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
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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
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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.
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10. Cecilia Linde JACC 2008
Resynchronization Reverses Remodeling
in
Systolic Left Ventricular Dysfunction
REVERSE)
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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”
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22. Response to CRT
Causes for “Non-response”
Lack of electrical dysynchrony
Lack of Mechanical dysynchrony
Myocardial scar
RV failure
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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
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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
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27. Apex in 14%
Apical lead placement
◦ Primary end point - up 64%
◦ Mortality – rose 2.6 times
◦ Resynchronization less effective
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28. How do you classify your patient
Why some patients do not respond
What do you do
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29. Clinical and Laboratory evaluation
Device parameters
LV lead position
ECHO guided AV optimitzation
Protocol evaluation
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37. ICD without issues associated with
transvenous leads
◦ Lead not exposed to heart stresses
◦ Infection
Patients without pacing indications
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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
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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.
