This document discusses ways to optimize cardiac resynchronization therapy (CRT) to increase the rate of responders. It suggests focusing on improving patient selection by avoiding those with high non-response potential, and selecting those with non-ischemic cardiomyopathy, wide QRS, and left bundle branch block. Other areas to optimize include left ventricular lead placement and pacing programming, medical treatment, device programming algorithms, and using remote monitoring. Remote monitoring is shown to reduce heart failure hospitalizations compared to standard follow-up without remote monitoring. Overall, the document outlines strategies for optimizing various aspects of CRT delivery and follow-up to improve clinical outcomes.

1. Insuffisance cardiaque et resynchronisation
peut-on mieux faire?
C. Leclercq
Service de Cardiologie
Centre Cardio-Pneumologique
Rennes

2. Quelles sont les indications de
reynchronisation cardiaque?
Eur Heart J 2013; 34: 2281-2329

3. CRT: NYHA class II, III and ambulatory NYHA class IV and SR
LBBB / Non-LBBB
Eur Heart J 2013; 34: 2281-2329

4. CRT: NYHA class II, III and ambulatory NYHA class IV and SR
Eur Heart J 2013; 34: 2281-2329

5. CRT: NYHA class II, III and ambulatory NYHA class IV and SR
Eur Heart J 2013; 34: 2281-2329

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. Heart Rhythm 2012;9:1524 –76

8. is the non response related to a
reversible cause ?
• Myocardial ischemia?
• Valvulopathy (AS?)
• COPD?
• Anemia?
• Observance of tt
• Salt excess
• …

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. Eur Heart J 2013; 34: 2281-2329

11. QRS width
• COMPANION:
•
• CARE-HF:
• Reverse
• Madit-CRT
• RAFT

12. Zareba. Circulation 2011; 123: 1061-72
Importance of conduction disorders

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. • 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. 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. LV lead and latest LV activation
Kahn. J Am Coll Cardiol 2012; 59: 1509-18
Eur Heart J 2013; 34: 2281-2329

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. 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. Hemodynamic improvement with MPP?

20. Optimization of pacing modalities

21. Hemodynamic improvement with MPP?
BiV
with apical pacing LV

22. Hemodynamic improvement with MPP?
BiV
with basal LV pacing

23. Hemodynamic improvement with MPP?
BiV
with MPP LV pacing

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. Medical treatment
Altman. Eur Heart J 2012;33: 2181-8

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. 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. 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. Arrythmias
• Loss of biventricular capture due to
– Atrial arrhythmias
• Specific algorithm to overdrive
• Consider AV node ablation

30. Importance of AV node ablation

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. Exercise test in a CRT patient (I)

33. Exercise test in a CRT patient (II)

34. Europace (2009) 11, 931–936
Importance of LV auto-capture

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. 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. Importance of the exercise test
Inadequate AV delay
Shorten
AV delay

40. Causes of non response
Mullens. J Am Coll Cardiol 2009; 53: 675-73

41. 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

42. 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

43. 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)

44. 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

45. • 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?

47. 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%