Follow-up of CRT patients ESC Munich Clinical and biological follow-up of CRT patients

Transcription

1 Follow-up of CRT patients ESC Munich Clinical and biological follow-up of CRT patients Frieder Braunschweig MD PhD FESC Associate Professor of Cardiology Karolinska University Hospital Stockholm, Sweden

2 Disclosure Research grants: Medtronic, Biotronik Consultant: Medtronic, Biotronik Speakers Bureau: Medtronic, St-Jude Medical, Sorin

3 CRT patient management Pre-implant management Device implantation Post-implant management Patient selection Pre-implant assessment Choice of device Lead positioning Device optimization Time Treatment optimization Device follow-up Device optimization HF follow-up Comorbidities Arrhythmia control ICD-shock management Advanced HF therapies?

4 EP physician CRT network HF physician Pacemaker technician Device function Arrhythmia management Remote follow-up CRT- Patient In office follow-up Implantable monitoring Optimal medication HF nurse/ coordinator Cardiac imaging Quality of life Family practicioner Functional assessment Patient education Internist Imaging specialist

5 Collaboration HF-clinic Pace-clinic

6 HF-management unit ESC Guidelines for the diagnosis and treatment of acute and chronic HF 2012 FU FU FU Diagnostic evaluation Clinical, biochemical Echo CPX Medical treatment Drugs Exercise General measures Device follow-up CRT, ICD Remote monitoring

7 Frequency of CRT follow-up Minimum frequency of CRT device follow-up (in person or by remote monitoring) Within 72 hours after implantation (in person) 2 12 weeks post implantation (in person) CRT: every 3 12 months (in person or remote) CRT-D: every 3 6 months (in person or remote) Annually until battery depletion (in person) Every 1 3 months at signs of battery depletion (in person or remote) Wilkoff, Auricchio et al: HRS, EHRA, ESC, HFA, HFSA, ACC, AHA Expert Consensus on the Monitoring of Cardiovascular Implantable Electronic Devices. Europace 10: , 2008:.

8 Factors determining type and frequency of CRT follow-up Patient related Disease severity Clinical stability Changes in medical therapy Patient compliance Patient distance from follow-up clinic Other medical/social factors Specific patient request Device related Complexity of the device High / unstable pacing thresholds ICD therapy delivery Reliability of the device/leads Expected device longevity Arrhythmia/heart failure diagnostics Wilkoff, Auricchio et al: HRS, EHRA, ESC, HFA, HFSA, ACC, AHA Expert Consensus on the Monitoring of Cardiovascular Implantable Electronic Devices. Europace 10: , 2008:.

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10 Remote arrhythmia monitoring (TRUST) Home Monitoring - is as safe as conventional in-office FU - reduces in-office FU visits by 45% Median time to evaluation of arrhythmia events VT 1 VF 1 AF Days (Home Monitoring vs conventional in-office FU) Varma N et al, Circulation Jul 27;122(4):325-32

11 Remote heart failure monitoring Device based monitoring features

12 Models of collaboration HF management unit Liaison clinic, consecutive encounters (pace - HF) The HF electrophysiologist The interventional HF specialist Joint access to - chart notes - device check protocol - arrhythmia and HF monitoring - home monitoring Case conferences Mutual education

13 CRT-follow-up: treatment adjustments Treatment options for patients with chronic symptomatic systolic heart failure (NYHA class II IV). ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012

14 Braunschweig et al, EHJ 2006 Decrease diuretics? Effect of CRT on pulmonary artery diastolic pressure CRT CRT CRT ON OFF ON day

15 Bristow et al. NEJM 2004;350:2140 Increase ACE-I/ARB, ß-blocker, MRA? COMPANION

16 Promote regular exercise Walking distance *** *** *** ** Mean improvement: 12M: +69m/20% 24M: +89m/25% 36M: +117m/33% *** *** [m] Baseline 6M 12M 18M 24M 30M 36M n=35 n=27 n=23 n=21 n=18 n=18 n=15 *:p<0.05, **:p<0-01; ***:p<0.001 compared with baseline. M: months Ståhlberg M et al. PACE Oct;28(10):

17 CRT - non-response Device related, suboptimal CRT delivery Loss of LV pacing (high threshold? lead dislodgement?) Discordant LV lead position AV-, VV-interval programming Basic heart rate, rate response programming Insufficient CRT delivery (<95% LV pacing)

18 CRT non-response Non device related No dyssynchrony at baseline Arrhythmia Anemia Valvular disease Ischemia Primary RV failure COPD Sleep apnea Renal failure Depression.

19 CRT optimization clinic n=75 Changes in device settings and/or other therapy modifications in 74%. fewer adverse events (13% vs. 50%) compared with pat w/o therapy modification. W. Mullens et al. J. Am. Coll. Cardiol. 2009;53:

20 AV-delay, VV-delay optimization List of methods proposed (incomplete): Echo LV mitral inflow pattern ( Ritter ) Iterative method (A wave truncation) Maximal filling time Myocardila performance index Aortic VTI Mitral inflow VTI LVEF 3-D echo Doppler velocity imaging Tissue tracking ECG ECG (effective VV-interval) ECG (QRS pattern) AV EGM method Invasive Invasive bloop pressure LV dp/dt LV pulse pressure Pressure volume loop Other Radionucleid ventriculography Finapress Transthoracic bioimpedance Device feature SmartDelay QuickOpt SonR Pressure sensors

21 AV-delay, VV-delay optimization List of controlled studies proving improved clinical outcome with AV-/VV-delay optimization:

22 AV-Delay optimization Impact of changes in AV-delay (+/- 40 ms) on CO Ståhlberg et al, Europace (2009) 11,

23 Arrhythmia Fluid Index Impedance AT/AF total % Pacing/day Avg V. rate Patient activity

24 Advanced HF treatment End stage HF: LVAD? Htx? Palliative care? Termination of ICD therapy?

25 Screening device patients for Htx/LVAD 194 screened (CRT/ICD) 60 NYHA III/IV eligible 55 included 134 NYHA I/II excluded 5 no consent 1 indication HTx 9 indication LVAD S. Zabarovskaja, L. H. Lund et al, ISHLT Prague 2012 abstract

26 Summary (I) The follow-up of CRT patients demands close collaboration between different specialties. Pacemaker and HF specialists need to establish organizational and logistic standards that ensure optimal patient care before and after device implantation.

27 Summary (II) The complexity of the matter and the increasing number of device patients demand cross education of HF and pacemaker specialists and more research into the optimal multidisciplinary management of CRT patients.

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29 ICD shock issue

30 Increase betablocker? Betablocker therapy 12 [No pf pts] 9 Increased Betablocker 6 Decreased Betablocker M M M n=30 n=25 n=23 Compared to baseline Ståhlberg M et al. PACE Oct;28(10):

31 Concordance: LV lead / latest activation Reconstruction of rotational x-ray and 3D echo Contraction pattern with CRT off / discordant lead position RAO LAO LL Early contraction Late contraction Bettina Nitsche et al, EUROPACE, Madrid 2011

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33 Arrhythmia AV junctional ablation (n=118) vs drugs (n=125) Long term survival, mean follow up 34 months Overall survival Cardiac survival HF survival Gasparini et al European Heart Journal 2008;29: