Insuffisance cardiaque et resynchronisation
peut-on mieux faire?
C. Leclercq
Service de Cardiologie
Centre Cardio-Pneumolo...
Quelles sont les indications de
reynchronisation cardiaque?
Eur Heart J 2013; 34: 2281-2329
CRT: NYHA class II, III and ambulatory NYHA class IV and SR
LBBB / Non-LBBB
Eur Heart J 2013; 34: 2281-2329
CRT: NYHA class II, III and ambulatory NYHA class IV and SR
Eur Heart J 2013; 34: 2281-2329
CRT: NYHA class II, III and ambulatory NYHA class IV and SR
Eur Heart J 2013; 34: 2281-2329
Indication for CRT
in patients with permanent AF
Class Level
1) Patients with HF, wide QRS and reduced LVEF:
1A) should be...
Heart Rhythm 2012;9:1524 –76
is the non response related to a
reversible cause ?
• Myocardial ischemia?
• Valvulopathy (AS?)
• COPD?
• Anemia?
• Observ...
• Improvement in patient’s selection?
– Avoiding pts with high potential of NR
• COPD++, RV dysfunction with PH, large sca...
Eur Heart J 2013; 34: 2281-2329
QRS width
• COMPANION:
•
• CARE-HF:
• Reverse
• Madit-CRT
• RAFT
Zareba. Circulation 2011; 123: 1061-72
Importance of conduction disorders
• QRS duration > 140 ms (men) or 130 ms (women),
• QS or rS in leads V1 and V2,
• Mid-QRS notching or slurring in 2 of lea...
• Improvement in patient’s selection?
– Avoiding pts with high potential of NR
• COPD++, RV dysfunction with PH, large sca...
Apical versus Non-apical position
Overall population
Apical versus Non-apical position
LBBB population
Location of the LV ...
LV lead and latest LV activation
Kahn. J Am Coll Cardiol 2012; 59: 1509-18
Eur Heart J 2013; 34: 2281-2329
Baseline
1ms150ms
Dysycnchronous
LV
Dysycnchronous
LV
LV lead 2LV lead 2
LV lead 2
RV leadRV lead
LV lead 1
RV leadRV lead...
Variable RV and LV Activation in LBBB
Total Ventricular Activation
Time: 205 msec
RV Activation Time: 130
msec
LV Activati...
Hemodynamic improvement with MPP?
Optimization of pacing modalities
Hemodynamic improvement with MPP?
BiV
with apical pacing LV
Hemodynamic improvement with MPP?
BiV
with basal LV pacing
Hemodynamic improvement with MPP?
BiV
with MPP LV pacing
• Improvement in patient’s selection?
– Avoiding pts with high potential of NR
• COPD++, RV dysfunction with PH, large sca...
Medical treatment
Altman. Eur Heart J 2012;33: 2181-8
• Improvement in patient’s selection?
– Avoiding pts with high potential of NR
• COPD++, RV dysfunction with PH, large sca...
Importance of BiV pacing rate
Hayes D, et al. Heart Rhythm 2011;8:1469 –1475
Survival
Hayes D, et al. Heart Rhythm 2011;8:...
Atrial arrhythmias
• Atrial arrhythmias are commonly observed in
patients with severe heart failure
• Major hemodynamic co...
Arrythmias
• Loss of biventricular capture due to
– Atrial arrhythmias
• Specific algorithm to overdrive
• Consider AV nod...
Importance of AV node ablation
Upper rate programming
• Some CRT patients have normal SR and AV
conduction with during exercise rapid atrial
rate
• Progr...
Exercise test in a CRT patient (I)
Exercise test in a CRT patient (II)
Europace (2009) 11, 931–936
Importance of LV auto-capture
Chronotropic incompetence
CO = HR X SV
 Lack of increase in HR will result in HF pts with
reduced LVEF in a lack of incre...
Importance of the exercise test
• Usually the device programming is performed at rest, but
the assessment of the functioni...
Importance of the exercise test
Inadequate AV delay
Shorten
AV delay
Causes of non response
Mullens. J Am Coll Cardiol 2009; 53: 675-73
Which method to optimize AV delay?
