Cardiac Resynchronisation Therapy
Upcoming SlideShare
Loading in...5
×
 

Cardiac Resynchronisation Therapy

on

  • 1,304 views

 

Statistics

Views

Total Views
1,304
Views on SlideShare
1,303
Embed Views
1

Actions

Likes
0
Downloads
13
Comments
0

1 Embed 1

http://www.slideshare.net 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

Cardiac Resynchronisation Therapy Cardiac Resynchronisation Therapy Presentation Transcript

  • Cardiac Resynchronisation Therapy September 2008
  • The Effect of Cardiac Resynchronization on Morbidity and Mortality in Heart Failure (CARE-HF) John G.F. Cleland, M.D., Jean-Claude Daubert, M.D., Erland Erdmann, M.D., Nick Freemantle, Ph.D., Daniel Gras, M.D., Lukas Kappenberger, M.D. and Luigi Tavazzi, M.D. N Engl J Med Volume 352;15:1539-1549 April 14, 2005
  • Background
    • Despite pharmacological advances in treatment of HF, mortality & morbidity remain high
    • Cardiac dyssynchrony (regions of delayed myocardial activation & contraction) is common
    • Small studies (up to 6/12) cardiac resynchronisation therapy (CRT) improved quality of life, exercise capacity & ventricular function
    • Trials with CRT +/- ICD (COMPANION) showed that with CRT alone the decrease in risk of death was insignificant
    • Meta-analysis are inconclusive
    • This trial was designed to assess the effect of CRT on mortality in patients with severe HF
  • Methods
    • Multicenter, randomised, non blinded, international trial comparing
    • “ the risk of complications & death of standard pharmacological therapy alone with that of combination of standard therapy and CRT (without ICD) in patients with LV systolic dysfunction, cardiac dyssynchrony and symptomatic heart failure”
    • 82 European centers between Jan 2001 & March 2003
    • Inclusion Criteria:
      • 18yrs+
      • HF for at least 6 weeks
      • NYHA III/IV
      • LVEF < 35%
      • QRS of at least 120ms
    • Exclusion Criteria:
      • Conventional indications for PPM/ICD
      • Major CV event in last 6/52
      • HF requiring IV therapy
      • Atrial arrhythymias
  • Methods
    • End Points
      • Primary: Composite of death from any cause or an unplanned hospitalisation for major CV event (worsening HF, MI, USA, Stroke, Arrhythmia)
      • Secondary: Death from any cause, Quality of life assessment
    • Statistical Analysis
      • Intention to treat Principle
      • Statistical power of 80% to identify a 14% relative reduction given an α value of 0.025 & predicted number of events as 300
  • Baseline Characteristics of the Patients Cleland, J. et al. N Engl J Med 2005;352:1539-1549
  • Kaplan-Meier Estimates of the Time to the Primary End Point (Panel A) and the Principal Secondary Outcome (Panel B) Cleland, J. et al. N Engl J Med 2005;352:1539-1549
  • Study Outcomes in Analyses Stratified According to NYHA Class Cleland, J. et al. N Engl J Med 2005;352:1539-1549
  • Hemodynamic, Echocardiographic, and Biochemical Assessments Cleland, J. et al. N Engl J Med 2005;352:1539-1549
  • Discussion
    • CRT substantially reduced risk of complications & death among patients with moderate/severe heart failure
    • Consistent with a reduction in cardiac dyssynchrony leading to improved physiological parameters and clinical outcome:
      • Quality of Life
      • Ventricular function
      • Blood pressure
      • Mortality
    • For every 9 devices implanted 1 death and 3 hospitalisations are prevented
  • Cardiac Resynchronisation Therapy
  • Background 1
    • Approx 25% of patients with CHF have intraventricular conduction delay; commonly LBBB
    • Electrical activation of lateral aspect of LV can be delayed in relation to that of RV and/or interventricular septum
    • This results in
      • Dyssynchronous electrical activation & contraction
      • Unequal distribution of myocardial workload
      • Altered myocardial blood flow & metabolism
    • Patients with conducting disease have worse prognosis from CHF
    • Patients with a paced RV end up having an artificially induced interventricular conducting delay and overall systolic function is poorer
  • Procedure 2
