Dyssynchronous heart failureA device needed and helpful?

J. Janoušek

Kardiocentrum and Cardiovascular Research Centre

University Hospital Motol

Prague, Czech Republic

Kardiocentrum

No relationships to disclose

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

Recommendation in patients with heart failurein New York Heart Association function class III/IV

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

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

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

CRT helpful?The puzzle of (non)response to CRT

Gorcsan J, Circulation 2010

Myocardial scar/

underlying

myocardial

disease

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

Clustered

Helm RH et al.,Circulation 2005

Amenable to CRT

Kass DA, JACC 2008

Types of mechanicalintra-ventricular dyssynchrony

J Cardiovasc Electrophysiol 2010

Dispersed

Helm RH et al.,Circulation 2005

Not amenable to CRT

Kass DA, JACC 2008

Types of mechanicalintra-ventricular dyssynchrony

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!

Lead placement concordant with latest mechanical

activation carries optimal CRT response…

Suffoletto MS, Circulation 2006

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

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

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

Predictors of non-response to CRT in CHD

Janousek J et al. Heart 2009, 95:1165-71

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

Thank you for your attention