Dr. Darío Di Toro Electrophysiology Sector Dr. Cosme Argerich Hospital Resynchronization Therapy...

Dr. Darío Di ToroElectrophysiology Sector

Dr. Cosme Argerich Hospital

Resynchronization TherapyHeart Failure

Prevalence of Delay in Inter or Intraventricular Conduction

1 Havranek E, másoudi F, Westfall K, et al. Am Heart J 2002;143:412-4172 Shenkman H, McKinnon J, Khandelwal A, et al. Circulatión 2000;102(18 Suppl II): abstract 22933 Schoeller R, Andersen D, Buttner P, et al. Am J Cardiol. 1993;71:720-7264 Aaronson K, Schwartz J, Chen T, et al. Circulatión 1997;95:2660-26675 Farwell D, Patel N, Hall A, et al. Eur Heart J 2000;21:1246-1250

IVCD 15%IVCD >30%

General population with CHF1,2Population with moderate to severe CHF3,4,5

60%

70%

80%

90%

100%

0 60 120 180 240 300 360

Days in Trial

Cu

mu

lati

ve S

urv

ival

QRS QRS Duration Duration (msec)(msec)

<90<90

90-12090-120

120-170120-170

170-220170-220

>220>220

Increase in Mortality Proportional to QRS Width

• NYHA Class II-IV patients• 3,654 ECGs digitally scanned

• Age, creatinine, LVEF, heart rate, and QRS duratión

found to be independent predictors of mortality

• Relative risk of widest QRS group 5x greater

than narrowest

1 Gottipaty V, Krelis S, Lu F, et al. JACC 1999;33(2) :145 [Abstr847-4].

Vesnarinone Study1

(VEST study analysis)

Prevalence and Significance of Prolonged AV Interval

• The prevalence of PR = or > 200 ms reported in patients with advanced HF varies between 30 and 53%. 1

• The effects of a very prolonged PR, even in structurally normal hearts, may lead to a partial or total loss of atrial input to ventricular filling, premature closure of

mitral valve, and different degrees of telediastolic mitral valve regurgitation.

• In certain cases, in spite of normal PR, mechanic AV could be prolonged due to the delay in interatrial conduction2, 3

• In patients with cardiomyopathy, a combination of slightly prolonged PR with CLBBB, and because of the delay of the addition of both, it may behave as

“concealed long PR syndrome” (similar to marked prolongatoin of AV interval), generating subsequent hemodynamic alterations.

1 Linde et al. Am. J. Cardiol. 1995, Nishimura et. al. J. Am. Cardiol. 19952 Freedman RA, Yock PG, Echi et al: Effect of variatión in PQ interval on patient of atrioventricular valve motión and flow in patients with normal ventricular Function. J Am Coll Cardiol 1986; 7: 595 – 6023 Ishikawa T, Sumita S, Kumura K, et al. Critical PQ interval for the appearance of diastolic mitral regurgitatión and optimal PQ interval in patients implanted With DDD pacemaker. Pacing Clin Electrophysiol 1994;17: 1989 - 1994

Ventricular Asynchrony and Cardiac Resynchronization

• Ventricular asynchrony1 – Electric: inter or intraventricular conduction disorders, typically manifesting as CLBBB– Structural: disruption of the myocardial collagen matrix with

impairment of electrical conduction and mechanical efficiency– Mechanical: anomalies in regional parietal motility with increased

enlargement and parietal stress, compromising ventricular mechanics

• Cardiac resynchronization

– Therapeutic attempt of synchronized atrio-biventricular pacing

• Modification of interventricular, intraventricular, and atrio-ventricular activation sequence in patients with ventricular dyssynchrony

• Supplement to optimal medical treatment

1 Tavazzi L. Eur Heart J 2000;21:1211-1214

Yu C-M, Chau E, Sanderson J, et al. Circulatión 2002;105:438-445

Intraventricular Intraventricular synchronysynchrony

AtrioventricularAtrioventricularsynchronysynchrony

Interventricular Interventricular synchronysynchrony

LA LA pressurepressure

LV diastolic LV diastolic fillingfilling

LVESVLVESV

LVESVLVESV LVEDVLVEDV

Reverse remodelingReverse remodeling

Cardiac ResynchronizationCardiac Resynchronization

MVIMVI dP/dt, dP/dt, EF, EF, CO CO(( pulse pressure) pulse pressure)

