Α Καρδιολογική Κλινική ΑΠΘ, Νοσοκοµείο ΑΧΕΠΑ, Θεσσαλονίκη

EΠΙΛΕΓΟΝΤΑΣ ΤΟ ΣΩΣΤΟ ΑΣΘΕΝΗ ΓΙΑ CRT (CARDIAC RESYNCHRONIZATION THERAPY). ΠΟΥ ΒΡΙΣΚΟΜΑΣΤΕ? ΣΤΕΛΙΟΣ ΠΑΡΑΣΚΕΥΑÏΔΗΣ ΔΙΕΥΘΥΝΤΗΣ ΕΣΥ Α Καρδιολογική Κλινική ΑΠΘ, Νοσοκοµείο ΑΧΕΠΑ, Θεσσαλονίκη

NO CONFLICT OF INTEREST

HEART FAILURE (HF) 2% of the adult population in developed countries > 10% in patients > 70 years 50% have systolic HF, EF 5-10% of HF patients canditate for CRT Permanent atrial fibrillation (AF): 25% to 30% of CRT candidates

EuroHeart Failure survey LVEF 35% : 36% pts LBBB or IVCD ( intraventricular conduction delay): 34% RBBB: 7% QRS 120 ms: 41 % QRS 150 ms: 17 %

HEART FAILURE (HF) 25%-50 % of HF pts : PR or QRS on ECG duration QRS is : Hawkins N et al. Eur Heart J 2006

QRS DURATION AND SURVIVAL-VEST trial Feldman A et al, NEJM 1993

QRS MORPHOLOGY AND 3 YEAR MORTALITY IN HF-MADIT-CRT LBBB: 8% RBBB: 7% IVCD: 4%

QRS :120-160 QRS :160-200 QRS : > 200 Αm Heart J 2014

LBBB-HF PATHOPHYSIOLOGY

PATHOPHYSIOLOGY OF DYSSYNCHRONY LBBB alters the sequence of LV contraction causing : increased time delay between the peak of shortening of tissue velocity between LV free wall and septal wall redistribution of myocardial blood flow non-uniform regional myocardial metabolism changes in regional molecular processes as calcium handling and stress kinase proteins mitral valve regurgitation. and of LV filling

PATHOPHYSIOLOGY OF DYSSYNCHRONY

PATHOPHYSIOLOGY OF DYSSYNCHRONY- CRT Aurichio A, Prinzen F. Europace 2008

Electrical remodeling- CRT Aiba T, Curr Opin Cardiol 2010

PATHOPHYSIOLOGY OF DYSSYNCHRONY PR on ECG influence the optimal timing of the atrial systole and : cardiac output duration of diastolic filling pre-systolic mitral regurgitation.

MECHANISMS OF ACTION OF CRT V level (mitral regurgitation) Auricchio A, Circulation 2004

VENTRICULAR ACTIVATION SEQUENCE IN HF-DCM (3D MAPPING) LV NARROW QRS Narrow QRS LBBB

ENDOCARIAL-EPICARDIAL MAP SR-LBBB QRS: 214ms CRT-OPTIMAL QRS: 150 ms CRT-NOMINAL QRS: 170 ms

CLINICAL TRIALS AND CRT

METAANALYSIS 12 studies CRT n= 7538, All cause mortality : 22% Wells G et al, Can Med Ass J 2011

CRT THERAPY reduces mortality reduces HF hospitalizations improves functional outcome

Indications for CRT in sinus rhythm ΕSC 2013

Indications for CRT in permanent atrial fibrillation

AV Node ABLATION AND CRTD IN AFIB

Upgraded or de novo CRT in pts with conventional pacemaker indications and ΗF paced QRS > 200 ms

Indication for concomitant ICD (CRT-D)

CRT-D vs CRT-P in primary prevention

CRT-D vs CRT-P in primary prevention

MORTALITY - CRT-D vs ICD NYHA I-II : 20% III-IV: 14% (NS) Wells G et al, Can Med Ass J 2011

Comparison of Theoretical CRT Response According to Baseline LVEF, NYHA Class, Dyssynchrony, End Diastolic Volume Gasparini M, Galimberti P. JACC 2013 ; 61:945-7

Echo criteria dyssynchrony Δεν χρησιµοποιούνται ως κριτήρια επιλογής CRT προς το παρόν Mελέτες RETHIN-Q, ESTEEM-CRT, ECHO-CRT, LESSER-EARTH δεν έδειξαν όφελος στο CRT όταν: QRS < 130 ms δυσσυγχρονισµός στο echo

ECHO criteria for DYSSYNCHRONY NO GOLD STANDARD CRITERION Interventricular delay (LV-RV) > 50 ms Intraventricular delay > 65 ms TDI (Tissue Doppler Imaging) Strain, speckle tracking

