natale marrazzo francesco solimene quando la crt-p può bastare?

Natale MARRAZZOFrancesco SOLIMENE

Quando la CRT-P può bastare?

European Heart Journal (2008) 29, 2388–2442

Introduction

CRT in NYHA function class IVCRT in NYHA function class IV CRT in NYHA function class ICRT in NYHA function class I CRT in PERMANENT AFibCRT in PERMANENT AFib CRT in conventional PM INDICATIONCRT in conventional PM INDICATION CRT in RENAL FAILURECRT in RENAL FAILURE CRT in ADVANCED AGECRT in ADVANCED AGE

CRT in NYHA function class III/IVCRT in NYHA function class III/IV

Impact of CRT therapy on morbidityImpact of CRT therapy on morbidity

COMPANIONCOMPANION CARE-HFCARE-HF


Impact of CRT therapy on mortalityImpact of CRT therapy on mortality

COMPANIONCOMPANION CARE-HFCARE-HF


Ambulatory patients in NYHA function class IVAmbulatory patients in NYHA function class IV

Primary time to all-cause death or hospitalizationPrimary time to all-cause death or hospitalization Secondary time to all-cause deathSecondary time to all-cause death

COMPANIONCOMPANION

Key issuesKey issues

LV dilatation no longer required Class IV patients should be ambulatory Reasonable expectation of survival with good functional status for 1 y for CRT-D Evidence is strongest for patients with typical LBBB Similar level of evidence for CRT-P and CRT-D


CRT in NYHA function class I/IICRT in NYHA function class I/II

Clinical evidence

MADIT CRTMADIT CRT


Clinical evidence

REVERSEREVERSE


MADIT-CRT

REVERSE

NYHA I


In favour of implantation of CRT-D♥ Predominantly or exclusively implanted CRT-D♥ Younger age, lower comorbidity and longer life expectancy

In favour of implantation of CRT-P♥ Survival advantage with CRT-D was not shown♥ LVEF increase to > 35% (NO ICD indication in HF)♥ Higher risk of device-related complications with CRT-D

Device selectionDevice selection


MADIT-CRT and REVERSE demonstrate reduced morbidity In REVERSE and in MADIT-CRT NYHA I pts had been previously symptomatic Improvement primarily seen in pts with QRS ≥150 ms and/or typical LBBB. In MADIT-CRT, women with LBBB demonstrated a particularly favourable response Survival advantage not established In MADIT-CRT the extent of reverse remodelling was concordant with and predictive of improvement in clinical outcomes


CRT and PERMANENT AFibCRT and PERMANENT AFib

CRT and PERMANENT AFibCRT and PERMANENT AFib


Approximately one-fifth of CRT implantations in Europe are inpatients with permanent AF NYHA class III/IV symptoms and an LVEF of ≤35% are well-established indications for ICD Frequent pacing is defined as ≥95% pacemaker dependency Evidence is strongest for patients with an LBBB pattern Insufficient evidence for mortality recommendation

CRT and CRT and a conventional PM INDICATIONa conventional PM INDICATION

CRT and CRT and a conventional PM INDICATIONa conventional PM INDICATION


In patients with a conventional indication for pacing, NYHA III/IV symptoms, an LVEF of ≤35%, and a QRS width of ≥120 ms, a CRT-P/CRT-D is indicated RV pacing will induce dyssynchrony Chronic RV pacing in patients with LV dysfunction should be avoided CRT may permit adequate up-titration of b-blocker treatment

PACE 2008; 31:575–579

CRT and CRT and RENAL FAILURERENAL FAILURE

Retrospective study on n=239 ICD pts (all 1-ary prev)

CR-dysf = creatin.>2mg/dl or under dialysis

FU: 18±15 months

Mortality in CR-dysf: 48.6%

Mortality in controls: 8.2%

Cuculich P & al. PACE 2007




RF is associated with an increased risk for all-cause mortality, largely explained by an increased risk for pump-failure death High creatinine remaines an independent predictor of mortality in CRT recipients RF pts despite ICD implantation extract little, if any, survival benefit from this therapy

CRT and CRT and ADVANCED AGEADVANCED AGE

CRT and CRT and ADVANCED AGEADVANCED AGE


HF is predominantly a disorder of older adults Very few pts over age 75 were enrolled in the major ICD trials None of the CRT trials included pts in this age range With respect to ICDs: high procedural complication rates , short life expectancy, high risk of dying from causes other than SCD ICD is unlikely to be favorable for most pts

The challenge of selecting patients for ICD therapy

♥ Cost♥ Life expectancy♥ Complications♥ Inappropriate shocks♥ Patient’s persective

natale marrazzo francesco solimene quando la crt-p può bastare?

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