Νew evidence for CRT:Role of imaging Tρεχουσες ενδείξεις αμφικοιλιακής βηματοδότησης.

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1 Νew evidence for CRT:Role of imaging Tρεχουσες ενδείξεις αμφικοιλιακής βηματοδότησης. Ευαγγελία Χριστοφοράτου Καρδιολόγος Επιστημονικός Συνεργάτης Α Πανεπιστημιακής Καρδιολογικής Κλινικής ΙΓΝΑ Διευθύντρια Υπερηχοκαρδιογραφικού Τμήματος & Τμήματος Βηματοδοτών- Απινιδωτών Βιοκλινικής Aθηνών

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3 AV mechanical dyssynchrony Demonstration of AV dyssynchrony

4 Intraventricular mechanical Dyssynchrony IVMD values of > 40 ms and values of LV PEP of > 140 ms are considered pathological

5 Inter-ventricular mechanical dyssynchrony M-Mode: SPWMD> 130 ms was considered pathological TDI> 60 ms of time to Sm Peak between LV segments

6 Inter-ventricular mechanical dyssynchrony

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9 Πως έχουν διαμορφωθεί οι ενδείξεις για την αμφικοιλιακή βηματοδότη και ποια η συμβολή της υπερηχοκαρδιογραφίας;

10 PROSPECT (Results of the Predictors of Response to CRT Trial) Πολυκεντρική μελέτη (53): Europe, US, Hong Kong 467 ασθενείς, 54% ισχαιμική HF ΝΥΗΑ ΙΙΙ ή IV QRS > 130ms, EF 35% Εκτίμηση δυσυγχρονισμού:12 παράμετροι 5 +7 TDI Response to CRT: 0, 3, 6 months Κλινικά Επιβίωση NYHA CCS Νοσοκομειακή νοσηλεία Γενικότερη εκτίμηση ασθενούς Υπερηχογραφικά LVESV 15% Chung et al Circulation 2008;117:

11 CCS end point PROSPECT (Results of the Predictors of Response to CRT Trial) Results 5 non-tdi parameters, 1 TDI έδειξαν μέτρια στατιστική συσχέτιση με το κλινικό αποτέλεσμα που θεωρείται επιτυχής ανταπόκριση στη CRT. LVESV end point 4 non-tdi parameters, 1 TDI έδειξαν στατιστική συσχέτιση με το υπερηχογραφικό αποτέλεσμα που θεωρείται επιτυχής CRT. Η ευαισθησία και ειδικότητα των μελετηθέντων παραμέτρων ήταν χαμηλή. Η μελέτη δεν καταδεικνύει κάποιο από τους πολλούς υπερηχογραφικούς παράγοντες ως αξιόπιστο ώστε να χρησιμοποιηθεί στην κλινική πράξη για εκτίμηση του δυσυγχρονισμού. Πιθανόν η κλινική βελτίωση να έρχεται γρηγορότερα από την ηχοκαρδιογραφική σε κάποιους ασθενείς. Chung et al Circulation 2008;117:

12 Ruschitzka et al. N Engl J Med 2013;369:

13 Ruschitzka et al. N Engl J Med 2013;369:

14 Reason of Death Ruschitzka et al. N Engl J Med 2013;369:

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17 691 pts with AV block and indications for pacing, LVEF 50% randomized to RV pacing or CRT with a PM or ICD Primary endpoint : Time to death Urgent care visit for heart failure that required iv therapy, or Mean Follow-up: 37 months 15% or more increase in the LVESV index. Curtis et al. N Engl J Med 2013;368:

18 691 pts with AV block and indications for pacing, LVEF 50% randomized to RV pacing or CRT with a PM or ICD Primary endpoint : Time to death Urgent care visit for heart failure that required iv therapy, or Mean Follow-up: 37 months 15% or more increase in the LVESV index. Curtis et al. N Engl J Med 2013;368:

19 691 pts with AV block and indications for pacing, LVEF 50% randomized to RV pacing or CRT with a PM or ICD Primary endpoint : Time to death Urgent care visit for heart failure that required iv therapy, or Mean Follow-up: 37 months 15% or more increase in the LVESV index. Curtis et al. N Engl J Med 2013;368:

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21 LBBB Non-LBBB Sipahi et al. Am Heart J 2012;163:

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23 Ποια η συμβολή της υπερηχοκαρδιογραφίας στην αρχική αξιολόγηση των ασθενών που εμφανίζουν δυσυγχρονισμό με σκοπό να λάβουν αμφικοιλιακά συστήματα και να ωφεληθούν τα μέγιστα από αυτά;

