT+DFT-DFT-Results71 DFT -37 subsequent DFT testing34 no subsequentDFT testingResultsDelayed Delayed DFTDFTDFT - neverDFT - neverp valuep valueAgeAge73 +/- 1173 +/- 1168 +/- 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 +/- 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 testingResultsTiming of delayed DFT testing: Mean 3.4 months +/- 5.7 Range of 1 day to 26 months 13 patients tested <1 week after implantationResultsReasons 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 lead 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%)(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)Severe 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)SurvivalSurvivalSurvivalMonthsMonthsMonthsP<0.001P<0.001P<0.001CP1207784-3Survival Delayed DFT vs. DFT-Death or TransplantationDeath or TransplantationDelayed DFTDelayed DFTDFT- neverDFT- neverSurvivalSurvivalSurvivalMonthsMonthsMonthsp= 0.5p= 0.5p= 0.5CP1207784-2Delayed DFTDelayed DFTDFT +DFT +Survival DFT + vs. Delayed DFTDeath or TransplantationDeath or TransplantationConclusions•Prevalence 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 Conclusions•Patients who do not 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 implant•Implanting 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。