• No optimization : nominal setting (100-150 ms)
• Invasive hemodynamic method (dP/dt)
...
Long AV delay
(E and A fusion)
Decrease by 20 ms steps
Too short: truncated A-vawe
Optimal AV delay
LV filling > 40% RR cy...
DEVICE-BASED methods @ a glance …DEVICE-BASED methods @ a glance …
QuickOptQuickOpt
(SJM)(SJM)
SmartDelaySmartDelay
(BSC)(...
Follow-up
Patient/device
Clinical response
Device function
6 mo
Factor
identified
Echo
optimization
No
1 mo
Yes
Unsatisfac...
• Improvement in patient’s selection?
– Avoiding pts with high potential of NR
• COPD++, RV dysfunction with PH, large sca...
Optimization of the devices in CRT
axon. Circulation 2010;122: 2359 –67
CRT with and without RM
28%
Hindricks. ESC 2013
19...
Insuffisance cardiaque et resynchronisation : Peut-on mieux faire? (Pr C. Leclercq)
Insuffisance cardiaque et resynchronisation : Peut-on mieux faire? (Pr C. Leclercq)
Insuffisance cardiaque et resynchronisation : Peut-on mieux faire? (Pr C. Leclercq)
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Insuffisance cardiaque et resynchronisation : Peut-on mieux faire? (Pr C. Leclercq)

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  • Schemantic of venogram
  • Still some uniformity, hence placing a lead within the arc of mechanical dyssynchrony may help
    Venous constraints
  • tion
  • tion
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  • Insuffisance cardiaque et resynchronisation : Peut-on mieux faire? (Pr C. Leclercq)

    1. 1. Insuffisance cardiaque et resynchronisation peut-on mieux faire? C. Leclercq Service de Cardiologie Centre Cardio-Pneumologique Rennes
    2. 2. Quelles sont les indications de reynchronisation cardiaque? Eur Heart J 2013; 34: 2281-2329
    3. 3. CRT: NYHA class II, III and ambulatory NYHA class IV and SR LBBB / Non-LBBB Eur Heart J 2013; 34: 2281-2329
    4. 4. CRT: NYHA class II, III and ambulatory NYHA class IV and SR Eur Heart J 2013; 34: 2281-2329
    5. 5. CRT: NYHA class II, III and ambulatory NYHA class IV and SR Eur Heart J 2013; 34: 2281-2329
    6. 6. Indication for CRT in patients with permanent AF Class Level 1) Patients with HF, wide QRS and reduced LVEF: 1A) should be considered in chronic HF patients, intrinsic QRS ≥120 ms and LVEF ≤35% who remain in NYHA functional class III and ambulatory IV despite adequate medical treatment (d ), provided that a biventricular pacing as close to 100% as possible can be achieved IIa B 1B) AV junction ablation should be added in case of incomplete biventricular pacing IIa B 2) Patients with uncontrolled heart rate who are candidates for AV junction ablation. CRT should be considered in patients with reduced LVEF who are candidates for AV junction ablation for rate control. IIa B Eur Heart J 2013; 34: 2281-2329
    7. 7. Heart Rhythm 2012;9:1524 –76
    8. 8. is the non response related to a reversible cause ? • Myocardial ischemia? • Valvulopathy (AS?) • COPD? • Anemia? • Observance of tt • Salt excess • …
    9. 9. • Improvement in patient’s selection? – Avoiding pts with high potential of NR • COPD++, RV dysfunction with PH, large scar without viability – Selection of the best patients (NICM, wide QRS, LBBB…) • Optimization of the LV lead location and pacing programming • Optimization of medical treatment • Improvement in optimization of device’s programming • Remote monitoring How to increase the rate of responders?
