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Cardiac resynchronization therapy
- 2. CRT CRT Trials New Trials and Indications ◦ CRT in mildly symptomatic patients Non-Responders New Devices www.theafcenter.com
- 3. ◦Reduces mortality and hospitalization. ◦Improves functional capacity, quality of life, exercise capacity. ◦Promotes reverse remodeling. www.theafcenter.com
- 4. Yu C-M, Chau E, et al. Circulation 2002;105:438-445 Intraventricular Synchrony Atrioventricular Synchrony Interventricular Synchrony LA Pressure LV Diastolic Filling RV Stroke Volume LVESV LVEDV Reverse Remodeling Cardiac Resynchronization MRdP/dt, EF, CO ( Pulse Pressure) www.theafcenter.com
- 6. 1995-1997: Mechanistic and longer-term observational studies 1998-1999: Randomized studies to assess exercise capacity, functional capacity and QoL 2000-2002: Randomized trials to assess combined mortality and hospitalization NYHA III and ambulatory IV patients www.theafcenter.com
- 7. • Mortality benefit • Reduced HF hospitalizations• Mortality benefit in LBBB population* • Reduced HF hospitalizations • Improved cardiac function* • Improved CCR • Improved cardiac function • Reduced HF hospitalizations* • Improved CCR* • Improved cardiac function 2003: CONTAK CD 6 mos; n = 263 2004: MICD II 6 mos; n = 186 2008: REVERSE 12 mos, n = 610; 24 mos, n = 262 2009: MADIT CRT Average 29 mos, n = 1,820 2010: RAFT Average 40 mos, n = 1,438 • Improved cardiac function www.theafcenter.com
- 9. 57% 57% reduction (p < 0.001) in the risk of a composite of all-cause mortality or heart failure events. • 35% reduction (p = 0.048) in the risk of all-cause mortality • 63% reduction (p < 0.001) in the risk of heart failure events Moss AJ, et al. N Engl J Med. 2009;361:1329-1338. www.theafcenter.com
- 10. Cecilia Linde JACC 2008 Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction REVERSE) www.theafcenter.com
- 11. Time to First Heart Failure Hospitalization
- 12. Significant improvement in functional capacity Reverse remodeling Decrease in mortality and hospitalization Alters disease progression CRT NYHA I-II Patients REVERSE: Linde C, et al. JACC. 2008;52:1834-1843. RAFT: Tang A, et al. N Engl J Med. 2010;363: 2385-2395. MADIT-CRT: Moss A, et al. N Engl J Med. 2009;361:1329-1338. www.theafcenter.com
- 14. How do you classify your patient Why some patients do not respond What do you do www.theafcenter.com
- 15. How do you classify your patient Why some patients do not respond What do you do www.theafcenter.com
- 16. Responder ◦ Super-responders ◦ Delayed Progression Non-Responder Negatively affected Clinical or Echo parameters www.theafcenter.com
- 17. Ypenburg JACC 2008 CRT Response and Prognosis 6 months post CRT www.theafcenter.com
- 20. How do you classify your patient Why some patients do not respond What do you do www.theafcenter.com
- 21. Mullens W, et al. JACC 2009; 53:765 Response to CRT Causes for “Non-response” www.theafcenter.com
- 22. Response to CRT Causes for “Non-response” Lack of electrical dysynchrony Lack of Mechanical dysynchrony Myocardial scar RV failure www.theafcenter.com
- 23. We aim to correct mechanical dyssynchrony with CRT The amount of baseline mechanical dyssynchrony is currently the best predictor of response to CRT A wide QRS (electrical dyssynchrony) is a screening tool for mechanical dyssynchrony 1 Yu et al., PACE 2000;23-II:9 2 Nelson et al., Circulation 2001;101:2703-9 3 Yu et a., PACE 2000;23-II:148 4 Breithardt et al., PACE 2001;24-II:736 5. Sassara et al., Eurpace 2 SB, 2001 www.theafcenter.com
- 24. ~30% of patients with a wide QRS do not show LV mechanical dyssynchrony: ◦ 50% may have induced dyssynchrony with CRT Worse outcomes Auger et al. Eur H J 2012; 33:913www.theafcenter.com
- 25. Auger et al. Eur H J 2012; 33:913www.theafcenter.com
- 26. Response to CRT Pace Away From Scar Van Deursen C, et al. Circ Arrhythm Electrophysiol 2009; 2:580 • Speckle Tracking Echo • Target the most delayed actively contracting site in patients with ICMP www.theafcenter.com
- 27. Apex in 14% Apical lead placement ◦ Primary end point - up 64% ◦ Mortality – rose 2.6 times ◦ Resynchronization less effective www.theafcenter.com
- 28. How do you classify your patient Why some patients do not respond What do you do www.theafcenter.com
- 29. Clinical and Laboratory evaluation Device parameters LV lead position ECHO guided AV optimitzation Protocol evaluation www.theafcenter.com
- 30. Mullens, et al. JACC 2009www.theafcenter.com
- 34. CRT CRT Trials New Trials and Indications ◦ CRT in mildly symptomatic patients Non-Responders New Devices www.theafcenter.com
- 37. ICD without issues associated with transvenous leads ◦ Lead not exposed to heart stresses ◦ Infection Patients without pacing indications www.theafcenter.com
- 40. CRT is a well established treatment option for patients with HF and wide QRS ◦ NYHA Class I to IV Non-responders ◦ Important to identify the cause ◦ Favorable intervention often possible Advances in CRMD www.theafcenter.com
Editor's Notes
- Finally, the 4 trials (MADIT CRT, REVERSE, Miracle ICD II, and Contak CD) that evaluated cardiac structure and/or function all showed that, in the mildly symptomatic HF population, there was improved cardiac function and/or cardiac structure over time with CRT therapy.
- The aim of the current study was to evaluate the relation between the extent of left ventricular (LV) reverse re- modeling and clinical/echocardiographic improvement after 6 months of cardiac resynchronization therapy (CRT) as well as long-term outcome. Background Despite the current selection criteria, individual response to CRT varies significantly. Furthermore, it has been suggested that reduction in left ventricular end-systolic volume (LVESV) after CRT is related to outcome. Methods A total of 302 CRT candidates were included. Clinical status and echocardiographic evaluation were performed before implantation and after 6 months of CRT. Long-term follow-up included all-cause mortality and hospitaliza- tions for heart failure. Results Based on different extents of LV reverse remodeling, 22% of patients were classified as super-responders (de- crease in LVESV 30%), 35% as responders (decrease in LVESV 15% to 29%), 21% as nonresponders (decrease in LVESV 0% to 14%), and 22% negative responders (increase in LVESV). More extensive LV reverse remodeling resulted in more clinical improvement, with a larger increase in LV function and more reduction in mitral regurgi- tation. In addition, more LV reverse remodeling resulted in less heart failure hospitalizations and lower mortality during long-term follow-up (22 11 months); 1- and 2-year hospitalization-free survival rates were 90% and 70% in the negative responder group compared with 98% and 96% in the super-responder group (log-rank p value 0.001). Conclusions The extent of LV reverse remodeling at midterm follow-up is predictive for long-term outcome in CRT patients. (J Am Coll Cardiol 2009;53:483–90) © 2009 by the American College of Cardiology Foundation