Device Based Therapy for the Failing Heart: ICD and Cardiac Resynchronization Rx
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1 Device Based Therapy for the Failing Heart: ICD and Cardiac Resynchronization Rx Charles Gottlieb, MD Director of Electrophysiology Abington Memorial Hospital
2 Heart Failure Mortality Mechanism of death in heart failure 1 SCA 64% Other 24% SCA 59% Other 15% SCA 33% Other 11% CHF 12% CHF 26% CHF 56% NYHA Class II n = 103 deaths NYHA Class III n = 232 deaths NYHA Class IV n = 27 deaths The likely mechanism of death in heart failure patients moves from SCA to CHF as the disease progresses. 1 1 MERIT-HF Study Group. Lancet 1999;353:
3
4 CHF Rx: Quality vs Quantity Improved Quality of Life Diuretics Digoxin Inotopic agents Beta-blockers/ACEI/Aldactone Revascularization Increase Longevity ICD Antiarrhythmics
5 Therapy to Prevent SCD in CHF AARx: Marked Increase in Mortality (proarrhythmic effects) Amiodarone: Neutral Effect ICD: Marked improvement in survival in virtually all patient subsets (? CRI in elderly with co-morbidities?)
6 ICD Rx EF 35% Exponential Rise in Mortality Prophylactic ICD Ischemic and Non-ischemic Myopathy Efficacious for Men and Women
7 ACC/AHA/HRS Guidelines for ICD Therapy 1 Epstein, Andrew E et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy: Executive Summary. Circ 2008; 117: Jessup et al Focused Update:ACCF/AHA Guidelines. JACC 2009; 53:
8 Acute Exacerbations Contribute to the Progression of Heart Failure Clinical Status With each event, hemodynamic alterations/myocardial injury contribute to progressive ventricular dysfunction Acute event Heart failure progression may be accelerated by the aggressive therapies initiated during hospitalization Time 1 Jain P et al. Am Heart J. 2003;145:S3-S17.
9 Do We Have More to Offer? Not only do these patients have depressed LV function, but.. They frequently have dyssynchronous activation of the LV due to conduction system disease (or pacing) Cardiac Resynchronization Rx (CRT)
10 CHF Rx: Quality vs Quantity Improved Quality of Life Diuretics Digoxin Inotopic agents CRT-ICD Beta-blockers/ACEI/Aldactone Revascularization Increase Longevity ICD Antiarrhythmics
11 Conduction Issues often Associated with Heart Failure
12 Issues Associated with Heart Failure
13 Issues Associated with Heart Failure Ventricular Dyssynchrony Longer Relaxed Shorter
14 Cardiac Resynchronization Therapy
15 Implant
16 Movie of Implant
17 Implant
18 Implant
19 Movie of Implant
20 Movie of Implant
21 Movie of Implant
22 CRT: How Does it Work Cardiac Resynchronization Rx (CRT) Reduces dyssynchrony of LV activation Improves pumping performance Reverses the deleterious of LV remodeling Inhances appropriate atrio-ventricular timing as well as RV-LV activation Decreases mitral regurgitaion Papillary muscle activation 1 Briston MR, et al, NEJM, 2004 ; 350 (21):
23 Classic ACC/AHA/HRS Class I Indication for CRT Moderate to severe heart failure (NYHA Class III or IV) and Left ventricular dysfunction (EF 35%) and QRS 120 ms (including 2 o to pacing and Remain symptomatic despite stable, optimal heart failure drug therapy
24 CRT: Who Really Benefits? QRS 140 msec LBBB (Not IVCD or RBBB) Women >> Men Non-ischemic >> Ischemic CM 1 Jain P et al. Am Heart J. 2003;145:S3-S17.
25 Women: Smaller and Poorly Represented 70% of patients in all CRT Trials were MEN!! No Benefit for Biventricular pacing if QRSd<140 ms however.. Women in general have a QRS that is ms shorter than men!!!
26 Response to CRT based on QRSd
27 Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy (MADIT-CRT) Primary Effectiveness Hypothesis: Determine if CRT-D would reduce the risk of the combined endpoint of all-cause mortality or heart failure event, whichever came first, when compared to ICD in patients with: Asymptomatic or mildly symptomatic heart failure (I&II) Left ventricular dysfunction (EF 30%) Wide QRS ( 130ms)
28 MADIT-CRT Results 34 % 57 % Results showed that CRT-D was associated with a 34% reduction in the risk of the primary endpoint 41% reduction in CHF events LBBB subgroup, patients received substantial benefit from CRT-D. Non-LBBB patients did not show evidence of benefit. total MADIT- CRT population. 1. N Engl J Med Oct 1;361(14): Epub 2009 Sep 1. Cardiac-resynchronization therapy for the prevention of heart-failure events. Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP, Estes NA 3rd, Foster E, Greenberg H, Higgins SL, Pfeffer MA, Solomon SD, Wilber D, Zareba W; MADIT-CRT Trial Investigators. 2. COGNIS CRT-D System Guide
29 Conclusion CRT should be considered for the heart failure patient with: Depressed LV function ( 35%) LBBB men QRSd 140ms Women QRS 120ms Pacing (>40%)
30 Response to CRT: Conclusion Women >> men Non-ischemic > Ischemic CM Increases with prolonged QRSd (to a point) A patient with a LBBB and depressed LV function should be considered for a prophylactic biventricular pacing system even in the absence of severe heart failure symptoms!
31 Conclusion Thank you!!
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