    • Simultaneous pacing of RV & LV = Biventricular pacing
    • RA, RV & LV
    • LV paced via coronary sinus
  • Physiological Effects
    • Doesn’t restore normal physiological conducting pattern
    • RA pacing with short AV delay ensures all beats are paced
    • RV & LV pacing reduces the delay in electrical activation of LV free wall
    • QRS duration tends to decrease
    • Haemodynamic response:
    • Increase in rate of rise of LV pressure
    • Increases pulse pressure, LV stroke volume
    • Improves myocardial function without increasing myocardial energy consumption
  • Evidence
    • Early Trials : <500 patients, up to 1 year showed increases in functional capacity & improvements in quality of life
    • COMPANION 3 (ICD): mortality from all causes was reduced with CRT & ICD (p=0.003) but not from CRT alone (p=0.059)
    • CARE-HF 4 : mortality from all causes was reduced (p<0.002)
  • Guidance for CRT 5
    • NICE May 2007 ; must fulfil ALL the below
    • NYHA III or IV
    • SR with QRS >150ms
    • SR with QRS 120-149ms & echo evidence of dyssynchrony
    • LVEF < 35%
    • Optimal pharmacological therapy
    • Cost: £3809
    • Number: 500/year
  • Guidance for CRT-D 6
    • NICE May 2007 & January 2006
    • Criteria as before plus:
    • Primary Prevention
      • MI (>4/52) & either (LVEF <35% and NSVT on holter and inducible VT on EP studies) OR (LVEF <30% and QRS >120ms)
      • Familial Tendency (longQT, Brugada, HOCM, ARVD)
    • Secondary Prevention (in absence of treatable cause)
      • Post VT/VF arrest
      • Spontaneous sustained VT causing compromise
      • Sustained VT without compromise but LVEF >35%
    • Cost : £16000
    • Number : 500/year
  • Adverse Effects
    • Unable to implant LV lead due to unfavourable anatomy (3-10%)
    • Diaphragmatic stimulation due to proximity of phrenic nerve
    • Coronary sinus dissection (0.3-4.0%)
    • Coronary sinus perforation & tamponade (0.8-2.0%)
    • Periprocedural death (0.4%)
    • Dislodgement of LV lead (10%)
    • Pneumothorax
    • Complete Heart Block
    • Asystole
    • Pacemaker pocket infection
    • External electromagnetic field
  • Further Study
    • ? Benefit in NYHA I/II patients
      • REVERSE 7 : no significance at end point
      • MADIT-CRT: late 2009
    • Approx. 20-30% of patients with CRT are non-responders
      • Is the QRS duration a good predictor of CRT response?
      • Could echo evidence of ventricular dyssynchrony be more predictive? 8
      • “ Dyssynhcrony study” 9
    • Application in patients with AF?
  • References
    • Jarcho JA. Biventricular Pacing. N Engl J Med 2006;355:288-294 http://content.nejm.org/cgi/content/full/355/3/288
    • Jarcho JA. Resynchronising Ventricular Contraction in Heart Failure. N Engl J Med 2005;352:1594-1597 http://content.nejm.org/cgi/content/full/352/15/1594
    • Bristow MR, Saxon LA, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. (COMPANION) N Engl J Med 2004;350:2140-2150 http://content.nejm.org/cgi/content/full/352/15/1539
    • Cleland JGF, Daubert J-C, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure (CARE-HF) N Engl J Med 2005;352:1539-1549 http://content.nejm.org/cgi/content/full/350/21/2140
    • NICE: Heart Failure – Cardiac Resynchronisation; May 2007 http://www.nice.org.uk/TA120
    • NICE: Arrhythmias – Implantable Cardioverter defibrillators: January 2006 http://www.nice.org.uk/TA95
    • Linde C, Abraham WT, Gold MR, Daubert J-C. Results of the REVERSE trial. Program and abstracts from the American College of Cardiology 2008 Scientific Sessions, March 29-April 1, 2008, Chicago, Illinois http://www.medscape.com/viewarticle/573311
    • Yu CM, Bax JJ, Monaghan M, Nihoyannopoulos. Echocardiographic evaluation of cardiac dyssynchrony for predicting a favourable response to cardiac resynchronisation therapy. Heart 2004;90:vi17-vi22 http://heart.bmj.com/cgi/content/full/90/suppl_6/vi17
    • Bax JJ, Ansalone G, Breithardt et al. Echocardiographic evaluation of CRT: ready for routine clinical use? J Am Coll Cardiol 2004;44:1-9 http://content.onlinejacc.org/cgi/content/full/44/1/1