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Dyssynchronous heart failureA device needed and helpful?
J. Janoušek
Kardiocentrum and Cardiovascular Research Centre
University Hospital Motol
Prague, Czech Republic
Kardiocentrum
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No relationships to disclose
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Background
Dyssynchrony generates marked regional
heterogeneity of both function and loading
with subsequent structural and cellular
remodeling
The aim of CRT is to counteract mechanical
dyssynchrony caused by an electrical
activation delay
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Recommendation in patients with heart failurein New York Heart Association function class III/IV
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CRT in mildly symptomatic heart failure(NYHA class I-II)
CRT on
CRT off
Linde C et .al. REVERSE trial. JACC 2008
Zareba W et .al. MADIT-CRT trial. Circulation 2011
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Recommendation in patients with heart failurein New York Heart Association function class II
2010 Focused Update of ESC guidelines on device therapy in heart failure. Eur Heart J 2010
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Functional classification
NYHA 1/2
62 % of responders
Dubin AM et al. J Am Coll Cardiol 2005;46:2277-83
Cecchin F et al. JCE 2009;20:58-65
Janousek J et al. Heart 2009, 95:1165-71
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CRT helpful?The puzzle of (non)response to CRT
Gorcsan J, Circulation 2010
Myocardial scar/
underlying
myocardial
disease
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Types of electrical dyssynchronyin pediatric/CHD CRT studies
Dubin AM et al. J Am Coll Cardiol 2005;46:2277-83
Cecchin F et al. JCE 2009;20:58-65
Janousek J et al. Heart 2009, 95:1165-71
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Clustered
Helm RH et al.,Circulation 2005
Amenable to CRT
Kass DA, JACC 2008
Types of mechanicalintra-ventricular dyssynchrony
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J Cardiovasc Electrophysiol 2010
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Dispersed
Helm RH et al.,Circulation 2005
Not amenable to CRT
Kass DA, JACC 2008
Types of mechanicalintra-ventricular dyssynchrony
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Effectiveness of CRT by QRS Morphology
Zareba W et al. MADIT-CRT
trial. Circulation 2011
Risk of heart failure event or death after CRT
Non-LBBB
LBBB
Not just any prolonged QRS but a specific electrical activation delay
at the side of systemic ventricle is the indication for CRT!
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Lead placement concordant with latest mechanical
activation carries optimal CRT response…
Suffoletto MS, Circulation 2006
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P <0.05
mean
P <0.001
median
P <0.001
mean
Systemic ventricular ejection fraction
Dubin AM et al. J Am Coll Cardiol 2005;46:2277-83
Cecchin F et al. JCE 2009;20:58-65
Janousek J et al. Heart 2009, 95:1165-71
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Change after
CRT
EF/FAC units
mean (SD)
SVEDD z-score
median
NYHA
median
Upgrade from RV
pacing, systemic
LV (N=44)
+14.0 (16.5) -2.1 Grade 3 1
All other pts
(N=54)
+7.7 (10.9) -0.8 Grade 2 2
P =0.101 =0.036 =0.030
Janousek J et al. Heart 2009;95:1165-71
RV pacing-associated LV failure
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LV reverse remodeling vs substrate(CARE-HF trial)
Ghio S et al. EHJ 2009
Survival + ESV < -40 mL
NI + CRT
NI + MT
I + CRT
I + MT
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Predictors of non-response to CRT in CHD
Janousek J et al. Heart 2009, 95:1165-71
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Summary
CRT regardless of functional classification
» NYHA class I and II
Electromechanical activation delay in a substantial
part of the systemic ventricle
» Not just wide QRS!
» „Predict by ECG, prove by ECHO approach“
Intrinsic myocardial disease one of the limiting
factors of CRT efficacy
Very poor functional status may predict CRT
non-response
» Point of no return
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Thank you for your attention