    10. 10. Eur Heart J 2013; 34: 2281-2329
    11. 11. QRS width • COMPANION: • • CARE-HF: • Reverse • Madit-CRT • RAFT
    12. 12. Zareba. Circulation 2011; 123: 1061-72 Importance of conduction disorders
    13. 13. • QRS duration > 140 ms (men) or 130 ms (women), • QS or rS in leads V1 and V2, • Mid-QRS notching or slurring in 2 of leads V1, V2, V5, V6, I, and aVL. Redefining the LBBB definition Strauss. Am j cardiol 2011; 107: 927-34
    14. 14. • Improvement in patient’s selection? – Avoiding pts with high potential of NR • COPD++, RV dysfunction with PH, large scar without viability – Selection of the best patients (NICM, wide QRS, LBBB…) • Optimization of the LV lead location and pacing programming • Optimization of medical treatment • Improvement in optimization of device’s programming • Remote monitoring How to increase the rate of responders?
    15. 15. Apical versus Non-apical position Overall population Apical versus Non-apical position LBBB population Location of the LV lead Singh. Circulation 2011; 123: 1159-1166 Eur Heart J 2013; 34: 2281-2329
    16. 16. LV lead and latest LV activation Kahn. J Am Coll Cardiol 2012; 59: 1509-18 Eur Heart J 2013; 34: 2281-2329
    17. 17. Baseline 1ms150ms Dysycnchronous LV Dysycnchronous LV LV lead 2LV lead 2 LV lead 2 RV leadRV lead LV lead 1 RV leadRV lead LV lead 1LV lead 1 LV lead 3LV lead 3 LV lead 3 RV leadRV lead Courtesy: P. Ritter
    18. 18. Variable RV and LV Activation in LBBB Total Ventricular Activation Time: 205 msec RV Activation Time: 130 msec LV Activation Time: 145 msec LAO 60°LAO 60° Total Ventricular Activation Time: 157 msec RV Activation Time: 57 msec LV Activation Time: 105 msec Total Ventricular Activation Time: 189 msec RV Activation Time: 85 msec LV Activation Time: 137 msec Courtesy: Angelo Auricchio
    19. 19. Hemodynamic improvement with MPP?
    20. 20. Optimization of pacing modalities
    21. 21. Hemodynamic improvement with MPP? BiV with apical pacing LV
    22. 22. Hemodynamic improvement with MPP? BiV with basal LV pacing
    23. 23. Hemodynamic improvement with MPP? BiV with MPP LV pacing
    24. 24. • Improvement in patient’s selection? – Avoiding pts with high potential of NR • COPD++, RV dysfunction with PH, large scar without viability – Selection of the best patients (NICM, wide QRS, LBBB…) • Optimization of the LV lead location and pacing programming • Optimization of medical treatment • Improvement in optimization of device’s programming • Remote monitoring How to increase the rate of responders?
    25. 25. Medical treatment Altman. Eur Heart J 2012;33: 2181-8
    26. 26. • Improvement in patient’s selection? – Avoiding pts with high potential of NR • COPD++, RV dysfunction with PH, large scar without viability – Selection of the best patients (NICM, wide QRS, LBBB…) • Optimization of the LV lead location and pacing programming • Optimization of medical treatment • Improvement in optimization of device’s programming • Remote monitoring How to increase the rate of responders?
    27. 27. Importance of BiV pacing rate Hayes D, et al. Heart Rhythm 2011;8:1469 –1475 Survival Hayes D, et al. Heart Rhythm 2011;8:1469 –1475 AFib No AFib
    28. 28. Atrial arrhythmias • Atrial arrhythmias are commonly observed in patients with severe heart failure • Major hemodynamic consequences in CRT patients due to the loss of atrial contribution to cardiac output and loss of biventricular capture in case of ventricular rapid rate
    29. 29. Arrythmias • Loss of biventricular capture due to – Atrial arrhythmias • Specific algorithm to overdrive • Consider AV node ablation
    30. 30. Importance of AV node ablation
    31. 31. Upper rate programming • Some CRT patients have normal SR and AV conduction with during exercise rapid atrial rate • Programming a too low maximal tracking rate may result in pacemaker Wenckebach or 2:1 with the loss of biventricular capture • MTR: 70% of (220 – age) bpm and not nominal 120 bpm!!
