This document discusses cardiac resynchronization therapy (CRT) as a non-pharmacological treatment option for patients with mild, moderate, or severe heart failure that is refractory to medication. CRT can help patients in NYHA heart failure classes I through IV who have a prolonged QRS duration and reduced left ventricular ejection fraction. The document also reviews guidelines from the European Society of Cardiology on cardiac pacing and CRT. It presents a case study of a patient who may benefit from CRT and discusses ethical issues around reusing or re-sterilizing pacemakers in low-resource settings.

1. En tiempos de crisis………
Dr. José Mejías M
Marzo 2018

2. El tratamiento de resincronización cardiaca
(TRC) es una alternativa terapeutica no
farmacologica para los pacientes con
insuficiencia cardiaca (IC) leve, moderada o
grave refractaria a la medicación, en clase I, II,
III y IV de la New York Heart Association
(NYHA), con una duración del QRS prolongada
y con una disminución grave de la fracción de
eyección ventricular izquierda

5. 2013 ESCGuidelines on cardiac pacing and cardiac
resynchronization therapy

6. 2013 ESCGuidelines on cardiac pacing and cardiac
resynchronization therapy

7. Notable Recommendation Changes in 2012
ACCF/AHA/HRS Focused Update
2012 DBT Focused Update Recommendations Comments
Class I
1. CRT is indicated for patients who have LVEF less than or equal to 35%,
sinus rhythm, LBBB with a QRS duration greater than or equal to 150 ms,
and NYHA class II, III, or ambulatory IV symptoms on GDMT. (Level of
Evidence: A for NYHA class III/IV; Level of Evidence: B for NYHA class II)
Modified recommendation (specifying
CRT in patients with LBBB of 150 ms;
expanded to include those with NYHA
class II symptoms).
Class IIa
1. CRT can be useful for patients who have LVEF less than or equal to 35%,
sinus rhythm, LBBB with a QRS duration 120 to 149 ms, and NYHA class II,
III, or ambulatory IV symptoms on GDMT. (Level of Evidence: B)
New recommendation
2. CRT can be useful for patients who have LVEF less than or equal to 35%,
sinus rhythm, a non-LBBB pattern with a QRS duration greater than or equal
to 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT.
(Level of Evidence: A)
New recommendation
3. CRT can be useful in patients with atrial fibrillation and LVEF less than or
equal to 35% on GDMT if a) the patient requires ventricular pacing or
otherwise meets CRT criteria and b) AV nodal ablation or pharmacologic rate
control will allow near 100% ventricular pacing with CRT. (Level of Evidence:
B)
Modified recommendation (wording
changed to indicate benefit based on
ejection fraction rather than NYHA
class; level of evidence changed from
C to B).
4. CRT can be useful for patients on GDMT who have LVEF less than or
equal to 35% and are undergoing new or replacement device placement with
anticipated requirement for significant (40%) ventricular pacing. (Level of
Evidence: C)
Modified recommendation (wording
changed to indicate benefit based on
ejection fraction and need for pacing
rather than NYHA class; class
changed from IIb to IIa).
GDMT Guideline-directed medical therapy

8. Notable Recommendation Changes in 2012
ACCF/AHA/HRS Focused Update
2012 DBT Focused Update Recommendations Comments
Class IIb
1. CRT may be considered for patients who have LVEF less than or equal to
30%, ischemic etiology of heart failure, sinus rhythm, LBBB with a QRS
duration of greater than or equal to 150 ms, and NYHA class I symptoms on
GDMT. (Level of Evidence: C)
New recommendation
2. CRT may be considered for patients who have LVEF less than or equal to
35%, sinus rhythm, a non-LBBB pattern with QRS duration 120 to 149 ms,
and NYHA class III/ambulatory class IV on GDMT. (Level of Evidence: B)
New recommendation
3. CRT may be considered for patients who have LVEF less than or equal to
35%, sinus rhythm, a non-LBBB pattern with a QRS duration greater than or
equal to 150 ms, and NYHA class II symptoms on GDMT. (Level of
Evidence: B)
New recommendation
Class III: No Benefit
1. CRT is not recommended for patients with NYHA class I or II symptoms
and non-LBBB pattern with QRS duration less than 150 ms. (Level of
Evidence: B)
New recommendation
2. CRT is not indicated for patients whose comorbidities and/or frailty limit
survival with good functional capacity to less than 1 year. (Level of Evidence:
C)
Modified recommendation (wording
changed to include cardiac as well as
noncardiac comorbidities).
GDMT Guideline-directed medical therapy

9. 2013 ESCGuidelines on cardiac pacing and cardiac
resynchronization therapy

10. Electocateter
AD
Electocateter
SVC
VD
Electocateter

13. 2013 ESCGuidelines on cardiac pacing and cardiac
resynchronization therapy

14. 2013 ESCGuidelines on cardiac pacing and cardiac
resynchronization therapy

15. Caso Clinico:
Paciente masculino de 50 años de edad, Hipertenso y con antecedentes de Miocardiopatia dilatada con
Insuficiencia cardiaca a pesar de tratamiento óptimo con Betabloqueantes, BRAII, Eplerenone y Diureticos
de ASA. Recientemente ACV trombótico de ACM Izquierda y evidencia de hemorragia leve en nucleos de la
base.
Paciente en clase functional II-III de NYHA, Hemiplejia Derecha con afasia de expression.
ECG: RS/ BRIHH con BAV de primer grado, QRS de 190 mseg

21. MARCAPASOS, DAI Y
CRT REUSADOS……
…
NOS VOLVIMOS LOC S ???

23. Ningùn fabricante recomienda ni
apoya que se utilicen dispositivos
Usados ni siquiera reesterilizados

24. As a result of improvements in technology and
health care, the morbidity and mortality
attributed to cardiovascular disease has
declined in recent decades. However, this
dramatic improvement in disease burden has
not been witnessed in low- and middle-income
countries.2 This great disparity in medical
health care is clearly evident in the field of
cardiac electrophysiology—specifically
pacemaker implantation
Countries such as Bangladesh and India average 8 new implants per
million as compared with 738 new implants per million in France.
3 International aid organizations estimate that more than 1 million
people die annually from a lack of access to pacemakers.
4 Countries in Europe reported an average of 475 new implantations
per million as compared with 191 new implantations
per million in the Americas (excluding Canada and United
States) Numbers of pacemakers implanted per year per million population
are 782, 518 and 767 in France, the UK and the USA, respectively, while
they are 17, 5 and 5 in India, Bangladesh and Sudan, respectively.1

29. Circ Arrhythm Electrophysiol June 2011

30. INFECTION AFTER IMPLANTATION OF REUSED VS IMPLANTATION OF NEW PACEMAKER

31. RISK FOR MALFUNTION REUSED VS NEW
PACEMAKERS

32. Heart Asia 2017;9:30–33.

35. CONCLUSIONES
1.- El implante de Dispositivos Usados y re esterilizados es una alternativa valida en
países con bajos recursos económicos.
2.-La incidencia de Infecciones y de malfuncionamiento de estos equipos es similar
a los nuevos implantes
3.- Los equipo deben ser previamente evaluados por personal calificado y
esterilizados apropiadamente.