How to Maximize CRT Response?

Transcription

1 How to Maximize CRT Response? Chu-Pak Lau, MD Honorary Clinical Professor Department of Medicine University of Hong Kong Queen Mary Hospital Hong Kong 1

2 100% 1/3 of Patients Are Non-Responders of CRT 90% 80% % Improv ed Clinical Composite Score 70% 60% 50% 40% 30% 67% 52% 58% 67% 69% 67% 20% 10% 0% MIRACLE 1 MIRACLE MIRACLE II InSync III PROSPECT 5 FREEDOM 6 ICD 2 ICD 3 Marquis 4 * * AV optimised only 1 Abraham WT, et al. N Engl J Med. 2002;346: Abraham WT, et al. Heart Rhythm. 2005;2:S65. 2 Young JB, et al. JAMA. 2003;289: Chung ES, et al. Circulation. 2008;117: Abraham WT, et al. Circulation. 2004;110: v an Gelder BM, et al. J Cardiovasc Electrophysiol. 2008;19:

3 Causes of Suboptimal Response After CRT MullensW et al, JACC 2009; 53: (1) Pts & Methods : 75 consecutive patients between with CRT in Cleveland Clinic had persistence of HF Causes : 3

4 Reasons for Suboptimal Response Pacing Operation issue Arrhythmias AT / AF VA VA LV lead issues Site Threshold Phrenic nerve stimulation Optimal resynchronisation AV, VV VV timing timing Adaptive CRT CRT Changes in medical conditions 4

5 Pacing-operation Issues Pacing mode No AV synchrony e.g. DDI, VVI Atrial undersensing True Pseudo-atrial undersensing -e.g. Sinus tachycardia Atrial oversensing FFRW ( AMS) LV protection period Limits maximum LV pacing rate 5

6 Problems of AT / AF 1. Loss of AV synchrony 2. Loss of biventricular stimulation 3. Rapid ventricular rate 6

7 CRT for Class II/III HF: RAFT Study Tang ASL et al NEJM 2010;363: (1) Atrial rhythm 0.14 Permanent atrial fibrillation or flutter 104/229 Sinus or atrial paced 557/1596 Atrial rhythm Permanent atrial fibrillation or flutter 104/229 Sinus or atrial paced 557/

8 % BVP in ADHF & Mortality in CRT Pts. KoplanBA et al JACC. 2009; 53: (1) Pts & Methods : ADHF & Death from 1812 pts of CRT- RENEWAL and ENDOTAK RELIANCE were retrospectively analysed. Mean age 72yrs, 72% men, 67% CAD. Results : % BVP reduced end pts by 44% compared <92% BVP. Hx of AT/AF decreased % BVP. Conclusion : This retrospective multivariate analysis suggests BVP > 92% improves outcome. 8

9 % BVP in ADHF & Mortality in CRT Pts. KoplanBA et al JACC. 2009; 53: (2) No AF Hx AF Hx AF burden is related to ADHF + Mortality, but Increase in AF burden is not temporally related unlike % BVP 9

10 Methods to Maintain CRT When AF Occurs Pharmacological: rhythm / rate Pacing Algorithm -Boston: Ventricular Rate Regularisation -Medtronic: Conducted AF response, Ventricular Response Pacing -SJM: AF Suppression AV nodal ablation AF ablation 10

11 CRT in AF : Role of AVN Ablation for Rate Control Gasparini M. Auricchio A et al JACC 2006; 48: (1) 3 Gps: 1) SR + CRT; 2) CRT (Vp < 85%); 3) AF + AVN Ablation + CRT (Vp 100%) 11

12 AVN Ablation in CRT + AF: a Meta analysis GaresanAN et al. JACC 2012;59: Mortality Functional Class Conclusion: AVN ablation is superior to medical therapy in pts with HF + CRT who had AF 12

13 Ventricular Ectopic Beats Pharmacological Algorithm Ablation Medtronic : Ventricular sense response Boston : Ventricular preference pacing 13

14 Case 1 : Recurrent HF Despite Initial CRT Response (1) M/72 Gentleman DCM, LBBB, SR, with CRT-D implanted 2003 NYHC improved from IV to NYHC III LVEF improved from 15 to 30% Worsening dyspnoeafor 3 months in 2008, and EF reduced to 20% General: 1. Exclude aggravating medical conditions Anemia, infection, thyroid disease 2. Compliance 3. Cardiac disease: ischemia 14

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16 Case 1 : Recurrent HF Despite Initial CRT Response (2) Device check : Biventricular Pacing 88 % Foot print reference 28 current 20 Management : Echo : AV optimisation was difficult because of VPC Oral Amiodarone started with reduced VPC % biventricular pacing = 97% Foot print 32 16

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18 LV Lead Position & MADIT-CRT Singh J et al Circ2011; 123: The response of CRT-D to Death or HFH were prospectively evaluated as a 2 endpoint in MADIT-CRT in 799 pts. Conclusion: Apical position of LV lead worsens HFH & death 18

19 The QLV & CRT Response Gold MR et al. EHJ 2011;32: (1) QLV is a measure of intra-ventricular delay, and may promote CRT if maximise. 19

