Επιλογή υποψηφίων για θεραπεία καρδιακού επανασυγχρονισμού με βάση το ΗΚΓ/μα ΚΑΡΤΣΑΓΚΟΥΛΗΣ Κ. ΕΥΣΤΑΘΙΟΣ ΚΑΡΔΙΟΛΟΓΟΣ ΘΡΙΑΣΙΟ ΝΟΣΟΚΟΜΕΙΟ ΕΛΕΥΣΙΝΑΣ

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1 Επιλογή υποψηφίων για θεραπεία καρδιακού επανασυγχρονισμού με βάση το ΗΚΓ/μα ΚΑΡΤΣΑΓΚΟΥΛΗΣ Κ. ΕΥΣΤΑΘΙΟΣ ΚΑΡΔΙΟΛΟΓΟΣ ΘΡΙΑΣΙΟ ΝΟΣΟΚΟΜΕΙΟ ΕΛΕΥΣΙΝΑΣ

2 Σύγκρουση συμφερόντων: καμία

3 Καρδιακός επανασυγχρονισμός ενδεδειγμένη θεραπευτική αντιμετώπιση ασθενών με: καρδιακή ανεπάρκεια λειτουργική κλάση κατά NYHA (II, III, IV) επηρεασμένη απόδοση της Αρ.Κ 35% ευρύ QRS σύμπλεγμα στο ΗΚΓ/μα υπό πλήρη φαρμακευτική αγωγή 30-35% των ασθ. δεν ανταποκρίνονται στην θεραπεία

4 Το ΗΚΓ/μα αποτελεί σημαντικό εργαλείο (εύχρηστο, φθηνό), τον ακρογωνιαίο λίθο τόσο στην επιλογή των ασθ. οσο και στην παρακολούθησή τους Παράμετροι του ΗΚΓ/ματος: - Εύρος διάρκεια του QRS >150msec (class I - level A) - Μορφολογία του QRS (LBBB, non LBBB ) - βασικός ρυθμός - PR διάστημα και - αλληλουχία ενεργοποίησης LV RBBB NICD 2013 European Society of Cardiology guidelines on cardiac pacing and CRT

5 QRS Duration or QRS Morphology

6 150 Jeanne E. Poole et al: J Am Coll Cardiol 2016;67:

7 An individual patient meta-analysis of five randomized trials assessing the effects of cardiac resynchronization therapy on morbidity and mortality in patients with symptomatic heart failure 3782 pt in SR - median age 66 (58 73) yrs - QRSd160 ( ) ms, - LVEF was 24 (20 28)%, and - 78% had LBBB Outcomes: all-cause mortality and first hospitalization for HF or death. Conclusion: QRS duration is a powerful predictor of the effects of CRT on morbidity and mortality in patients with symptomatic HF and LVSD who are in SR. QRS morphology did not provide additional information about clinical response.

8 Association between QRS duration and outcome with cardiac resynchronization therapy: A systematic review and meta-analysis 6647 pt Outcomes: clinical/functional response, - mean age of 66 yrs, and (LV) remodeling - 24% females, hospitalizations and mortality - mean baseline QRSd:158 ms. - mean baseline (LVEF) 23 % Conclusions: RCTs demonstrate that benefit with CRT appears restricted to those with baseline QRSd wider than 150 ms. A.R. Bryant et al. / Journal of Electrocardiology 46 (2013) Jeanne E. Poole et al: J Am Coll Cardiol 2016;67:

9 W. Zareba et. Al:, Journal of Electrocardiology 46 (2013)

10 Effectiveness of Cardiac Resynchronization Therapy by QRS Morphology in the Multicenter Automatic Defibrillator Implantation Trial Cardiac Resynchronization Therapy (MADIT-CRT) CRT-D ICD only Relative risk of primary end point (heart failure event or death) by treatment W. Zareba, MD,. Circulation. 2011;123:

11 Cardiac-Resynchronization Therapy for Mild-to-Moderate Heart Failure: RAFT trial Anthony S.L. Tang, N Engl J Med 2010;363:

12 Effect of QRS morphology on clinical event reduction with cardiac resynchronization therapy: Meta-analysis of randomized controlled trials 5,356 pts Trials reporting adverse clinical events (eg, allcause mortality, heart failure hospitalizations) according to QRS morphology were included in the meta-analysis Conclusions: CRT was very effective in reducing clinical events in pts with LBBB, it did not reduce such events in pts with wide QRS due to other conduction abnormalities. Ilke Sipahi, MD,Am Heart J 2012;163: e3.

13 QRS Duration, Bundle-Branch Block Morphology, and Outcomes Among Older Patients With Heart Failure Receiving Cardiac Resynchronization Therapy Retrospective cohort study: pt P.N.Peterson.,JAMA.2013;310(6):

14 QRS duration versus morphology and survival after cardiac resynchronization therapy Retrospective: unselected HF pts 973 HF pts mean age 66.1 ±9.8 yrs, 76% male, 658 patients (68%) QRS duration 150 ms, and 772 patients (79%) had LBBB configuration median follow-up of 59 (range 29 85) months Conclusions: QRS morphology was independently associated with long-term survival. The association between QRS duration and long-term survival was not statistically significant. M.J.H. Khidir et al. ESC Heart Failure 2017; 4: 23 30

15 Cardiac resynchronization therapy is not associated with a reduction in mortality or heart failure hospitalization in patients with non-lbbb QRS morphology: meta-analysis of randomized controlled trials 1766 pts with non-lbbb QRS Outcomes: effect of CRT on the end points of death, HF hospitalization, and the composite of death and HF hospitalization. Conclusions: CRT is not associated with a reduction in death or HF hospitalization in patients with non-lbbb QRS morphology. Cunnington C, et al. Heart 2015;101:

