Right ventricular ejection fraction by cardiac magnetic resonance imaging is an additional predictor of response to cardiac resynchronization therapy (a single-center case-control study)

Introduction. Given the high cost of cardiac resynchronization therapy (CRT) devices, the search for reliable preoperative predictors of response to optimize patient selection becomes critically important. One promising prognostic factor is right ventricular (RV) systolic function. However, existing data are contradictory, and echocardiography does not provide an accurate quantitative assessment of right ventricular ejection fraction (RVEF) due to the chamber's anatomical peculiarities. Cardiac magnetic resonance imaging (MRI) is the gold standard for assessing RV volumes and function, but its role in predicting response to CRT has been insufficiently studied due to the limited number of existing studies.

Aim: To study the association between baseline RV EF, measured by cardiac MRI, and echocardiographic response to CRT. Material and Methods. A single-center retrospective study was conducted involving 368 patients who received a CRT-P or CRT-D (with cardioverter-defibrillator function) implant at the Federal Center for Cardiovascular Surgery (Penza, Russia) between 2014 and 2021 in accordance with current clinical guidelines and who underwent cardiac MRI immediately prior to implantation. A total of 113 patients were selected. CRT response criteria were defined as an increase in left ventricular ejection fraction (LVEF) by ≥ 5% and/or a reduction in left ventricular end-systolic volume (LVESV) by ≥ 15% from baseline. Based on response, patients were divided into two groups: responders and non-responders.

Results. The formed groups were comparable in terms of key clinical and demographic characteristics, as well as heart failure functional class, LVEF, and QRS duration. The only difference was a higher frequency of ischemic cardiomyopathy (ICM) in the nonresponder group. When comparing baseline MRI parameters, the non-responder group had significantly lower RVEF values (46 [39; 51] vs. 32 [22; 43], p = 0.001), higher right ventricular end-diastolic and end-systolic volumes, and a higher frequency of moderate (grade 2) or greater tricuspid regurgitation (TR). In the postoperative period, the groups did not differ in paced QRS duration. As expected, the groups differed significantly in LVEF and left ventricular end-diastolic volume. Univariate regression analysis identified four indicators statistically significantly associated with the endpoint: ICM (OR 0.381, 95% CI 0.157–0.924, p = 0.033), LVESV (OR 0.994, 95% CI 0.990–0.999, p = 0.011), RVEF (OR 1.060, 95% CI 0.992–1.132, p = 0.083), and TR grade ≥ 2 (OR 0.696, 95% CI 0.233–0.992, p = 0.040). Multivariate regression analysis using these indicators revealed that only two maintained a statistically significant association with CRT response: ICM (OR 0.326, 95% CI 0.115–0.924, p = 0.035) and RVEF (OR 1.057, 95% CI 1.022– 1.094, p = 0.001).

Conclusion. The study demonstrated that patients with standard indications for CRT and lower baseline RVEF measured by cardiac MRI are less likely to respond to therapy. RVEF and ICM were independently associated with CRT response: RVEF showed a direct relationship, while the presence of ICM showed an inverse relationship.

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