INTERVENTRICULAR DELAY Measurement of Interventricular Mechanical Asynchrony in LBBB Example: LPED (180ms) - RPED (120ms) = δ (60ms) R1 R2 R1 R2 P Q P A RPED (120ms) A Q LPED ( 180ms) δ (60ms) P A LBBB RV IVC Pulmonary Flow Aortic Flow Aortic Flow δ(180-120) = 60 ms 17 Measurement of Interventricular Mechanical Asynchrony in BiV Pacing. Example: LPED (155ms) - RPED (140ms) = δ (15ms) Optimum AVD BiV Pacing P P P BVP-CRT E A E A E A δ(155-140) = 15 ms Aortic Flow Aortic Flow 27

INTRAVENTRICULAR DELAY- DYSSYNCHRONY

INTRAVENTRICULAR DELAY- DYSSYNCHRONY CRT

DYSSYNCHRONY LV- TDI

Speckle-Tracking Echo to Determine Optimal CRT Sites

LV PACING CRT (VIA CORONARY SINUS-CS) Cazeau et al. 1994 target vein -lateral LV wall (delayed contraction) acceptable pacing and sensing threshold lead stability learning curve. Success 60% 98% complications: perforation-dissection of CS: 0,9-2%

Cardiac Venous Anatomy and Lead Placement 4 3 5 2 1 1. Lateral (marginal) cardiac vein 2. Postero-lateral cardiac vein 3. Posterior cardiac vein 4. Middle cardiac vein 5. Great cardiac vein

LV LEAD POSITION

Οptimal LV lead position posterolateral and lateral walls apical region: adverse outcome, (MADIT-CRT and REVERSE trial) anterior position: increased risk of ventricular arrhythmias LV lead implantation is limited by constraints of the venous anatomy, phrenic nerve pacing, lead stability, and pacing threshold

LV LEAD POSITION AND CLINICAL OUTCOME. MADIT-CRT Trial HF-DEATH Singh J et al, Circulation 2011

Left ventricular (LV) lead positioning outside scar and survival

Left ventricular lead positioning Q-LV distance

ANATOMY OF CORONARY SINUS NORMAL CHF

IMPLANTATION TECHNIQUES LV lead Anterolateral vein RAO 30

ΔΙΑΦΛΕΒΙΑ ΕΝΔΟΚΑΡΔΙΑΚΗ ΒΗΜΑΤΟΔΟΤΗΣΗ LV (atrial transseptal)

ΔΙΑΦΛΕΒΙΑ ΕΝΔΟΚΑΡΔΙΑΚΗ ΒΗΜΑΤΟΔΟΤΗΣΗ LV (atrial transseptal)

n=17, F/U: 6 mo pts with prior failed attempt for coronary sinus lead implantation non responders to a previous CRT device pts with a previous pacemaker or ICD meeting the standard indications for CRT Auricchio et al, Europace 2014;16:681-688

WIRELESS CARDIAC STIMULATION LV

WIRELESS CARDIAC STIMULATION LV

Success : n=13 or 76.5% Pericardial effusion: 3 or 17.5 % Biventricular pacing: in 83% at 1 month and 92% and 6 months Improvement in EF, NYHA class (2/3), QRS duration

CRT complications-30 days CRT: 11-14 % ICD: 4% Ruwald M, Bruun N. Res. Rep. Clin Card 2104;5:305-17

DISSECTION OF CORONARY SINUS

DISSECTION OF CORONARY SINUS

RESPONDERS Conclusions: The 26 most-cited publications on predicting response to CRT define response using 17 different criteria. Agreement between different methods to define response to CRT is poor 75% of the time and strong only 4% of the time, which severely limits the ability to generalize results over multiple studies. Fornwalt B et al. Circulation. 2010;121:1985-1991.

IDENTIFICATION OF RESPONDERS NON RESPONDERS: 30-35 % of CRT pts n=30% wide QRS : no dyssynchrony n=30% narrow QRS : dyssynchrony Leclercq C et al,. Circulation 2004

RESPONSE CRITERIA

REASONS FOR NONRESPONSE TO CRT Multifactorial myocardial scar from prior infarct inappropriate lead position suboptimal device programming lack of true mechanical dyssynchrony

SUPER-RESPONDERS ΕF : απόλυτη 20% ή τελικό ΕF > 45% ΝΥΗΑ στάδιο: 1 LV ESV: > 15 % Συχνότητα : 10-14 % Xαρακτηριστικά SUPER-RESPONDERS LBBB MR, LV EDV LA volume < 55 ml global longitudinal strain < -12 % KA < 12 µήνες Reant P et al. Am J Cardiol 2010 Antonio N et al. Europace 2009 Rickard J et al. Heart Rhythm 2010

CRT outcome

LBBB PRE-CRT POST-CRT

Συµπερασµα Ασθενείς µε KA κατάλληλοι για επιλογή και απάντηση (responders) στον καρδιακό επανασυγχρονισµό είναι: EF: 25-35 % LBBB (QRS >130 ms). IVCD, RBBB (QRS>150 ms) SR > AFib NYHA III-IV class Διατατικοί > ισχαιµικοί Xωρίς µεγάλη ουλή (MRI) Τοποθέτηση του LV ηλεκτροδίου σε πλάγια θέση CRT-D (απινιδωτής) > CRT-P (βηµατοδότης)

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