Cardiac Resynchronization Therapy

Who is the best candidate?

Raed Abu Shama, M.DCardiologist and Electrophysiologist

DISCLOSURE

None!

CARDIAC RESYNCHRONIZATION THERAPY

1. Improve ventricular systolic function.

2. Induce favorable remodeling.

3. Reduce metabolic costs

4. Ameliorate functional mitral regurgitation

5. Improve exercise capacity

6. Reduce HF symptoms on the MLWHF Scale

7. Decrease hospitalizations

8. Decrease mortality rate

CASE HISTORY

A 68 YOMP with CHF was referred for device implant.

IHD, S/P NSTEMI 2012 and CABG X 4

COPD, CHF, NYHA III

Echo: Dilated LV, LVEF 28%, mod-sev. TR, mod. PHTN

Optimal Medical Therapy

ECG: SR, IVCD, QRS 122 ms

Referring physician: “the one with the 3 wires may

make you feel better, and if not – no harm done”.

WHO IS THE BEST CANDIDATE?

1. NYHA class II, III, or ambulatory IV

2. LVEF ≤ 35%

3. Sinus rhythm

4. LBBB

5. QRS ≥ 150 ms

6. on GDMT

7. Life expectancy is > 1 yearEpstein et al. JACC (2013); 61, 3:e6–75Parkash R. et al. CJC; 29 (2013) 1346 – 1360Brignole, M et al. Eur Heart Journal (2013) 34, 2281–2329Yancy CW et al. Circulation. (2013);128:e240-e327McMurray JJ et al. Eur Heart Journal (2012) 33, 1787–1847

J Cardiac Fail 2014;20:379e386

CUMULATIVE PROBABILITY OF HF, DEATH OR VAS

Hsu J. et al. JACC 2012;59: 2366–73

Hsu J. et al. JACC 2012;59: 2366–73

*Per 1-U SD below mean.

Cardiac Resynchronization Therapy in

Women

KEY FINDINGS OF OBSERVATIONAL STUDIESEVALUATING SEX DIFFERENCES IN RESPONSE TO CRT Women are generally 30% or less of the study population. Compared with men, women typically:

1. Have higher rates of:

- Nonischemic HF cause

- LBBB configuration

- Procedural complications

2. Have lower rates of:

- Atrial fibrillation

- Ischemic HF cause

3. Have smaller LV volumes

Costanzo MR. Card Electrophysiol Clin 7 (2015) 721–734

Female

Male

LBBB and QRS of 130 to 149 ms

Women with LBBB and QRS of 130

to 149 ms have a 76% reduction in

heart failure events and mortality

from CRT-D.

Zusterzeel R et al. JAMA Intern Med. 2014;174(8):1340-1348.

QRS Morphology and Duration

MADIT CRT: LBBB WAS ASSOCIATED WITH SUBSTANTIALLY GREATER IMPROVEMENT ACROSS ALL ENDPOINTS AS COMPARED

TO THE ENTIRE STUDY POPULATION.

14

Birnie el al. Circ Heart Fail. 2013;6:1190-1198

JCE 2012, Vol. 23, pp. 163-168

Arch Intern Med. 2011;171(16):1454-1462.

QRS < 150ms

QRS ≥ 150ms

Arch Intern Med. 2011;171(16):1454-1462.

Circ Heart Fail. 2013;6:1190-1198

LBBB Non-LBBB

HAZARD RATIOS FOR PRIMARY COMPOSITEOUTCOME* BY QRS DURATION AND MORPHOLOGY

* death from any cause or HF hospitalization

Circ Heart Fail. 2013;6:1190-1198

NON-LBBB

QRS < 160ms

QRS ≥ 160ms

Circ Heart Fail. 2013;6:1190-1198

CLINICAL IMPLICATIONS

1. In patients with LBBB, the broader QRS the greater the

benefit from CRT.

there is likely potential benefit in all patients with LBBB

regardless of QRS duration.

2. There is no benefit of CRT in patients with non-LBBB,

especially when the QRS duration is <160 ms.

N Engl J Med 2013;369:1395-405

KAPLAN–MEIER ESTIMATES FOR PRIMARY-OUTCOME EVENTS

the combination of death from any cause, or

first hospitalization for worsening HF

All cause mortality Heart failure related mortality

Hospitalization Due to Heart Failure

CRT IN NARROW QRS COMPLEX

1. Does not reduce HF mortality.

2. Does not reduce HF hospitalizations.

3. Associated with higher all-cause mortality.

BACK TO OUR PATIENT . . . A 68 YOMP was referred for device implant. IHD, S/P NSTEMI 2012 and CABG X 4 COPD, CHF, NYHA III Echo: Dilated LV, LVEF 28%, mod-sev. TR, mod. PHTN Optimal Medical Therapy ECG: SR, IVCD, QRS 122 ms

Family doctor: “the one with the 3 wires may make youfeel better, and if not – no harm done”.