BIVENTRICULAR PACING IN HFBIVENTRICULAR PACING IN HF

“Conventional” target population

•High functional class (NYHA III or IV)

•Prolonged QRS ( >150 ms)• Presence of functional mitral valve regurgitation

•Dilated LV with EF <0.35

•PR interval >150 ms

•Clinical stability

Electrical Therapy in Heart Failure

BETTER QUALITY OF LIFE

GREATER FUNCTIONAL CAPACITY

GREATER TOLERANCE TO EXERCISE

REDUCTION OF HOSPITALIZATIONS

IMPROVEMENT IN STRUCTURE – CARDIAC FUNCTION

MORTALITY

2010 Focused Update of ESC guidelines on devicetherapy in heart failure

An update of the 2008 ESC guidelines for the diagnosis andtreatment of acute and chronic heart failure and the 2007 ESC

guidelines for cardiac and resynchronizatión therapyDeveloped with the special contributión of the Heart FailureAssociatión and the European Heart Rhythm Association

Randomized studies published with the inclusion criteria

Main findings from randomized studies on CRT

Current Considerations

• In the studies conducted, up to 30% of non-responsive patients is reported

– What are we going to consider to define a patient as responder?

– How to identify them?– What value do imaging methods have in selection and

follow up?

SELECTION OF POTENTIAL RESPONDERS TO CRT In most studies, CLBBB with QRS >150 ms was the best predictor

of appropriate response1, However, just the presence of CLBBB is not enough to predict a good response, nor is the only marker of altered ventricular synchrony1,2

Different patterns of activation in patients with CLBBB3,4

QRS narrowing does not always predict functional improvement5

Tissue Doppler could be useful to quantify the degree of ventricular dyssynchrony and to evaluate the effects of pacing5

1 Charles R.: Cardiac resynchronizatión therapy: when and for whom ?. Eur Heart J Supplemets 2002: 4 (Suppl D): D117-D1212 Sassara M et al: Efficacy of cardiac resynchronizatión in narrow QRS patients (Abs.) Europace 2001: 2 (Suppl B): 465

3 Rodriguez LM, et al : Variable Patterns of Septal Activatión in Patients with LBBB and HF. J Cardiovasc Electrophysiol., February 20034 Auricchio A, et al: Delayed Electrical activatión of BBB and lateral wall in LBBB: insight from 3-D electroanatomical mapping JACC 2002 (Abs.)

5 Ansalone G et al: Doppler myocardial imaging in patients with heart failure receiving biventricular pacing treatment. Am Heart J 2001; 142:881-96

Molhoek SG, Bax JJ, Van Erven L, et al. QRS duratión and shortening to predict clinical response to cardiac resynchronizatión therapy in patients with end-stage heart failure. Pacing Clin Electrophysiol 2004;27:308 –13.

QRS NARROWING

CONTRIBUTION OF ECHOCARDIOGRAPHY

Pulsed wave TDIcolor-coded TDItissue trackingDisplacement mapping strain and strain rate

imagingTissue synchronizatión

imaging (TSI).

– Patients with chronic AFPatients with chronic AF– Patients with previously implanted pacemakerPatients with previously implanted pacemaker

– Patients with conventional indication of pacemakerPatients with conventional indication of pacemaker– Patients with borderline QRS and dyssynchrony by Patients with borderline QRS and dyssynchrony by

echocardiogramechocardiogram– Patients with cardiomyopathy in FC I-IIPatients with cardiomyopathy in FC I-II

– Patients with EF >35%Patients with EF >35%

• CRT always with ICD? Who shouldn’t?

