I NON RESPONDERS ALLA CRT: UN PROBLEMA DI NON SEMPLICE SOLUZIONE
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1 I NON RESPONDERS ALLA CRT: UN PROBLEMA DI NON SEMPLICE SOLUZIONE Gaetano Senatore S.C. CARDIOLOGIA OSPEDALE DI CIRIE & OSPEDALE DI IVREA LABORATORIO di
2 Today s Patient Selection for CRT +AF and PM patients LVEF > 35 %: Echo? Echo Investigation in IHD ++ QRS < 150 ms (<130:Echo CRT) Earlier CRT consideration LABORATORIO di DIVISION HF Hospitalization, OF CARDIOLOGY CIRIE & BNP IVREA
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11 How to define Non Responders (?) Follow-up: 6 months, 1 year, Longer Clinical (Soft): NYHA, QoL, 6 MNW, VO2 Clinical (Strong): Morbidity (HFH), Mortality Echocardiography: LVESV -10 or 15%, LVEF Combined: Clinical and Echocardiography Device-related complications: never considered Other. LABORATORIO di
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13 Rethinq follow-up too short - Lessons from CARE-HF LABORATORIO di Cleland NEJM 2005
14 Consistency between REVERSE and MADIT CRT REVERSE MADIT-CRT Time to first heart failure Kaplan-Meier estimate of hospitalization in the first heart-failure 12 free survival probability onths (secondary end point) (part of primary end point) RR - 53 % RR-34% and for HF only 41 % LABORATORIO di C. Linde et al., JACC 2008; 52: DIVISION OF Moss, CARDIOLOGY AJ, et al., NEJM CIRIE 2009 & IVREA
15 REVERSE: Remodeling Parameters LVESVi LVEDVi (ml/m2) LVEF (%) LVESVi (ml/m ) , , ,5 CRT OFF 91,6 88,8 69,2 94,5 P< CRT ON 76,8 73,6 69, Months Since Randomization LVEDVi (ml/m ) CRT ON CRT OFF P< LVEF (%) ,1 27,8 0 CRT ON 33,4 32,7 29,0 29,1 CRT OFF 6 12 Months 34,9 34,8 P< ,9 29, Months LABORATORIO di P-values compare 24-month changes.
16 Prospect Study CCS versus Echo Response LABORATORIO di
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20 How Much CRT Pacing is Really Needed? Pts. with AT (n=617) HF hospitalization/mortality p < BiVpacing 100% 98-99% 93-97% 0-92% LABORATORIO di DIVISION OF Koplan CARDIOLOGY et al., JACC CIRIE 2009 & IVREA
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24 CRT failed to benefit Key importance of CRT lead Placement LABORATORIO di
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26 Parameters influencing CRT Response Comorbidities: age-related, COPD, anemia Advanced CM vs Early Stage CM Ischemic vs non ischemic origin RV dysfunction Lead Position, difficult anatomy Device settings: AV & VV delays Others. LABORATORIO di
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34 Unsolved issues after CRT device implant Non Responders Background How to Define non Responders? Parameters Influencing CRT Response Potential Solutions to Optimize CRT LABORATORIO di
35 Dual site RV Pacing to optimize CRT LABORATORIO di
36 J Am Coll Cardiol 2008;51: Hypothesis: CRT with 1 RV + 2 LV leads in opposite position might better improve cardiac synchrony and thus patients clinical status LABORATORIO di
37 Existing Clinical Experience in Transseptal LV Endocardial Lead Implant Brockenbrough needle Mullins transseptal sheath/dilator Guidewire 6226 DEF or C304 Jais P et al, PACE, 1998 VanGelder BM et al, Heart Rhythm, 2007 Morgan et al, EuroPace, 2009 Lau E, J Interv Card Electrophysiol.,2009 LABORATORIO di
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39 Unsolved issues after CRT device implant Non Responders Response to CRT: CCS, Hospitalization, LV Reverse Remodeling, Mortality.. Limitations to CRT Age and Comorbidities, advanced CM, Ischemic origin, Anatomical, RV Dysfunction, Lead Placement.. Management of non responders: Earlier CRT Consideration: Madit CRT, Reverse, Raft Appropriate Lead Placement Optimized CRT Settings (Automaticity, Telemonitoring ) Triple site RV/LV CRT, LV Endocardial Pacing LABORATORIO di
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41 957 pts (597M, 340F), mean age 68.2yrs (49-81) - Responder 75% - Sopravvivenza a 5 anni 65% LABORATORIO di DIVISION DIVISION OF CARDIOLOGY OF CARDIOLOGY CIRIE & CIRIE IVREA
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43 ARE WE DOCTORS OR ELECTRICIANS? LABORATORIO di DIVISION DIVISIONE OF CARDIOLOGY DI CARDIOLOGIA CIRIE CIRIE & IVREA
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