Association of Cardiac Resynchronization Therapy With Change in Left Ventricular Ejection Fraction in Patients With Chemotherapy-Induced Cardiomyopathy.

Abstract

Importance:

The incidence of chemotherapy-induced cardiomyopathy is increasing and is associated with poor clinical outcomes.

Objective:

To assess the association of cardiac resynchronization therapy (CRT) with improvement in cardiac function, as well as clinical improvement in patients with chemotherapy-induced cardiomyopathy.

Design, Setting, and Participants:

The Multicenter Automatic Defibrillator Implantation Trial-Chemotherapy-Induced Cardiomyopathy was an uncontrolled, prospective, cohort study conducted between November 21, 2014, and June 21, 2018, at 12 tertiary centers with cardio-oncology programs in the United States. Thirty patients were implanted with CRT owing to reduced left ventricular ejection fraction (LVEF≤35%), New York Heart Association class II-IV heart failure symptoms, and wide QRS complex, with established chemotherapy-induced cardiomyopathy and were followed up for 6 months after CRT implantation. The date of final follow-up was February 6, 2019.

Exposures:

CRT implantation according to standard of care.

Main Outcomes and Measures:

The primary end point was change in LVEF from baseline to 6 months after initiating CRT. Secondary outcomes included all-cause mortality and change in left ventricular end-systolic volume and end-diastolic volume.

Results:

Among 30 patients who were enrolled (mean [SD] age, 64 [11] years; 26 women [87%]; 73% had a history of breast cancer; 20% had a history of lymphoma or leukemia), primary end point data were available for 26 patients and secondary end point data were available for 23 patients. Patients had nonischemic cardiomyopathy with left bundle branch block, median LVEF of 29%, and a mean QRS duration of 152 ms. Patients with CRT experienced a statistically significant improvement in mean LVEF at 6 months from 28% to 39% (difference, 10.6% [95% CI, 8.0%-13.3%]; P < .001). This was accompanied by a reduction in LV end-systolic volume from 122.7 to 89.0 mL (difference, 37.0 mL [95% CI, 28.2-45.8]) and reduction in LV end-diastolic volume from 171.0 to 143.2 mL (difference, 31.9 mL [95% CI, 22.1-41.6]) (both P < .001). Adverse events included a procedure-related pneumothorax (1 patient), a device pocket infection (1 patient), and heart failure requiring hospitalization during follow-up (1 patient).

Conclusions and Relevance:

In this preliminary study of patients with chemotherapy-induced cardiomyopathy, CRT was associated with improvement in LVEF after 6 months. The findings are limited by the small sample size, short follow-up, and absence of a control group.

Trial Registration:

ClinicalTrials.gov Identifier: NCT02164721.

• Authors: Jagmeet P Singh, Scott D Solomon, Michael G Fradley, Ana Barac, Kristina A Kremer, Christopher A Beck, Mary W Brown, Scott McNitt, Susan Schleede, Wojciech Zareba, Ilan Goldenberg, Valentina Kutyifa, MADIT-CHIC Investigators
• Journal: JAMA (JAMA) Vol. 322 Issue 18 Pg. 1799-1805 (11 12 2019) ISSN: 1538-3598 [Electronic] United States
• PMID: 31714987 (Publication Type: Clinical Study, Journal Article, Multicenter Study)

Chemical References

• Antineoplastic Agents

Topics

• Aged
• Antineoplastic Agents (adverse effects)
• Cardiac Resynchronization Therapy
• Cardiac Resynchronization Therapy Devices
• Cardiomyopathies (chemically induced, physiopathology, therapy)
• Defibrillators, Implantable
• Female
• Humans
• Male
• Middle Aged
• Prospective Studies
• Stroke Volume
• Ventricular Dysfunction, Left