Cardiac Resynchronization ICD Therapy: What is New?
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1 Cardiac Resynchronization ICD Therapy: What is New? Emile Daoud, MD Section Chief, Cardiac Electrophysiology Professor of Medicine The Ohio State University Normal Activation, Narrow QRS Synchrony Abnormal Activation Left Bundle Branch Block Dyssynchrony 1
2 Add Pacing Electrode to Left Ventricle for LV Pacing What Is Not New: ICD s Still Best Way to Manage SCD Hazard Ratio MADIT (1996) AVID (1997) MUSTT (1999) n = 196 n = 1016 n = 704 EF < 0.35, NSVT, EP+ Aborted Cardiac Arrest EF < 0.40, NSVT, EP+ MADIT II (2002) n = 1232 SCD-HeFT (2005) n = 2521 Prior MI & EF < ICD Better ICD Worse 2
3 What is New: Primary Prevention Programming MADIT RIT: Reduction in Inappropriate Therapy and Mortality Through ICD Programming N Engl J Med 2012;367: Conventional = Low HR and Short time bpm: 2.5-second delay before therapy 200 bpm: 1.0-second delay before therapy High Heart Rate 200 bpm: 2.5-second delay before therapy Delayed Therapy bpm, 60-second delay before therapy bpm, 12-second delay before therapy 250 bpm. 2.5-second delay before therapy Inappropriate Therapy Reduced Inappropriate Shocks and Reduced Total Mortality Total Mortality N Engl J Med 2012;367:
4 What is New MADIT-RIT Improved ICD programming for primary prevention therapy with high-rate (>200 bpm) or 60-sec duration-delay is associated with: 1) ~75% reduction in 1st inappropriate therapy 2) ~50% reduction in all-cause mortality OSU: - Cut off rate for delivery of ICD therapies 250 patient s age - Duration set to 10 sec. (rather than 2.5) N Engl J Med 2012;367: What Is Not New: Cardiac Resynchronization Therapy Reduces HF and Mortality in LBBB Native LBBB conduction or RV Pacing (results in LBBB activation) Associated with HF and increased mortality BiV Pacing/CRT - reduces HF and total mortality 4
5 What is New: Refinement of Who Should Receive CRT QRS Morphology QRS Duration Meta Analysis of CRT in LBBB NYHA Class III & IV HF Hospitalization and Total Mortality Am Heart J 2012;163:
6 Meta Analysis of CRT in Non LBBB NYHA Class III & IV HF Hospitalization and Total Mortality Am Heart J 2012;163: LBBB, p = Benefit with CRT On CRT Off CRT On REVERSE: Impact of CRT NYHA Class I & II Non-LBBB, p = No difference On vs Off CRT Off CRT On HF Hospitalization and Total Mortality Stratified by QRS Morphology CRT On vs CRT Off Circulation. 2012;126: ) 6
7 Risk of Death or HF According to Clinical Characteristics Variable Age < 65 yr 65 yr Sex Male Female NYHA class Ischemic I Ischemic II Nonischemic II QRS duration < 150 msec 150 msec LVEF 25% > 25% LVEDV 240 ml > 240 ml LVESV 170 ml > 170 ml All patients No. of Events/No. of Patients 142/ / / /453 53/ / / / / / / / / / / /1820 Hazard Ratio No benefit for QRS < 150ms 1.0 CRT-ICD Better ICD Only Better Moss, et al. N Engl J Med 2009;361:1-10. CRT Meta-Analysis of QRSd 150ms n = 3623 Arch Intern Med. 2011;171(16):
8 CRT Meta-Analysis of QRSd ms n = 2189 Arch Intern Med. 2011;171(16): Meta-Analysis CRT-D for Narrow QRS, mean QRSd =106ms n = 1186 Shah et al, Europace Aug 27. 8
9 ECHO-CRT CRT in Narrow QRS + ECHO Dyssynchrony - QRS 106ms Increased Mortality with CRT Meta-Analysis of CRT-D in Narrow QRS All Cause Mortality, HF mortality, HF Hospitalization Europace Aug 27. 9
10 ACC/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR ICD Appropriate Use Guidelines Appropriate Use CRT, Ischemic and NonIschemic Cardiomyopathy X YES, II, III and IV, ± I YES, Class I - IV??? True Class III & IV - monitor Probably, esp III & IV - CRT therapy can be harmful: QRSd<130 increased mortality - All patients need careful reassessment post CRT to assess response, esp narrow QRS and non LBBB - OSU Post CRT: CPX and ECHO 3-4 months post implant Random Thoughts Regarding CRT Any pt with CHB and EF <45%: CRT Nonresponder, 30% Goal is BiV pacing of 94% Careful programming re triggered mode pacing Falsely elevates the device reported percent BiV pacing If CRT device + AF Favor ablation of AF improves HF If permanent AF, RF AVN even if rate is controlled PVCs in a HF pt with CRT are a big deal PVC Ablation Lead Location Matters! Bury the lead..bury the patient Not toward Apex 10
11 SOLVE CRT trial 2 Failed CS Leads; First OSU Pt 11
12 Summary Program ICD to high cut off rate and/or long duration mortality benefit Benefits of CRT are best for LBBB Benefits of CRT best for QRS 150ms When CRT used in other populations, careful to reassess Best therapy may be to turn off CRT HF + Narrow QRS > HF + CRT New: Ultrasound-driven for LV pacing 12
