1

Optimization of AV and VV Delays

Lumax 540

CRM Training and Education

2

Optimization of BiV Pacing

A-V Delay

V-V Delay

3

AV Delay Optimization

Ensure BiV pacing

Improve diastolic filling

Reduce mitral regurgitation

Cardiac Output

Goals

4

AV Delay Optimization

AV too long

Close to intrinsic PR (fusion)

Loss of CRT

AV too short

Premature mitral valve closure

Hemodynamic compromise

5

AV Delay Optimization

Empirical Calculation

Echocardiography

Pulse pressure

Methods

6

AV Delay Optimization

Aortic Pressurein percent

Auricchio et al., Circulation 1999

LV dP/dtmax

in percent

A-V Delay A-V Delay

RV

LV

BiV

-8

-4

0

4

8

12

16

0

PR - 30 ms

-12

-6

0

6

12

18

24

0 PR - 30 ms

7

AV Delay Optimization

Example for As-Vs = 220 msAVopt = (220-30)/2 = 95 ms

Calculation

Auricchio et al., Circulation 1999

2AVopt =

(PR interval) - 30 ms

8

AV Delay Optimization

LV lead in anterior vein

RBBB

Intrinsic PR > 300 ms

AV block II°/III°

Limitations of Calculation Methods

9

AV Delay Optimization

Flow Velocity at Mitral Valve

Aortic Velocity Time Integral

Doppler Echocardiography

10

Echocardiography

Apical Position

4 Chamber View

11

Apical 4-Chamber View

12

Doppler-Echocardiography

Fd = Doppler frequency

f0 = Ultrasound frequency(e.g., 2.4 MHz)

V = Blood flow velocity

= Angle between sound beamand direction of blood flow

c = Speed of sound in humantissue (1,530 m/s)

Fd =2 V cos

cf0

13

Doppler-Echocardiography

Spectral analysisBlood flowvelocity

1.5

1.0

0.5

14

Mitral Valve Doppler Echo

SampleVolume

P

A

R

E

T

LV EjectionFilling

ECG

Doppler

15

Pulsed Wave Doppler Echo

4 Chamber View E/A Ratio

Mitral Valve

16

Pulsed Wave Doppler Echo

EA

Velocity(cm/s)

Time (50mm/s)

ECG

17

AV Delay Optimization

Transmitral Flow Velocity LV filling pressure

E waveEarly diastolic passive filling of the left ventricle

A waveLate diastolic active filling of the left ventricle atrial contribution

Doppler Echo

18

Normal Heart Cycle

P P

A A

R

A

P

E EE

LVFT

S Q

T

IVR IVC IVRIVC

AorticFlow

AorticFlow

Left VentricularFilling Time

Isovolumic Contraction

IsovolumicRelaxation

19

Left Bundle Branch Block

Q T

A A

R1 R2 R1 R2

T

AE EE

P P P

A A A

20

LBBB: Late MV Closure

*IVC = Isovolumic Contraction

P Q T P

A A

R1 R2 R1 R2

IVC* A

P

IVC*

Aortic Valve Opening AVO

MVCMitral Valve Closure

21

LBBB: Late End of LV Systole

P Q T P

A A

R1 R2 R1 R2

IVC

AorticFlow

A

MVC

Aortic Valve Closure

P

LV Systole

AorticFlow

MVC

IVC

AVO

Ejection

22

LBBB: Late Start of LV Filling

* MVO = Mitral Valve Opening** IVR = Isovolumic Relaxation

P Q T P

A

R1 R2 R1 R2

Q T

IVC IVR*

AorticFlow

A

MVC MVO*

AVO AVC

P

AorticFlow

A

23

LBBB: Fusion of E and A

P Q T P

A A

R1 R2 R1 R2

Q T

A

P

E E

ShortLV

FillingTime

E

AorticFlow

AorticFlow

250 ms at HR 65/min

24

P Q T P

A A

R1 R2 R1 R2

Q T

IVC IVRA

MVC

P

E EE

AorticFlow

AorticFlow

Pre Ejection Period (PEP)

LBBB: Resynchronization

25

Biventricular Pacing

PT

P

A A

T

A

P

E EE

AVD

AorticFlow

AorticFlow

IVC IVC

BiV

Pro-longed

LV FillingTime

325 ms at HR 65/min

PEP

BiV BiV

MVC MVC

26

AV Optimization

Short AV Delay Long AV Delay

Ritter Formula

P

A

QA

A wave truncation

ForcedMVC

E

P

AE

SpontaneousMVC

QA

AV AV

27

AV Delay Optimization

Programmed AV Delays

AVshort = short AV (25% of PR)

AVlong = long AV (75% of PR)

Ritter Formula

Ritter et al., PACE 1995

AVopt = AVshort + [(AVlong - AVshort) - (QAshort - QAlong)]

"The Difference of the Differences"

Measured QA Intervals

QAshort = QA at short AV

QAlong = QA at long AV

28

Transmitral Flow

At short AV delay

AVshort = 50 ms

QAshort = 128 ms

128 ms

Begin Q

EA

29

Transmitral Flow

At long A-V delay

AVlong = 160 ms

QAlong = 48 ms

48 ms

Q

E A

30

AV Delay Optimization

Result

Programmed AV Delays

AVshort = 50 ms

AVlong = 160 ms

Measured QA Intervals

QAshort = 128 ms

QAlong = 48 ms

AVopt = AVshort + [(AVlong - AVshort) - (QAshort - QAlong)]

"The Difference of the Differences"

