Ενδείξεις αμφικοιλιακής βηματοδότησης. Ποιοι ασθενείς με καρδιακή ανεπάρκεια πρέπει να λάβουν αμφικοιλιακό απινιδωτή;

Transcription

1 Ενδείξεις αμφικοιλιακής βηματοδότησης. Ποιοι ασθενείς με καρδιακή ανεπάρκεια πρέπει να λάβουν αμφικοιλιακό απινιδωτή; Άννα Κωστοπούλου Επιμελήτρια Α Ωνάσειο Καρδιοχειρουργικό Κέντρο Τμήμα Ηλεκτροφυσιολογίας και Βηματοδότησης

2 Heart failure Two of the most significant advances in the treatment of HF are ICDs to treat ventricular tachyarrhythmias and prevent SCD CRT left ventricular-based pacing to achieve cardiac resynchronization therapy

3 Cardiac resynchronization therapy CRT improves NYHA functional class, exercise capacity and quality of life. CRT reverses ventricular remodeling and CRT reduces interstitial remodelling, TNF-a expression, and apoptosis- Based on biopsies before and 6 months later CRT has antiapoptotic and antiinflammatory effects. Improves myocardial performance. Cristoforo D Ascia et al European Heart Journal

4 First CORE trials 2001 Donal et al Eur Heart Journal Jan 2006

5 The COMPANION trial and the CARE-HF study established CRT as a treatment for HF and reduction in mortality

6 2008 ACC/AHA/HRS guidelines IA CRT SR QRS >120 NYHA III amb IV EF<35% W or w/o ICD EVEF <40% critical point And OPT medical treatment

7 Issues Non responding Expanding indications

8 Non responding

9 Non responding- Why do patients respond variably to cardiac resynchronization therapy? Substrate the site of LV stimulation programming Criteria for selection

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12 Ideally Venous anatomy should be assessed noninvasively to determine whether a transvenous approach is feasible a surgical approach should be used for LV lead. Implantation shoud be targeted to areas of dyssynchrony Estimation of scar areas with nuclear imaging, echocardiography or cardiovascular magnetic resonance (CMR).

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14 184 pts AV nodal ablation and CRT implantation (103 vs 81) Improvement in 6 min walk and ejection fraction compared to RV pacing Non response was due to non pacingpared to RV pacing Cardiovasc Electrophysiol, Vol. 16, , November 2005

15 PROSPECT hope for an echo goldstandard a prospective, multicenter, nonrandomized trial involving 53 centers in the U.S., Europe, and Hong Kong, and 498 subjects with standard indications for CRT were enrolled. 12 parameters Not useful Circulation 2008

16 Expanding indications

17 Mild symptoms REVERSE JACC 2008 MADIT CRT NEngJ2009 RAFT NEng J2010

18 610 pts NYHA I &II 83 % NYHA II QRS>120 mean QRS 153 EF<30% CRT on off

19 Non LBBB MADIT CRT 1817 pts Ischemic NYHA I, II EF <30% QRS>130 93% primary prevention implants 3:2 CRT-D or ICD Circulation 2011

20 QRS duration electrical and mechanical dyssynchrony electrical asynchrony is not always synonymous with mechanical asynchrony. Bleeker et al. J Cardiovasc Electrophysiol 2004;15:544 9.

21 RETHINQ narrow QRS 172 with ICD indication randomized to crt or no crt, 6 m FU

22 New Guidelines 2012 (I) IIA Ευρος QRS >150 LBBB LBBB>120 EF<35% NYHA >ΙΙ EF<35% non LBBB>150msec Afib and nodal ablation EF<35% with need of pacing >40% No indication in pts with narrow QRS

23 ICD indication Companion

24 ICD indication

25 problems still not fully addressed after revision Preserved HF EF>35% Non responding Low eligibility for CRT

26 Preserved EF QRS>120 NYHA I-IV

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28 2013 BLOCK HF CRT superior to conventional pacing Biventricular pacing was superior to conventional RV pacing in patients with atrioventricular block and left ventricular systolic dysfunction with NYHA class I, II, or III heart failure critized for long recruitment and including pts already w a CRT indications

29 Cardiac resynchronization therapy in chronic heart failure with moderately reduced left ventricular ejection fraction: Lessons from the Multicenter InSync Randomized Clinical Evaluation MIRACLE EF study Failure to enroll pts not feasable despite the careful design randomized Based on available national HF registries estimated that 4 5% of HF patients have both LBBB and an EF 35 50%, compared to 10 13% of HF patients with LVEF b35% International Journal of Cardiology 2016

30 Non responders echo guided and individual programming - fine tuning AV VV delays

31 RESPOND CRT Device based optimiazation - Safety of SON R algorhithms for optimization Echo AV VV vs automatic AV and VV DP/DT based Equally effective European Heart J2017

32 Low eligibility 1% of pts with heart failure discharged alive met trial eligibility European Heart Journal (2006) 27,

33 QRS New criteria Narrowed selection even more RBBB/LBBB Lyons et al 2017 JACC HF.

34 Narrow QRS - ECHO CRT worse European Heart Journal 2015

35 DANISH Critisized

36 Conclusions No changes in ICD indications Gasparini et al

37 The Future Preserved EF- CRT and ICD indications Advances in pacing Leedless pacing

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