13 ACC/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR ICD Appropriate Use Guidelines, 2013 Appropriate Use CRT, Ischemic and NonIschemic Cardiomyopathy X LBBB QRS II, III and IV, ± I LBBB QRS 150ms Class I - IV Non LBBB ms Probably not? Non LBBB 150ms Probably, esp III & IV - CRT therapy can be harmful: QRSd<130 increased mortality - All patients need careful reassessment post CRT to assess response, esp narrow QRS and non LBBB - OSU Post CRT: CPX and ECHO 3-4 months post implant 13
14 Determination of LV Lead Placement by Venogram - Originally: Advance lead to distal vein, apical pacing - Increased mortality compared to basal/mid LV pacing - Challenge: secure LV pacing in ideal position ACC/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR ICD Appropriate Use Guidelines, 2013 Appropriate Use CRT, Ischemic and NonIschemic Cardiomyopathy X YES, II, III and IV, ± I YES, Class I - IV Probably not ENHANCE CRT Probably, esp III & IV ENHANCE CRT - CRT therapy can be harmful: QRSd<130 increased mortality - All patients need careful reassessment post CRT to assess response, esp narrow QRS and non LBBB - OSU Post CRT: CPX and ECHO 3-4 months post implant 14
15 CRT: Indications Despite optimal medical therapy, pt has: QRS > 120ms LVEF 35% Heart Failure CRT Trials for CHF Every trial has shown significant benefit Remodeling of LV with reduction in size Increase in LVEF Reduced Hospitalization Increase exercise tolerance Increased QOL Significant placebo effect! Mortality benefit probably yes Thus cardiac resynchronization is important 15
16 What is New: Refinement of Who Should Receive CRT QRS Morphology QRS Duration Meta Analysis of CRT in LBBB NYHA Class III & IV HF Hospitalization and Total Mortality Am Heart J 2012;163:
17 Meta Analysis of CRT in Non LBBB NYHA Class III & IV HF Hospitalization and Total Mortality Am Heart J 2012;163: LBBB, p = Benefit with CRT On CRT Off CRT On REVERSE: Impact of CRT NYHA Class I & II Non-LBBB, p = No difference On vs Off CRT Off CRT On HF Hospitalization and Total Mortality Stratified by QRS Morphology CRT On vs CRT Off Circulation. 2012;126: ) 17
18 Risk of Death or HF According to Clinical Characteristics Variable Age < 65 yr 65 yr Sex Male Female NYHA class Ischemic I Ischemic II Nonischemic II QRS duration < 150 msec 150 msec LVEF 25% > 25% LVEDV 240 ml > 240 ml LVESV 170 ml > 170 ml All patients No. of Events/No. of Patients 142/ / / /453 53/ / / / / / / / / / / /1820 Hazard Ratio No benefit for QRS < 150ms 1.0 CRT-ICD Better ICD Only Better Moss, et al. N Engl J Med 2009;361:1-10. CRT Meta-Analysis of QRSd 150ms n = 3623 Arch Intern Med. 2011;171(16):
19 CRT Meta-Analysis of QRSd ms n = 2189 Arch Intern Med. 2011;171(16): Meta-Analysis CRT-D for Narrow QRS, mean QRSd =106ms n = 1186 Shah et al, Europace Aug
20 ECHO-CRT Total Mortality Increased Mortality Related to BiV pacing Meta-Analysis of CRT-D in Narrow QRS All Cause Mortality, HF mortality, HF Hospitalization Europace Aug
21 ACC/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR ICD Appropriate Use Guidelines, 2013 Appropriate Use CRT, Ischemic and NonIschemic Cardiomyopathy X YES, II, III and IV, ± I YES, Class I - IV Probably not ENHANCE CRT Probably, esp III & IV ENHANCE CRT - CRT therapy can be harmful: QRSd<130 increased mortality - All patients need careful reassessment post CRT to assess response, esp narrow QRS and non LBBB - OSU Post CRT: CPX and ECHO 3-4 months post implant Random Thoughts Regarding CRT Any pt with CHB and EF <50%: CRT Nonresponder, 30% Goal is BiV pacing of 94% Careful programming re triggered mode pacing Falsely elevates the device reported percent BiV pacing If CRT device + AF Favor ablation of AF improves HF If permanent AF, RF AVN even if rate is controlled PVCs in a HF pt with CRT are a big deal PVC Ablation 21
22 Summary Program ICD to high cut off rate and/or long duration mortality benefit Benefits of CRT are best for LBBB, 150ms When CRT used in other populations, careful to reassess Best therapy may be to turn off CRT HF + Narrow QRS > HF + CRT 22
23 Random Thoughts Re: CRT Prefer QRS at least 130ms If QRS ms, or if QRS <120ms: Be careful!!! CRT may worsen HF need to reassess patient Try not to pace atria almost all studies: VDD Nonresponders still in 30% of patients Quadripolar LV pacing electrode? Adaptive CRT? Apical pacing 23
24 NYHA class III or IV heart failure on optimized medical therapy LVEF 35% QRS <130 ms Echocardiographic evidence of left ventricular dyssynchrony: Tissue Doppler imaging 80ms Speckle-tracking radial strain 130ms 405 pts assigned to CRT ON vs 403 CRT OFF 24
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