ESC Paris, August 2011
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1 Controversial Issues in CRT: Is The Optimisation of AV & VV Delays Useful? ESC Paris, August 2011 D Gras, MD, Nantes, France
2 DECLARATION OF CONFLICT OF INTEREST Consultancy Minor Medtronic Saint Jude Medical Biotronik
3 Controversial Issues in CRT: Is The Optimisation of AV & VV Delays Useful? Background Optimal AV & VV Delays: The Theory Clinical Examples Results of Studies Particular Cases
4 How Much CRT Pacing is Really Needed? Pts. with AT (n=617) HF hospitalization/mortality BiVpacing 100% 98-99% 93-97% 0-92% p < Koplan et al., JACC 2009
5 Europace (2009) 11,
6 Importance of the exercise test Loss of AV sensing
7 Controversial Issues in CRT: Is The Optimisation of AV & VV Delays Useful? Background Optimal AV & VV Delays: The Theory Clinical Examples Results of Studies Particular Cases
8 R Relationship between PR interval & LV Filling Time (LVFT) E A IVC E A IVR IVC IVR E A Isovolumic Contraction Aortic Flow LVFT Aortic Flow Isovolumic Relaxation
9 AV & Ventricular Dyssynchrony alter LVFT Normal Normal LBBB LBBB The longer the PR, the larger the LBBB, the later the E wave
10 AV Delay Optimization: Short AV Delay Short AV Delay AV Forced MVC E QA A A wave truncation
11 AV Delay Optimization: Long AV Delay BiV BiV BiV AVD E MVC A A A E E IVC MVC IVC Pre-systolic MR Pre-Ejection period Aortic Flow Shortens LV Filling Time Aortic Flow
12 AV Delay adjustment to improve LV filling in CRT Minimum AVD value without truncated A wave Short AVD: 50 ms Long AVD: 160 ms Opt AVD: 80 ms Opt E Opt A Opt E + A
13 Limitations of AVD adjustment during CRT Ventricular Lead Placement interference VV timing adjustment may interact with AVD Prolonged atrial conduction time May depend on RA Lead Position (appendage vs Lat) Delayed LV Local Contraction Local overlap between systole and Diastole Interatrial Conduction Block
14 LV Lead position & Clinical Outcomes
15 Key importance of lead Placement to achieve successful CRT
16 Controversial Issues in CRT: Is The Optimisation of AV & VV Delays Useful? Background Optimal AV & VV Delays: The Theory Clinical Examples Results of Studies Particular Cases
17 AV Dyssynchrony : LVFT < 40% Cardiac Cycle due to Long PR Interval + LBBB DFT at Baseline: 280 ms
18 AV Dyssynchrony : LVFT < 40% Cardiac Cycle DFT at Baseline: 280 ms DFT during CRT: 400 ms
19 LVFT > 40% Cardiac Cycle after AVD Tuning AV Delay 130 msec
20 InterV Dyssynchrony : InterV Delay > 40 ms IVMD = LV PEI - RV PEI = 14 ms (baseline 81 ms)
21 VV interval and IntraV Dyssynchrony
22 Controversial Issues in CRT: Is The Optimisation of AV & VV Delays Useful? Background Optimal AV & VV Delays: The Theory Clinical Examples Results of Studies Particular Cases
23 FREEDOM Trial Results: Primary Endpoint HF Clinical Composite Score (Intent-to-Treat Analysis) Treatment Control HF CCS n % n % p-value Improved Unchanged Worsened Total No treatment differences in pre-specified ischemic and non-ischemic sub groups
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26 Atrial depolarization: 102 ms PR interval: ~130ms PV delay =width of atrial depolarization (PE) + 60 ms (if PE < 100 ms) PV = = 158 ms rounded to 160ms
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31 Clear Study: Primary Endpoint
32 Controversial Issues in CRT: Is The Optimisation of AV & VV Delays Useful? Background Optimal AV & VV Delays: The Theory Clinical Examples Results of Studies Particular Cases
33 Bi-atrial, Bi-ventricular Pacing in Pt with IACB
34 Ideal RA Lead position (?) AP View LAO View
35 IACB: Interest of LA Pacing via Prox CS
36 Advanced Dysssynchrony in Heart Failure Related to the disease process (ischemic or not ) Secondary to RV Pacing
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38 Atrial based, Dual Site LV, RV Pacing
39 LV Endo Pacing to improve synchronicity AP View LAO View
40 Controversial Issues in CRT: Is The Optimisation of AV & VV Delays Useful? Optimal AVD promotes optimal LV Filling ECHO and Exercise Test during FU Optimal VVD remains controversial MR, advanced dyssynchrony (IHD) Systematic Delays adjustment not validated/studies Optimisation Recommended in Particular Cases IACB, Severe Dyssynchrony, Advanced CM..
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