Unconventional Indications

Patients with heart failure, AF and Patients with heart failure, AF and conventional indication of pacemakerconventional indication of pacemaker

Patients with heart failure and permanent Patients with heart failure and permanent AF with indication of resynchronizationAF with indication of resynchronization

Resynchronization in Patients with Advanced Heart Failure and AF

Comparative effects of permanent biventricular andright-univentricular pacing in heart failure patients

with chronic atrial fibrillation

Comparative effects of permanent biventricular andright-univentricular pacing in heart failure patients

with chronic atrial fibrillation

European Heart Journal (2002) 23, 1780–1787European Heart Journal (2002) 23, 1780–1787

NYHA FC III Optimal treatmentNYHA FC III Optimal treatment

EF <35% and LVEDD> 60 mmEF <35% and LVEDD> 60 mm

AF >3 MONTHS WITH LOW RESPONSE OR AV BLOCKAF >3 MONTHS WITH LOW RESPONSE OR AV BLOCK

6-MINUTE WALK <450 M6-MINUTE WALK <450 M

Patients with heart failure and conventional Patients with heart failure and conventional indication of pacemakerindication of pacemaker

Resynchronization in patients with advanced heart failure and AF

Comparative effects of permanent biventricular andright-univentricular pacing in heart failure patientswith

chronic atrial fibrillation

Comparative effects of permanent biventricular andright-univentricular pacing in heart failure patientswith

chronic atrial fibrillation

European Heart Journal (2002) 23, 1780–1787European Heart Journal (2002) 23, 1780–1787

C. Leclercq1, S. Walker2, C. Linde3, J. Clementy4, A. J. Marshall5, P. Ritter6,P. Djiane7, P. Mabo1, T. Levy2, F. Gadler3, C. Bailleul8 and J.-C. Daubert1 on behalf

of the MUSTIC study group

C. Leclercq1, S. Walker2, C. Linde3, J. Clementy4, A. J. Marshall5, P. Ritter6,P. Djiane7, P. Mabo1, T. Levy2, F. Gadler3, C. Bailleul8 and J.-C. Daubert1 on behalf

of the MUSTIC study group

RV pacing Biventricular

P

6-minute walk (mean and SD)

342±103 374±108 0,05

O2 consumption (ml Kg min)

13,2±3,9 14,9±4,2 0,04

QoL 37,9±21,8 33,6±21 0,11

Preference of patients (%)

89,1 10,8 0,001

Hospitalizations (%) 23 7 0,01

Class I–Patients with chronic HF in FC III-IV (at least 6 months of evolution) under maximal medical treatment, with EF <35%, sinus rhythm and QRS width ≥ 50 ms (Level of evidence A).–Patients that have indication of pacemaker or that have it implanted already, and need an exchange (probably upgrade it), who have chronic HF in FC III-IV (at least 6 months of evolution) under the maximal medical treatment possible, with EF <35% (Level of evidence B).

Class I–Patients with chronic HF in FC III-IV (at least 6 months of evolution) under maximal medical treatment, with EF <35%, sinus rhythm and QRS width ≥ 50 ms (Level of evidence A).–Patients that have indication of pacemaker or that have it implanted already, and need an exchange (probably upgrade it), who have chronic HF in FC III-IV (at least 6 months of evolution) under the maximal medical treatment possible, with EF <35% (Level of evidence B).


Patients with heart failure and conventional indication of Patients with heart failure and conventional indication of pacemakerpacemaker

Patients with heart failure, AF and conventional Patients with heart failure, AF and conventional indication of pacemakerindication of pacemaker

Patients with heart failure, and permanent Patients with heart failure, and permanent AF with indication of resynchronizationAF with indication of resynchronization

Resynchronization in Patients with Advanced Heart Failure and AF

Cardiac Resynchronizationin Patients With Atrial Fibrillation

A Meta-Analysis of Prospective Cohort Studies



Cardiac Resynchronizatión TherapyCardiac Resynchronizatión Therapy

Journal of the American College of Cardiology Vol. 52, No. 15, 2008Journal of the American College of Cardiology Vol. 52, No. 15, 2008

