Dipartimento di Scienze Cardiovascolari Università Campus Bio-Medico di Roma Dott. Vito Calabrese

Transcription

1 Dipartimento di Scienze Cardiovascolari Università Campus Bio-Medico di Roma Dott. Vito Calabrese

2 Because the primary objective was cure symptomatic bradicardya due to syncope Because this is the common way of treating Because actually, standard electro-catheters are projected for an easy and stable positioning in RV apex Because there were no convincing reasons for stimulate another site

3 BI-SITE septal Stimulation (RVS) RVOT stimulation bi-focal stimulation (RVOT + RVA) para-hisian pacing RVOT RVS PARA-HISIAN Bourke JP, Europace 02 Lieberman, PACE 04 Rev Esp Cardiol 01

4 Risk of AF relative to VVIR patient with Cum%VP=0 Risk of AF relative to DDDR patient with Cum%VP=0 (1339pts, 67% with know Cum%VP) 4 Cumulative percentage of RVP is an INDIPENDENT PREDICTOR of AF development RR of AF INCREASE LINEARLY with the RVP until about 80-85%, both in the DDDR group and VVIR group Cum%VP 4 3 AF risk is REDUCE of 1% for each 1% of reduction of Cumulative % of VP in the DDD(R) group Cum%VP Sweeney MO, Circulation 03

5 Higher level of Cum %VP in DDDR has adverse long-term effects that mitigate the benefit of AV synchrony. Conventional DDD systems often result in a higher level of RVA pacing due to: AVD programmed shorter than intrinsic AV conduction Lower rate settings higher than necessary Rate-responsive algorithms which increase VP in response to stress Mean Cum%VP VVI: 3% Mean Cum%VP DDD: 56% Sharma AD, HRS `05

6 567 pts (76% of 742 MADIT II pts) 369 CumVP 0-50% (median VP 0,2%) 198 CumVP % (median VP 95,6%) Average F>U 20 mo hazard ratio 1.93; P = Pts in MADIT II who were predominantly paced had higher rate of new or worsened HF and were more likely to receive therapy for VT/VF, suggesting the deleterious consequences of RVAP, particularly in the setting of severe LV dysfunction. J Cardiovasc Electrophysiol. 2005

7

8

9

10

11 Topos et al, JACC 2009

12 Size and Shape: from an ellipse to a sphere

13

14

15

16

17 VD VS VD VS (1) Surawicz B, Circul 2009;119:e235-e240; (2) Peichl P, et al. PACE 2004;27:

18

19 Interventricular dyssynchrony Intraventricular dyssynchrony Topos et al, JACC 2009

20

21

22

23

24

25

26

27

28

29

30 from mechanical differences to molecular/cellular changes

31

32

33

34 from haemodinamic to biological effects of CRT

35

36

37

38 Biventricular rather than RV pacing is associated with better LV function, better quality of life, and better exercise capacity.

39 Biventricular versus Right Ventricular Pacing in Patients with Left Ventricular Dysfunction and Atrioventricular Block

40 Control: RV pacing Follow-up Every 3 months Implant (CRT-P/D) Establish OMT (30-60 days) Randomize 1:1 Double- Blind Treatment: BiV pacing Follow-up Every 3 months ELIGIBILITY CRITERIA AV block necessitating pacing Left ventricular ejection fraction (LVEF) < 50% NYHA functional class I, II or III Absence of a Class I indication for resynchronization therapy No previous pacemaker or implantable cardioverter defibrillator (ICD) Echocardiography performed at Randomization, 6, 12, 18 and 24 months OMT=optimal medical therapy CRT-P=cardiac resynchronization therapy pacemaker CRT-D=CRT defibrillator 40

41 Event-Free Rate (%) BiV Arm RV Arm Number at Risk Number of Months BiV: RV:

42 Biventricular Pacing for Atrio-ventricular Block to Prevent Cardiac Desynchronization Randomized, multicentric, international, prospective, single-blind, parallelgroup-design Comparing two pacing modes: Conventional RVP vs BVP Primary End-points: higher survival rate (at 3-5 years) longer distance covered in 6-minutes walk test better QoL (Minnesota LwHF questionnaire) Main Secondary End-points: hospitalization adverse events: implant, LV lead, all leads etc. successful implantation of LV-lead (SJM) conversion to permanent AF cardiac structure and function (Echo core-lab)

43 Pts with conventional indication for PM implantation and high likelyhood for predominant VP Permanent III degree of AVB Type II Mobitz 1 oder 2 or intermittent III degree AVB in combination with 1 degree AVB and pq-interval >220 msec 1 degree AVB and indication for VP (long HV-interval) SSS with symptomatic sinus-bradycardia or sinus arrest as primary indication for PM implantation in combination with 1 degree of AVB (>220 ms) Chronic AF with HF at rest <75 bpm if initiation or increase of pharmacological treatment with a relevant HR lowering effect is planned for time after PM implantation AF and being scheduled for AV node ablation Any spontaneous (unpaced) QRS-width

44

45

46