24 Septal Flash-Apical Rocking

25 Scores

26 Prediction of secondary MR improvement Inter-ventricular mechanical dyssynchrony

27 Improvements? 75% Increase Response? 25% Decrease Non-Response?

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29 Response to CRT

30 Stess echocardiograrphy Left ventricular contractile reserve Role of predictor of response to CRTs

31 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

32 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

33 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

34 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

35 Potential Reasons for Suboptimal CRT Response: Need for CRT Optimization? Mullens et al. JACC 2009;53:

36 The TARGET Study: A Randomized, Controlled Trial. Echo guided LV lead placement offers additional benefits Echocardiographic speckle-tracking 2-D radial strain imaging 220 pts randomized 1:1 to Echo guided vs standard LV lead CRT implantation Segments with radial strain amplitude 10% were regarded as nonviable (scar) The LV pacing lead was placed in the most delayed segment in 63% of pts in TARGET Group vs 47% in control group. Compared with standard CRT treatment, the use of speckle-tracking echocardiography to the target LV lead placement yields significantly improved response and clinical status and lower rates of combined death and heart failure related hospitalization Khan F et al. J Am Coll Cardiol 2012;59:

37 The TARGET Study: A Randomized, Controlled Trial. Echo guided LV lead placement offers additional benefits The greatest benefit is demonstrated in pts with a concordant LV lead at sites free of scar Khan F et al. J Am Coll Cardiol 2012;59:

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41 Speckle tracking: Classical LBBB longitudinal strain pattern

42 Speckle tracking: Classical LBBB longitudinal strain pattern

43 Improvement of outcome prediction after CRT Use of speckle tracking (longitudinal strain with 17 segments) to assess the amount of residual LV dyssynchrony (by measured dispersion of LV mass, LVMD) Testing the reduction of LV mechanical dispersion prior to and after 6 months >84ms <84ms 1185 pts studied HR 1.33 Risk of all-cause mortality P. Van der Bijl et al. Leiden at ESC 2017

44 3D Echocardiography

45 3D Echocardiography

46 3D Speckle Tracking

47 Συμπεράσματα Για να επαυξησουμε την αποκριση στην αμφικοιλιακη βηματοδοτηση πρεπει να κανουμε καλή επιλογή ασθενών,που σημερα όπως φανηκε με την διαχρονική εξελιξη των guidelines μπορουμε καλύτερα να την κάνουμε Προς το παρόν η επιλογή ασθενών για θεραπεία δυσυγχρονισμού βάσει υπερηχογραφήματος δεν είναι τεκμηριωμένη. Στοιχεία από μελέτες καθιστούν υπερηχογραφικές παραμέτρους προ και μετά τη CRT ανεξάρτητους προγνωστικούς παράγοντες επιτυχίας της θεραπειας. H πιο σημαντικη συνιστώσα είναι ο ενδοκοιλιακός δυσυγχρονισμός-οσο πιο μεγάλος τόσο πιο μεγάλη η πιθανότητα για ανάστροφη αναδιαμόρφωση. Νεώτερες τεχνικές όπως το stress echo, το speckle tracking και η 3D υπερηχοκαρδιογραφία υπόσχονται πολλά στην επιλογή των ασθενών που θα ανταποκριθούν τα μέγιστα μετα τον επανασυγχρονισμό και στην μείωση των non-responders(25%).

48 Σας Ευχαριστώ!

49 Summary Better pacing techniques should help to improve resynchronization also for RBBB pts More objective Echo-Parameters (strain measurements) and better integration of cardiac MRI will improve patient selection and outcome evaluation The future will be multi-polar or multi-site pacing with automatic VV and AV adaptation algorithms for the conventional CRT technique New techniques, such as LV-septal pacing and His Bundle pacing, are already on the horizon to offer similar or even better resynchronization of LV dyssynchrony

50 Echo Optimization of VV Delay: Aortic VTI Sinus node AV node Conduction block Stimulation therapy

51 Ευχαριστώ για την προσοχή σας!

52 VV Optimization Echocardiography Aortic VTI ECG TDI Device Algorithms EGM Peak Endocardiac Acceleration (Sorin Group)

53 AV Optimization Echocardiography Iterative Method Simplified inflow method Ritter Method Maximal filing time Mitral VTI ECG Aortic VTI Device Algorithms EGM Peak Endocardiac Acceleration (Sorin Group)

54 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

55 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

56 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

57 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

58 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

59 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

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61 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

62 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

63 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

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65 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

66 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

67 Left ventricular contractile reserve by stress echocardiography as a predictor of response to cardiac resynchronization therapy in heart failure: a systematic review and meta-analysis Ciampi et al. BMC Cardiovascular Disorders DOI /s

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