John D. Fisher, MD. Montefiore Medical Center Professor of Medicine, Albert Einstein College of Medicine, NY
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1 John D. Fisher, MD Montefiore Medical Center Professor of Medicine, Albert Einstein College of Medicine, NY
2 Multisite pacing in CRT does it help? John D. Fisher, MD Professor of Medicine Montefiore Medical Center Albert Einstein College of Medicine New York, USA
3 Disclosures Consultant: Medtronic. Investigator: many device & drug companies. Fellowship support: Boston Scientific, Medtronic, St. Jude Medical, Biotronik
4 Dual-Site Pacing Atrial For prevention/reduction of AF Remains controversial For termination (ATP) of atrial and ventricular arrhythmias (Mehra and others). For atrial and ventricular CRT. Some early Bi-V CRT was called multisite.
5 Multisite Pacing (MSP) What are we talking about? RA + LA pacing. RV + LV pacing. RA + RA pacing. RV + RV pacing RV + RV + LV pacing. RV +LV + LV pacing. Present area of greatest interest
6 Pilot for dual site atrial pacing to prevent atrial fibrillation (DAPPAF)
7 Conventional CRT (RA) + RV + LV
8
9 Cazeau et al 1996 Multisite here = conventional CRT RVA or RVOT to LV produced favorable results.
10 CRT may favor Reversion of AF to SR, ( which may further improve CHF?)
11 Dual Site RV RV + RV Some reports that if an LV site cannot be achieved, then dual RV may be better than single site RV.
12
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14 Dual site RV + single-site LV. RV + RV + LV
15 J Saudi Heart Assoc 2013
16 Dual site RV, + LV CRT Chase et al 2013 AF patient. A-port connected to RVS lead. Near 0ms AV I. RV & LV ports connected normally. Good response.
17
18 RV + RV + LV 21 patients, over medium-term follow up. Dual RV, + 1LV better than standard CRT. No RCT yet.
19 However
20
21 Disappointing Stambler et al, JCE 2003 In pts with CHF, LV Dysfunction, CAF: RVOT or dual site RV pacing shorten QRS. But after 3 months, no change in QOL or other outcomes compared with RVA pacing. Thus CRT with LV pacing is needed.
22 Multisite LV pacing
23
24
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27 Features of Quadripolar LV Leads Need only 1 LV lead. Choice of poles may avoid phrenic nerve stimulation. May or may not provide multisite LV stimulation depending on anatomy. May or may not provide CRT equal to 2 separate LV leads.
28 Ischemic CM may benefit most from Multisite LV or Endocardial Pacing Ginks Circ A&E 2012, Europace 2012
29 LV MSP can overcome scar limitations of CRT
30 ACC 2013
31
32 Thibault et al
33
34 But remember RV + RV + LV Also poduced favorable early results That lessened over time.
35 How many sites are needed to optimize MSP? Studied in canines with chronic LBBB
36
37
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39 MultiPoint Pacing Trial ClinTrials.gov NCT BSC-Guidant European trial Randomize: Conventional CRT. CRT-MSP with Quad LV lead.
40 MORE-CRT ClinTrials.gov NCT SJM European trial All get quad LV lead but programmed to conventional CRT. After 6 months: responders continued as CRT. Non-responders randomized to conventional or MSP-CRT.
41 Hierarchy? Sometimes a good LV position cannot be achieved through the coronary sinus. A hierarchy has been suggested: RV + LV Maybe RV + LV + LV. Or RV + RV +LV Dual site RV (RV + RV). RVOT. RVA. Known to be bad with poor LV function.
42 Thinking out of the Box
43 Impulse Dynamics Multisite RV Cardiac Contractility Modulation (CCM) delivered during RP at multiple RV sites
44 His Bundle Pacing for CRT Early studies (Rosen, Narula) indicated that some LBBB originated proximally in fibers in the HB that were destined to become the LBB. Early attempts at chronic HB pacing (Furman, Karpawich) foiled by development of fibrosis. Small modern steroid-eluting screws have re-opened interest in HB pacing.
45
46 LBB variations Updated from: Demoulin JC and Kulbertus HE. Br Heart J 1972;34:807-14
47
48
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50 HB pacing may give results similar to conventional CRT
51 Conclusions CRT is important for heart failure patients especially with LBBB. Conventional CRT (RV + LV) is sufficient for most. For others, quadripolar LV leads give option of LV MSP. Other entities also should be considered: Endocardial and surgically placed LV leads, unconventional stimulation, His Bundle pacing.
52 All Done!
53 AF + CHF: AVJ ablation + CRT, or PVI?
54 AF + CHF: AVJ ablation + CRT, or PVI?
55 AV Node Ablation in AF + CRT: Choose patients carefully: There s no turning back!
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