    32. 32. Exercise test in a CRT patient (I)
    33. 33. Exercise test in a CRT patient (II)
    34. 34. Europace (2009) 11, 931–936 Importance of LV auto-capture
    35. 35. Chronotropic incompetence CO = HR X SV  Lack of increase in HR will result in HF pts with reduced LVEF in a lack of increase in CO at exercise  Assessment of the profile of HR during exercise is of major importance  If chronotropic incompetence: program the rate response algorithm
    36. 36. Importance of the exercise test • Usually the device programming is performed at rest, but the assessment of the functioning of the device should be performed also systematically during exercise • Reasons of disappearance of biventricular capture: - loss of atrial sensing - frequent PVCs - Atrial tachyarrhythmias - NSVT or SVT - Spontaneous AV conduction more rapid than the programmed AV delay….
    37. 37. Importance of the exercise test Inadequate AV delay Shorten AV delay
    38. 38. Causes of non response Mullens. J Am Coll Cardiol 2009; 53: 675-73
    39. 39. Which method to optimize AV delay? • No optimization : nominal setting (100-150 ms) • Invasive hemodynamic method (dP/dt) • Echocardiographic methods • Finger Plethysmography • Impedance cardiography • Acoustic cardiography • Device-based algorithms • … Manufacturer SAV (ms) PAV (ms) Adaptive AV (min. SAV) VV (ms) Biotronik Lumax 540 HF 120 150 On 5 Boston Scientific Cognis 120 180 Off 0 Medtronic Concerto 100 130 On (70) 0 Sorin Paradym CRT 125 190 On (80) 0 SJM Unify 150 200 On (100) 0
    40. 40. Long AV delay (E and A fusion) Decrease by 20 ms steps Too short: truncated A-vawe Optimal AV delay LV filling > 40% RR cycle The iterative method
    41. 41. DEVICE-BASED methods @ a glance …DEVICE-BASED methods @ a glance … QuickOptQuickOpt (SJM)(SJM) SmartDelaySmartDelay (BSC)(BSC) AdaptivCRTAdaptivCRT (MDT)(MDT) SonRSonR (Sorin)(Sorin) Based on IEGMs measures IEGMs measures IEGMs measures Hemodynamic sensor (= contractility) AVD optimiz. Only @ REST; Paced & sensed Only @ REST; Paced & sensed Only @ REST; Paced & sensed @ REST & under EFFORT; Paced & sensed VVD optimiz. OK OK OK (LV synchro or BiV) OK In-clinic (@ FU) vs Ambulatory (Automatic) In-clinic In-clinic Ambulatory (every minute) In-clinic + Ambulatory (Weekly) Outcomes from trials: SAFETY OK OK OK OK Outcomes from trials: EFFICACY AV & VV opt @ FU visits NOT INFERIOR to clinical practice (0 or 1 echo) clinically @ 1Y (FREEDOM) AV opt @ FU visits EQUIVALENT to ECHO- guided or Empiric programming, structurally & functionally @ 6M (SMART-AV) Adaptive-CRT approach is NON-INFERIOR to Echo-optimized BiV, clinically @ 6M (Adaptive-CRT) AV (weekly) & VV (@ FU visits) optimization by SonR is SUPERIOR to clinical practice, clinically @ 1Y (CLEAR pilot)
    42. 42. Follow-up Patient/device Clinical response Device function 6 mo Factor identified Echo optimization No 1 mo Yes Unsatisfactory Good Modify settings Implantation Echo screening A wave truncation? No Echo AV optimization Yes Device algorithm ECG Proposal of Burri / Leclercq / Oliviera
    43. 43. • Improvement in patient’s selection? – Avoiding pts with high potential of NR • COPD++, RV dysfunction with PH, large scar without viability – Selection of the best patients (NICM, wide QRS, LBBB…) • Optimization of the LV lead location and pacing programming • Optimization of medical treatment • Improvement in optimization of device’s programming • Remote monitoring How to increase the rate of responders?
    44. 44. Optimization of the devices in CRT axon. Circulation 2010;122: 2359 –67 CRT with and without RM 28% Hindricks. ESC 2013 19% 9% 3.4%

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