16 Relation of QRS Duration to Clinical Benefit of Cardiac Resynchronization Therapy in Mild Heart Failure Patients Without Left Bundle Branch Block The Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy Substudy 537 non LBBB pts Conclusions: Overall, non LBBB pts with mild HF did not derive clinical benefit with CRT-D during long-term follow-up. Relatively shorter QRS was associated with a significantly increased risk with CRT-D relative to ICD-only. Patients with QRS (>134 ms) and PR (>230 ms) were protected with CRT-D P: <0,005 QRS >134msec Biton et al Circ Heart Fail. 2016;9:e

17 Assessment of cardiac resynchronization therapy in patients with wide QRS and non-specific intraventricular conduction delay: rationale and design of the multicenter randomized NICD-CRT study The NICD-CRT study (July 2015): prospective, double-blind, randomized (1:1), parallelarm, multicenter trial comparing the effects of CRT in HF pts, with a reduced LVEF <35% and NICD 100 pts 100 pts Primary end point: is the comparison of the proportion of patients improved, unchanged or worsened over the subsequent 12 months due to all-cause deaths and hospitalizations for HF. Eschalier R, et al. BMJ Open 2016;6:e

18 Should women have different ECG criteria for CRT than men? N.S. Lee et al. / Journal of Cardiology 70 (2017) 1 6 Jeanne E. Poole et al: J Am Coll Cardiol 2016;67:

19 Narrow QRS complex in HF pts Effect of QRS duration in EchoCRT:, European Heart Journal (2015) 36, Jeanne E. Poole et al: J Am Coll Cardiol 2016;67: Rachit M. Shah et al., Europace (2015) 17,

20 QRS Duration or QRS Morphology

21 Ηλεκτρικό υπόστρωμα - Ενεργοποίηση LBBB μορφολογία: καθυστερημένη εκπόλωση του πλαγίου & οπισθιοπλαγίου τοιχωμάτων U-shaped activation pattern

22 RBBB μορφολογία: καθυστερημένη εκπόλωση της ΔΕ κοιλίας και σχετικά πρώιμη ενεργοποίηση της ΑΡ κοιλίας Συγκεκαλυμμένο LBBB: παρουσία RBBB+LAHB

23 survival estimate free of heart failure hospitalization or all-cause death The definition of left bundle branch block influences the response to cardiac resynchronization therapy M.L. Caputo et al. International Journal of Cardiology 269 (2018)

24 survival estimate free of heart failure hospitalization or all-cause death Combined survival estimate free of heart failure hospitalization or all-cause death for QRS duration and five LBBB definitions. M.L. Caputo et al. International Journal of Cardiology 269 (2018)

25 Definition criteria include: a terminal negative deflection in V1, QRS duration 140 ms for men or 130 ms for women, and mid-qrs notching/slurring in at least two of the leads V1, V2, V5, V6, I, and/or avl. L. Galeotti et al., Europace (2013) 15,

26 LBBB morphology strict (true) LBBB: better response, fewer non-responders

27 QRS Duration QRS Morphology

28 Not for NYHA functional class IV Not for NYHA functional class IV. Only for NYHA functional class IV. Normand et al. J A C C : H E A R T F A I L U R E V O L. 6, N O. 4,

29 -sinus rhythm, -typical LBBB with mid-qrs slurring in lateral leads, -QRS duration >200 ms, -long PR interval and -long LVATmax measured by subtracting RVAT from the QRS duration. RVAT LVAT max = QRS RVAT LVAT: χρόνος ενεργοποίησης Αρ. Κ RVAT: χρόνος ενεργοποίησης Δε. Κ Elien B. Engels et al: J. of Cardiovasc. Trans. Res. (2016) 9: RVAT

30 Jeanne E. Poole et al: J Am Coll Cardiol 2016;67:

31 Ευχαριστώ πολύ για την προσοχή σας

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33 QRS AREA >69 μvs T-wave area Vectorcardiogram (VCG)

34 (LVATmax[ms]= XQRSd [ms] xqrsd [ms] 2)

35 Jeanne E. Poole et al: J Am Coll Cardiol 2016;67:

36 LBBB pattern RBBB pattern RBBB + LAH pattern

37

38 Giosue Mascioli et ai., Pace 2012; XX 1-8:

39 -sinus rhythm, -typical LBBB with mid-qrs slurring in lateral leads, -QRS duration >200 ms, -long PR interval and -long LVATmax measured by subtracting RVAT from the QRS duration. Arrow indicates the end of RVAT. RVAT LVAT max = QRS RVAT Elien B. Engels et al: J. of Cardiovasc. Trans. Res. (2016) 9:

40 Annals of Global Health 2014;80:61-68

41 QRS >134msec

42 Am Heart J 2012;163: e3.

43 Jeanne E. Poole et al: J Am Coll Cardiol 2016;67:

44 An individual patient meta-analysis of five randomized trials assessing the effects of cardiac resynchronization therapy on morbidity and mortality in patients with symptomatic heart failure

45 Association between QRS duration and outcome with cardiac resynchronization therapy: A systematic review and metaanalysis Jeanne E. Poole et al: J Am Coll Cardiol 2016;67:

46

47 Identification of the strict LBBB QRS duration of 120 ms, QS or rs pattern in V1, intrinsicoid deflection (ID) time defined as time from start QRS to R peak of 60 ms inv6 and T waves in opposite direction to the preceding QRS complex (discordant T waves) C.J.M. van Deursen et al. / Journal of Electrocardiology 47 (2014)

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