AVopt = 50 + [(160-50)-(128 - 48)]

= 50 + (110 - 80)

AVopt = 80 ms

31

AV Delay Optimization

Short AV Long AV Optimal AV

32

AV Delay Optimization

Doppler Echocardiography

Flow Velocity at Mitral Valve

Aortic Velocity Time Integral

33

Doppler Echo

Apical Five Chamber View

34

Doppler Echo

Aortic Flow Velocity

Kruck, Biamino 1988

35

Aortic Flow Velocity

LBBB

A A A

AorticFlow

AorticFlow

Velocity

Time

36

Aortic Flow Velocity

Biventricular Pacing

AE

AVD

AorticFlow

AorticFlow

Velocity

Time

37

Velocity Time Integral

Fehske 1988

Integral = Area under the curve

VTI =

AVO

AVC

V * dt

(cm)

38

Velocity Time Integral

ECG

Velocity(m/s)

Time

vmax

Ejection time

vmean Vmax = 1.58 m/s

Vmean = 1.09 m/s

ET = 288 ms

VTI = Vmean * ET

VTI = 0.31 m

39

AV Delay Optimization

Dr. Uhrig, Vivantes Urban Hospital Berlin

VTI = 12.7 cm VTI = 20.5 cm

Velocity Time Integral

40

VTI Method

Fehske 1988

Derived Parameters

Stroke VolumeSV = VTI * AVTI = Velocity Time

IntegralA = Aortic Valve Area

Cardiac OutputCO = SV * HRHR = Heart Rate

41

VTI Method

Objective

Identify optimal AV delay at max. VTI

Procedure

CW Doppler of aortic outflow tract

Decrement AV delay by 20 ms down to ≥ 80 ms

Limitations

Doppler signal quality

Breathing modulations

Intrinsic error 10 - 15%

42

AV Delay Optimization

30 Pts. after CRT implantation NYHA III-IV, LVEF < 35%, SR

BiV on atrial sensed beats AV optimization on LV dp/dt max

Comparison to Ritter formula, diastolic filling time (DFT), LV VTI, E/A VTI

Jansen et al., Am J Cardiol 2006

43

LV dP/dt max

LVPressure(mmHg)

dP/dt(mmHg/s)

Jansen et al., Am J Cardiol 2006

44

Compliance with LV dP/dt max. measurements

Good

Good toreasonable

%

Jansen et al., Am J Cardiol 2006

0

67

43

97

57

87

73

100

0

20

40

60

80

100

Ritter DFT LV VTI E/A VTI

45

AV Delay Optimization

Empirical Calculation

Echocardiography

Pulse pressure

Methods

46

Pulse Pressure Method

Objective

Identify AV delay that provides maximal differencebetween systolic and diastolic blood pressure

Procedure

Arterial line to measure central aortic pressure accurately

47

Pulse Pressure Method

Intrinsic Paced

Auricchio et al., PACE 1998

P R

Aorta

LV

PEP

Time

Pressure

P Vp Time

Pressure

48

Pulse Pressure Method

BiV Pacing

AorticPressure(mmHg)

LV IEGM

Time (s) 0 1 2 3 4 5 6 7 8 9

60

85

110

49

AV Delay Optimization

Pulse pressure: hemodynamic testing

Calculation: initial programming

Doppler Echo: non-responders

Summary

50

Optimization of BiV Pacing

A-V Delay

V-V Delay

51

V-V Delay Optimization

LV first

AS

RVP

AV

LVP LVPRVP

VV VV

AV

RV first

AS

VV = 0

AS

RVP

AV

LVP

52

V-V Optimization

41 pts. with CHF after CRT-PM

AV delay optimization

RV-/LV pre-activation: 0, 12, 20, 40, 80 ms

Endpoints: Cardiac output, mitral regurgitation from echo

Bordachar et al., JACC 2004

53

V-V Optimization

Echocardiographic Parameters

M-mode: septal-to-posterior wall motion delay (SPWMD)

Doppler: Interventricular mechenical delay (IVMD)

Tissue Doppler:

Intra LV delay onset (LV onset)

Intra LV delay peak (LV peak)

SD from 12 segments intra LV delay peak (SDLV peak))

Delayed longitudinal contraction (DLC)

Bordachar et al., JACC 2004

54

V-V Optimization

Bordachar et al., JACC 2004

Parameter

Correlation to Hemodynamics

CardiacOutput

Mitral Regurgitation

LV peak

SD LV peak

LV onset

DLC

SPWMD

IVMD

-0.67

-0.67

-0.64

-0.48

-0.41

-0.24

0.68

0.68

0.63

0.51

0.24

0.06

55

41 CHF pts. with CRT-PM

V-V Optimization

No. of pts.

Bordachar et al., JACC 2004

0

2

4

6

8

10

8040200204080 12 12 ms

LV first RV first

56

166 DCM pts. with CRT (Doppler Echo)

V-V Optimization

0

20

40

60

LV first

80

RV first

40200204080

At Implant

3 months

No. of pts.

Delurgio et al., NASPE 2002

ms

57

V-V Optimization

V-V Optimization

van Gelder et al., Am J Cardiol 2004

AF

SR ischemic

SR non-ischemic

58

Optimizing BiV Pacing

59

Optimizing BiV Pacing

I

V1

RV only LV only BiV BiV LVfirst

60

Optimizing V-V Delay

Start with standard setting

VV optimization in patients with persistent dyssynchrony

Trouble shooting option in clinical non-responders

Summary

61

Optimization of BiV Pacing

A-V Delay

V-V Delay