A single chamber ICD was implanted!

WITH OPTIMAL SELECTION THE RESPONSE RATE IS NOT 100%

POTENTIAL REASONS FOR NONRESPONSE

1. Suboptimal lead placement

2. Failure of the LV lead to capture

3. Atrial fibrillation with rapid response

4. Lack of viable myocardium

5. Suboptimal AV and/or V to V delays

6. Latency to LV stimulation

CASE HISTORY

JJ is a 43 YOMP with ICMP, severe LV dysfunction on

OMT for 2 years.

NYHA class III with frequent hospitalization.

He was referred for CRTD implant.

ECG Per-implant

ECG Post-implant

Non Responder

FOLLOW UP ECHOCARDIOGRAM

LV systolic function is severely reduced, LVEF < 20%.

Left ventricular diastolic function is suggestive of

restrictive filling pattern.

Novel Predictors of

Non-Response to CRT

Acute improvement in diastolic function independently

predicted reverse remodeling after CRT.

Restrictive Filling Pattern at 1 week after CRT was

independent predictor of mortality and hospitalization

for HF.

NOVEL MARKERS OF NON-RESPONSE

Abu Sham’a R. et al. Europace (2013) 15, 266–272

Tricuspid Regurgitation

P value < 0.001

adjusted for age, gender, MR grade ≥2, PHTN, RV dysfunction, and upgrading from PM

OUTCOMES IN PATIENTS WITH AND WITHOUT TR DETERIORATION

Variables TR deterioration 25 (13%)

No TR deterioration 168 (87%) P value

Clinical response 10 (42%) 112 (70%) 0.006

Echo response 13 (52%) 93 (56%) 0.73

∆ ESPAP 4.5 +13 2.7 +12 0.438

∆ RV-FAC 0.89 +10.8 0.65 +8.5 0.886

Mortality–long term 2 (8%) 13 (8%) 0.96

Abu Sham’a R. et al. Europace (2013) 15, 266–272

CASE HISTORY A 56 YOFP diagnosed as NICMP. Her ECG showed SR, LBBB at

163 ms. She was put on OMT.

Three months later, she was referred for CRTD implant due to poor

clinical response (NYHA class III).

One month post implant, she suffered from multiple ICD shocks

associated with worsening of her Heart failure.

ECG: SR, proper BiV pacing.

Echo: Improved LVEF from 25% to 35%

Device interrogation showed:

1. Normal electric parameters

2. Multiple appropriate ICD shocks

3. Complete Heart Block!

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1

3

4

Raed Abu Sham’a, Hiroshi Ohira, Pablo Nery, Girish Nair, Calum Redpath, Rob Beanlands, David Birnie

Response to Cardiac Resynchronization

Therapy in Patients with Cardiac Sarcoidosis

The University of Ottawa Heart Institute

Heart Rhythm Society May 8, 2014

CONCLUSIONS

1. Patients with CS have an expected remodeling

response rate (66.7%).

2. However only minority patients had a clinical response

to CRT.

Abu Sham’a et al. HRS 2014

CASE HISTORY

A 58 YOFP with NICMP for 8 months.

LVEF <30%. NYHA lass III despite OMT.

Referred for CRTD. Very poor cardiac venous anatomy.

Referred for EPICARDIAL LV lead implant.ECG Post-CRT

THANK YOU FOR YOUR ATTENTION

Raed Abu Shama, M.D

BACKUP SLIDES

COMPLETE LBBB CRITERIA1. QRS ≥ 120 ms

2. Broad notched or slurred R wave in leads I, aVL, V5, and V6.

3. Absent q waves in leads I, V5, and V6, but in the lead aVL, a narrowq wave may be present.

4. R peak time greater than 60 ms in leads V5 and V6 but normal inleads V1, V2, and V3.

5. ST and T waves usually opposite in direction to QRS.

6. Positive T wave concordance may be normal.

7. Depressed ST segment and/or negative T wave in leads with negativeQRS (negative concordance) are abnormal.

8. The appearance of LBBB may change the mean QRS axis in thefrontal plane to the right, to the left, or to a superior, in some cases ina rate-dependent manner.

Surawicz B et al. J Am Coll Cardiol 2009;53:976–81.