Talk on Cardiac resynchronization therapy for CHF

1. CARDIAC RESYNCHRONIZATION

2. Wiggers CJ (1925) The muscular reactions of mammalian ventricles to artificial surface stimuli. Am J Physiol 73:346–378 Cardiac Resynchronization History: Adverse Effects of Dyssynchrony

4. Lateral X-ray view of the first fully transvenous cardiac resynchronization therapy system (University Hospital of Rennes, August 1994). Ritter P et al. Eur Heart J Suppl 2007;9:I107-I112 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007.For Permissions, please e-mail: journals.permissions@oxfordjournals.org Note RV lead in RVOT, 2 Leads in CS, one for LA pacing

12. Right bundle branch block patients do not respond to CRT Fact or Myth?

19. Mullens, W. et al. J Am Coll Cardiol 2009;53:765-773 Potential Reasons for Suboptimal Response Cleveland Clinic Nonresponders Clinic

24. Studies of the use of echo to predict response to resynchronization and to optimize AV and VV delays Conclusion: total confusion, ? Possibly use AV and VV optimization in non-responders FLEMING LM et al. Use of Echocardiography to Manage Cardiac Resynchronization Therapy. Innovations in Cardiac Rhythm Management, Sept 2011

27. Coronary Sinus Anatomy Anterior Interventricular Vein Posterior Cardiac Vein- Often Has Lateral Extension

28. © 2011 American Heart Association, Inc. Left ventricular lead position and clinical outcome in the multicenter automatic defibrillator implantation trial-cardiac resynchronization therapy (MADIT-CRT) trial. Singh JP; Klein HU; Huang DT; Reek S; Kuniss M; Quesada A; Barsheshet A; Cannom D; Goldenberg I; McNitt S; Daubert JP; Zareba W; Moss AJ Circulation. 123(11):1159-66, 2011 Mar 22. Figure 1 . Angiographic classification of left ventricular lead position. A, Right anterior oblique (RAO) view representative of the long axis of the heart. This view enables segmentation of the heart into basal, midventricular (MID), and apical segments. B, Left anterior oblique (LAO) view used to divide the left ventricular wall along the short axis of the heart into 5 equal parts; anterior, anterolateral, lateral, posterolateral, and posterior. For the analysis, the anterolateral, lateral, and posterolateral segments were grouped together as the lateral wall. AIV indicates anterior interventricular vein; CS, coronary sinus; and MCV, middle cardiac vein. Conclusion: Apical Placement Worse Outcomes

29. ACCESSING THE CORONARY SINUS

30. ACCESSING THE CORONARY SINUS

31. Coronary Sinus Venogram

33. Advancing Lead over 0.014” Guidewire

35. Placement of 4 Fr Lead Via Attain Select Attain outer catheter Chronic pace/sense lead

36. Medtronic Starfix Lead Issues: Unipolar EXTRACTION

37. Attain StarFix ® Deployment

38. Electronic Repositioning

39. New Technology: St. Jude's Quadrapolar Lead Four Narrow Electrodes Quadripolar lead enables greater pacing flexibility than unipolar or bipolar leads and provides more options for pacing complication avoidance. Optim™ Lead Insulation Optim insulation is a hybrid insulation material–the first of its kind, developed specifically for cardiac lead use. It blends the biostability and flexibility of high-performance silicone rubber with the strength, tear resistance and abrasion resistance of polyurethane. This insulation allows for an abrasion-resistant, thin diameter lead. Low Profile Entire lead body: 4,7 F Lead tip: 4,0 F Steerable Tip Distal tip angle can be controlled to manoeuvre the lead through venous anatomy. Over-the-wire or Stylet-approach Compatibility Specially designed leads give the implanting physician the option of using either approach during the same procedure. Fast-Pass™ Lubricious Coating Enables multiple leads to easily slide against one another, possibly reducing inadvertent dislodgement. S-shaped for Stability The S-curve shape is designed to provide enhanced lead stability in a wide variety of vein sizes. Suture Sleeve The suture sleeve has been designed with silicone ridges to secure a thin lead body. Titanium Nitride (TiN) Coating TiN coating on the tip and ring electrodes has been shown to improve stimulation efficiency and lower polarisation. Steroid Elution Steroid elution minimizes inflammatory reaction at the electrode-tissue interface and provides lower acute and chronic thresholds than nonsteroid-eluting leads.

40. LV Only Pacing From Coronary Sinus Twelve-lead ECG showing monochamber LV pacing from the coronary venous system. There is typical right bundle branch pattern and right axis deviation. Note the dominant R wave from V1 to V6 consistent with basal LV pacing. LV pacing from the traditional site for resynchronization produces a RBBB pattern in lead V1 virtually without exception. When lead V1 shows a negative QRS complex during LV pacing, one should consider incorrect ECG lead placement (lead V1 too high) or location in the middle or great (anterior) cardiac vein S. Serge Barold et al. Diagnostic Value of the 12-lead ECG During Conventional and Biventricular Pacing for Cardiac Resynchronization. Cardiology Clinics 24(3), August 2006:471-490.

41. R-wave in V1 with RV apical pacing Diagram showing evaluation of a dominant R wave in lead V1 during uncomplicated RV pacing. When a dominant R wave occurs when V1 is recorded one or two ICS too high, a negative QRS complex will often be recorded in the fourth ICS which is the correct site for V1. If the dominant R wave persists or is initially recorded in the fourth ICS, a negative QRS complex will be recorded one ICS lower in the fifth ICS. Never see R-wave in V1 with uncomplicated RVOT pacing S. Serge Barold et al. Diagnostic Value of the 12-lead ECG During Conventional and Biventricular Pacing for Cardiac Resynchronization. Cardiology Clinics 24(3), August 2006:471-490.

42. RV Outflow Tract Pacing Combined With LV Pacing Biventricular pacing with the RV lead in the outflow tract. There was a very prominent R wave in lead V1 during monochamber LV pacing. Note the typical absence of a dominant R wave in lead V1, and the presence of right axis deviation, an uncommon finding during biventricular pacing with the RV lead at the apex. S. Serge Barold et al. Diagnostic Value of the 12-lead ECG During Conventional and Biventricular Pacing for Cardiac Resynchronization. Cardiology Clinics 24(3), August 2006:471-490.

44. Frontal Plane Axis With Various Pacing Configurations Diagram showing the usual direction of the mean frontal plane axis during apical RV pacing, RV outflow tract pacing, LV pacing from the coronary venous system, and biventricular pacing with LV from the coronary venous system + RV from the apex. The axis during biventricular pacing from the LV from the coronary sinus + RV outflow tract usually points to the right inferior quadrant (right axis) as with monochamber LV pacing. S. Serge Barold et al. Diagnostic Value of the 12-lead ECG During Conventional and Biventricular Pacing for Cardiac Resynchronization. Cardiology Clinics 24(3), August 2006:471-490.