CRT: whom does it benefit?

Transcription

1 CRT: whom does it benefit? Francisco Leyva BSH Revalidation and Training 2018 Queen Elizabeth Hospital

2 NICE guidelines for CRT LVEF 35% NYHA class I II III IV QRS <120ms ICD if there is a high risk of SCD ICD and CRT not clinically indicated QRS ms No LBBB ICD ICD ICD CRT-P QRS ms with LBBB ICD CRT-D CRT-P or CRT-D CRT-P QRS 150ms CRT-D CRT-D CRT-P or CRT-D CRT-P

3 Benefit from CRT Malini Madhavan et al. JACC 2017;69:

4 Benefit from CRT BETTER RESPONSE Female NICM LBBB WORSE RESPONSE Male ICM Non-LBBB AF Dilated RV / TR / PHT Valvular cardiomyopathy Renal impairment

5 QRS morphology and haemodynamics in CRT Auricchio A, et al. Circ A&E 2014;7:

6 QRS duration and benefit from CRT Leyva F, et al. JACC 2014 Leyva F, et al. JACC 2014

7 QRS and benefit from CRT Individual patient data meta-analysis: Cleland JG, et al. Eur Heart J2013;34:

8 RV function and pulmonary hypertension

9 Effects of CRT on pulmonary haemodynamics N = 40 CRT implanted >3 months Mullens W, et al. J Am Coll Cardiol 2009;53:600 7

10 RV LAX at 6 months LV dysynchrony and RV remodelling after CRT Baseline RV LAX Bleeker GB, et al. JACC 2005;46:2264-9

11 RV function and survival after CRT Increasing predictive value + NYHA + Aetiology + DM + AF + Creat + LVESV + LV dyssynchrony + RV function TOTAL MORTALITY No internal or external validation No blinding Leong DP, et al. Heart 2013;99:

12 RV function and survival after CRT: CARE-HF Grouped according to tertiles of TAPSE Damy T, et al. JACC 2013;61:

13 Better outcome TAPSE and response to CRT: REVERSE trial CLINICAL COMPOSITE SCORE PREDICTORS OF LVRR AT 1 YEAR Kjaergaard J, et al. J Cardiac Fail 2011;17:

14 Renal function

15 CRT and CKD in RCTs CKD Stage 3 Study Renal function exclusion (µmol/l) CKD MIRACLE > CARE-HF NA 50 REVERSE > MADIT-CRT >265 - RAFT None 50 Relative risk (Primary outcome) No interaction between CKD and therapy CKD Stage 4-5: No evidence available Adapted from Damman K, et al. JACC 2014;63:853-71)

16 Renal dysfunction in MADIT-CRT ICD, GRF>60 CKD ICD, GFR>60 CRT-D, GFR<60 CRT-D, GFR>60 CRT-D, GFR>60 HR: 0.50 ( ), p <0.01 Reduction in total mortality / HF hospitalisation: GFR<60: 25% reduction GFR>60: 15% reduction Daimess UA, et al. Circ Heart Fail 2015 (online)

17 Renal function and outcomes after CRT Garg N, et al. CJASN 2013;8:

18 Renal function and outcomes after CRT 432 consecutive patients CRT-D Worsening renal function Daly DD, et al. PACE 2016; 39:

19 Event free Event free Renal function and outcomes after CRT 1.00 TOTAL MORTALITY TOTAL MORTALITY TM OR or HF HF HOSPITALIZATION egfr egfr logrank P <.001 egfr< Years Number at risk 60 ml/min <60 ml/min logrank P <.001 egfr< Years Number at risk 60 ml/min <60 ml/min Leyva F, et al. Europace 2018

20 Renal function and outcomes after CRT Event free Event free Event free Event free egfr 60 egfr<60 TOTAL MORTALITY ml/min 1.00 <60 ml/min CRT-D CRT-D 0.25 CRT-P 0.25 CRT-P 0.00 logrank P = Years Number at risk CRT-P CRT-D logrank P = Years Number at risk CRT-P CRT-D TOTAL MORTALITY OR HF HOSPITALIZATION ml/min 1.00 <60 ml/min CRT-D 0.50 CRT-D 0.25 logrank P = CRT-P Years Number at risk CRT-P CRT-D logrank P = CRT-P Years Number at risk CRT-P CRT-D Leyva F, et al. Europace 2018

21 Relative risk Renal function and outcomes after CRT CRT-D CRT-P egfr Leyva F, et al. Europace 2018

22 Valvular cardiomyopathy

23 Valves and the conduction system Pulmonary valve RCC LCC Aortic valve NCC AVN Mitral valve Tricuspid valve

24 PPI (%) Pacemaker implantation after valve surgery CABG AVR MVR AVR+MVR AVR+MVR+TVR Post-operatively Year 1 Year 5 Year 10 Leyva F, et al. HRJ 2017

25 CRT in post-surgical valvular cardiomyopathy TOTAL MORTALITY CARDIAC MORTALITY TOTAL MORTALITY OR MAC Outcome of CRT in PSVCM is poor Symptomatic response is similar to NICM Leyva F, et al. Europace. 2016;18(5):

26 MDT discussions NYHA CLASS I-III, LVEF < 35% HIGH RISK FEATURES Previous MI * NICM with presumed arrhythmic syncope INTERMEDIATE RISK FEATURES NICM +scar or: >10PVC s/hr and/or NSVT LOW RISK FEATURES NICM with no scar - PVC s, - NSVT RISKS OF ICD GREATER THAN BENEFIT HAEMODIALYSIS FRAILTY Recurrent pump failure MULTIPLE COMORBIDITIES PATIENT PREFERENCE SURVIVAL <1 YR

27 Conclusions Worse outcome is not the same as no benefit from CRT All variables are relative QRS: 130 ms is an arbitrary cut-off CKD: CRT-D is better than CRT-P (not stage 5?) Valvular CM: RV dysfunction: beware of TAVI Less benefit, but better than medical therapy