Gaurav A. Upadhyay, MD,* Niteesh K. Choudhry, MD, PHD,† Angelo Auricchio, MD, PHD,‡Jeremy Ruskin, MD,* Jagmeet P. Singh, MD, PHD*Boston, mássachusetts; and Lugano, Switzerland


Pacientes con ICC y FA con indicación de CRTPacientes con ICC y FA con indicación de CRT









0

5

10

15

20

25

30

35

40


Change in EF % in SR and AFChange in EF % in SR and AF










EF EF

FCFC

Distance in 6-minute walk testDistance in 6-minute walk test

Score of QoL survey Score of QoL survey

Long-term survival in patients undergoing cardiac resynchronizatión therapy: the importance of performing atrio-ventricular junctión

ablatión inpatients with permanent atrial fibrillation

Long-term survival in patients undergoing cardiac resynchronizatión therapy: the importance of performing atrio-ventricular junctión

ablatión inpatients with permanent atrial fibrillation

Maurizio Gasparini1*, Angelo Auricchio2,3, Marco Metra4, Franc¸ois Regoli1, Cecilia Fantoni2,3, Barbara Lamp5, Antonio Curnis4, Juergen Vogt5, andCatherine Klersy6 for the Multicentre LongitudinalObservational Study (MILOS) Group

Maurizio Gasparini1*, Angelo Auricchio2,3, Marco Metra4, Franc¸ois Regoli1, Cecilia Fantoni2,3, Barbara Lamp5, Antonio Curnis4, Juergen Vogt5, andCatherine Klersy6 for the Multicentre LongitudinalObservational Study (MILOS) Group

Four-Year Efficacy of Cardiac ResynchronizationTherapy on Exercise Tolerance and Disease Progression

The Importance of Performing AtrioventricularJunctión Ablatión in Patients With Atrial Fibrillation

Maurizio Gasparini, MD,* Angelo Auricchio, MD, PHD,‡§ François Regoli, MD,* Cecilia Fantoni, MD,‡Mihoko Kawabata, MD,‡ Paola Galimberti, MD,* Daniela Pini, MD,* Carlo Ceriotti, MD,*Edoardo Gronda, MD,* Catherine Klersy, MD, MSC,† Simona Fratini, MD,‡ Helmut H. Klein, MD‡ Milan and Pavia, Italy; Magdeburg, Germany; and Lugano, Switzerland

Four-Year Efficacy of Cardiac ResynchronizationTherapy on Exercise Tolerance and Disease Progression

The Importance of Performing AtrioventricularJunctión Ablatión in Patients With Atrial Fibrillation

Maurizio Gasparini, MD,* Angelo Auricchio, MD, PHD,‡§ François Regoli, MD,* Cecilia Fantoni, MD,‡Mihoko Kawabata, MD,‡ Paola Galimberti, MD,* Daniela Pini, MD,* Carlo Ceriotti, MD,*Edoardo Gronda, MD,* Catherine Klersy, MD, MSC,† Simona Fratini, MD,‡ Helmut H. Klein, MD‡ Milan and Pavia, Italy; Magdeburg, Germany; and Lugano, Switzerland


2010 Focused Update of ESC guidelines on

devicetherapy in heart failure

The European cardiac resynchronizatión therapy surveyThe European cardiac resynchronizatión therapy survey

Resynchronization therapy is a useful therapeutic tool in patients with CHF in FC III-IV, wide QRS and EF <35 % and under optimal medical treatment

In these patients, resynchronizing improves survival.

In patients in FC I II there could be a benefit, but not in terms of survival, but in terms of functional capacity and hospitalizations by CHF

CONCLUSIONS

Resynchronization therapy is useful in patients with atrial fibrillation, both in patients with indication of conventional pacemaking or patients candidates to CRT.

The benefit manifests in terms of improvement in EF, exercise capacity, symptoms, and quality of life without evidence in mortality.

CONCLUSIONS

CONCLUSIONS CRT in AF must be accompanied by RF

ablation procedure of the AV node.

We should NOT think on the benefit in AF in comparison to SR

Thank you for your attention

Dr. Darío Di Toro Electrophysiology Sector Dr. Cosme Argerich Hospital Resynchronization Therapy...

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