20 The QLV & CRT Response Gold MR et al. EHJ 2011;32: (1) Conclusion: In this SMART-AV subgroup analysis, QLV improves LV remodelling ( %) and QoL 50-72%. 20

21 Loss of LV Pacing Dislodgement Microdislodgement (Exit Block) Mismatch between vein / lead size Epicardial Phrenic nerve stimulation? Long Term Stability stable over 30 months (Daoud et al transvenous LV V at 30m; Epicardial 2.4V) 21

22 Phrenic Nerve and Cardiac Structures Sancheq-Quintana D et al, JCE 2005; 16: R phrenic nerve : SVC mm; RSPV mm; L phrenic nerve : 79% over OM; 21% anterior 22

23 Phrenic Nerve Stimulation Often underestimated at implant (Supine, anesthetics) Once demonstrated, often persistent Differential stimulation, -LV and phrenic nerve - capture management Pacing Algorithms - Unipolar, bipolar -Electronic repositioning 23

24 Quadripolar Stimulation Sperzel et al. Europace 2012 A novelsystem involving quadripolar LV lead (Quartet model 1458Q, St Jude Medical, Inc.) -with three ring electrodes located 20, 30, and 47 mm from the tip. Enable delivery of independent pacing pulses to multiple electrodes of the lead. Improve acute systolic function and low rates of lead dislocations and PNS. 24

25 Quadripolar lead Forleo et al. Heart Rhythm

26 Medtronic Quad LV Leads: Steroid elution & Close Bipoles

27 Avoid PNS Short Bipole Design Bipolar Spacing <2mm has Been Proven to significantly increase the phrenic nerve stimulation threshold (P: <0.001, ) without impacting pacing capture threshold [PCT] (P: 0.640, ). The dashed lines represent the effect in each animal, and the solid line represents the overall trend in the study. 1 Biffi M, et al. Circ Arrhythm Electrophysiol. 2012;5: Biffi M, et al. Heart Rhythm 2013;10:

28 Causes of Suboptimal Response After CRT MullensW et al, JACC 2009; 53: (1) Pts& Methods : 75 consecutive patients between with CRT in Cleveland Clinic had persistence of HF Causes : 28

29 Main Problems of Electrical Alterations 1. PR prolongation (improper LV filling) 2. Interventricular asynchrony (RV-LV asynchrony) 3. Intraventricular asynchrony (regional LV asynchrony) Results in : 1. Stroke volume 2. Contractility 3. MR 29

30 Methods of Programming AVI Methods Acute hemodynamics Echo-Doppler TDI Bioimpedance Formula based on QRS width Automatic Authors Auricchio, Kass Ritter s Formula Yu, Sogaard Tse Auricchio All industries 30

31 How the Waves Are Related P QRS ECG Mitral Flow E A E A PW Doppler Echo Isovolumic Contraction ao Isovolumic Relaxation Aortic Flow Mitral Valve Closed 31

32 AV Optimization -The Ritter Technique Short AV Interval AVshort QAshort QAshort = Qactivation Premature Mitral Valve Closure E AA 32

33 V-V Optimized Hemodynamics SogaardP et al, Circulation 2002; 106 : n= 20; V-V optimized at the optimum AVI 33

34 Role of AV Optimisation in CRT (SMART-AV) Ellenbogen KA et al Circ 2010; 122: Pts& Methods : 1014pts with CRT-D were randomisedto EGM guided (SmartDelay), Echo guided and fixed AVI (120ms) Interpretation: There is no change in 2 endpoints of LVEF, QOL, 6MHW and NYHA. Routine AV optimisationis not warranted, individual AV programming for non-responder. Post-hoc MADIT-CRT: AVD < 120ms is superior to AVD 120ms [Brenyo A, HR 2013] 34

35 Role of Automatic AV/VV Optimisationin BVP 1. Abraham WT et al: FREEDOM trial Am Heart J. 2010;159: (Protocol) HRS 2010 late breaking news Empiric AV/VV programming = ~3 monthly algorithm-base reprogramming 2. Boriani G et al: RHYTHM II ICD study PACE 2009;32 Suppl 1():S120-5 Post-hoc analysis with VV delay=0 Vs echo VV optimisation Acute benefit but no difference in LV reverse remodeling nor responder rate 35

36 Problems of AV/VV Adjustment Echo-optimisation is time consumingand AV/VV parameters likely to change over time and during exercise In prospective trials using BVP Formula-based AV optimisation is not superior to fixed AV VV optimisation is not superior to VV=0 None of these studies have used LV only pacing to exploit intact RV conduction 36

37 LVP Improves LV and RV function compared to BVP. Lee KL Lau CP, JCE 2007;18: Synchronisationof LV pacing to spontaneous RV conduction may obviate RVP in CRT. Acute hemodynamic study on 17 pts with LVEF 30±1% and QRS 135±25 ms with LVP vs BVP. [ADAPTIVE CRT trial confirmed benefit in implants] 37 LV Function

38 Conclusions The main causes of sub-optimal CRT are AV/VV programming, AT/AF, LV lead issues and change in programming needs AT/AF are managed medically, by device programming or ablation Appropriate implant choice to ensure optimal LV position and LV capture without phrenic nerve stimulation New LV leads to optimise pacing sites and perform multisite pacing. Optimization of A-RV/LV operations can enhance CRT 38

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