insuffisance cardiaque et resynchronisation : peut-on mieux faire? (pr c. leclercq)
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Insuffisance cardiaque et resynchronisationpeut-on mieux faire?
C. LeclercqService de Cardiologie
Centre Cardio-Pneumologique Rennes
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Quelles sont les indications de reynchronisation cardiaque?
Eur Heart J 2013; 34: 2281-2329
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CRT: NYHA class II, III and ambulatory NYHA class IV and SR
LBBB / Non-LBBB
Eur Heart J 2013; 34: 2281-2329
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CRT: NYHA class II, III and ambulatory NYHA class IV and SR
Eur Heart J 2013; 34: 2281-2329
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CRT: NYHA class II, III and ambulatory NYHA class IV and SR
Eur Heart J 2013; 34: 2281-2329
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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
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Heart Rhythm 2012;9:1524 –76
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is the non response related to a reversible cause ?
• Myocardial ischemia?
• Valvulopathy (AS?)
• COPD?
• Anemia?
• Observance of tt
• Salt excess
• …
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• 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?
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Eur Heart J 2013; 34: 2281-2329
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QRS width• COMPANION: •
• CARE-HF:
• Reverse
• Madit-CRT
• RAFT
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Zareba. Circulation 2011; 123: 1061-72
Importance of conduction disorders
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• 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
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• 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?
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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
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LV lead and latest LV activation
Kahn. J Am Coll Cardiol 2012; 59: 1509-18
Eur Heart J 2013; 34: 2281-2329
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Baseline
1 ms
150 ms
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
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Variable RV and LV Activation in LBBB
Total Ventricular Activation Time: 205 msec RV Activation Time: 130 msecLV Activation Time: 145 msec
LAO 60°LAO 60°
Total Ventricular Activation Time: 157 msec RV Activation Time: 57 msecLV Activation Time: 105 msec
Total Ventricular Activation Time: 189 msec RV Activation Time: 85 msecLV Activation Time: 137 msec
Courtesy: Angelo Auricchio
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Hemodynamic improvement with MPP?
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Optimization of pacing modalities
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Hemodynamic improvement with MPP?
BiV with apical pacing LV
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Hemodynamic improvement with MPP?
BiV with basal LV pacing
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Hemodynamic improvement with MPP?
BiV with MPP LV pacing
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• 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?
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Medical treatment
Altman. Eur Heart J 2012;33: 2181-8
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• 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?
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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
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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
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Arrythmias• Loss of biventricular capture due to
– Atrial arrhythmias • Specific algorithm to overdrive • Consider AV node ablation
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Importance of AV node ablation
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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!!
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Exercise test in a CRT patient (I)
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Exercise test in a CRT patient (II)
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Europace (2009) 11, 931–936
Importance of LV auto-capture
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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
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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….
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Importance of the exercise testInadequate AV delay
Shorten AV delay
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Causes of non response
Mullens. J Am Coll Cardiol 2009; 53: 675-73
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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 ScientificCognis
120 180 Off 0
Medtronic Concerto
100 130 On (70) 0
SorinParadym CRT
125 190 On (80) 0
SJMUnify
150 200 On (100) 0
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Long AV delay
(E and A fusion)
Decrease by 20 ms steps
Too short: truncated A-vawe
Optimal AV delayLV filling > 40% RR cycle
The iterative method
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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 isNON-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)
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Follow-upPatient/device
Clinical responseDevice function
6 mo
Factor identified
Echo optimization
No
1 mo
Yes
Unsatisfactory
Good
Modifysettings
Implantation
Echoscreening
A wave truncation?
No
Echo AVoptimization
Yes
Device algorithmECG
Proposal of Burri / Leclercq / Oliviera
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• 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?
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Optimization of the devices in CRT
Saxon. Circulation 2010;122: 2359 –67
CRT with and without RM
28%
Hindricks. ESC 2013
19%
9%3.4%