Importance of CRT team for optimization of the results: a European point of view Matteo Bertini, MD, PhD Arcispedale S. Anna Azienda Ospedaliero-Universitaria Cona-Ferrara
No conflict of interest to declare
No. patients Clinical improvement Echo. improvement PATH-CHF 41 NYHA/QoL/6MWT/less hospitalizations PATH-CHF II 86 QoL/6MWT/less hospitalizations CONTAK-CD 490 NYHA/QoL/6MWT LVEF / LV volumes MUSTIC-SR 58 NYHA/QoL/6MWT/Peak VO 2 /less hospitalizations Ischemic and non-ischemic DCM: MIRACLE 453 NYHA/QoL/6MWT LVEF/LVEDD/MR MIRACLE-ICD 362 NYHA/QoL sinus rhythm Still, (also up to AF) 45% of COMPANION 1520 Reduced all-cause NYHA III-IV (also mortality/hospitalizations non-response II) rate! QRS duration> 120 msec (LBBB) CARE-HF 813 NYHA/QoL/Reduced morbi-mortality LVEF/LVESV PROSPECT 426 Composite (NYHA/hospitalizations/mortality) EF < 35% REVERSE 610 Composite (NYHA/hospitalizations/mortality) LVESV LVESV MADIT-CRT 1820 Reduced all-cause mortality/hospitalizations RAFT 1798 Reduced all-cause mortality/hospitalizations LVEF/LVESV
REASONS FOR FAILURE OF CRT IN HF PTS Dyssynchrony Scar at pacing site Left ventricular lead position Optimization of device setting Optimization of medical therapy Modifiable Older age Total scar burden Impaired renal function Gender Etiology Not modifiable
MODIFIABLE FACTORS Dyssynchrony Scar at pacing site Left ventricular lead position Optimization of device setting Optimization of medical therapy
Mechanical dyssynchrony 95ms
LV Mechanical Dyssynchrony Assessment Echocardiography?? Pitzalis et al. JACC 2002 Bax et al. JACC 2004 Yu et al. Circ 2004 Achilli et al. PACE 2006 Suffoletto et a. Circ 2006 Marsan H&R 2008
MODIFIABLE FACTORS Dyssynchrony Scar at pacing site Left ventricular lead position Optimization of device setting Optimization of medical therapy
Cardiac MRI: scar location LAO Marsan et al. Eur Hear J 2009
MODIFIABLE FACTORS Dyssynchrony Scar at pacing site Left ventricular lead position Optimization of device setting Optimization of medical therapy
Khan FZ et al. J Am Coll Cardiol 2012;59:1509 18
MODIFIABLE FACTORS Dyssynchrony Scar at pacing site Left ventricular lead position Optimization of device setting Optimization of medical therapy
Summary of current evidence for CRT optimization Parameter Standard (current practice) CRT optimization Clinical benefit (compared to standard) AV delay Fixed empirical (100-120 ms) -Echo Doppler -device-based algorithms -mild -mild VV delay Simultaneous BIV -Echo: dyss -Echo: Doppler -ECG -Device-based algorithms -Uncertain -Uncertain -Unknown -Uncertain
What do we do in Ferrara? Multimodality imaging guide LV lead placement
METHODS Observational study Population: 100 HF pts Imaging guided group Control group 50 pts prospectively enrolled, underwent CMR and speckletracking echo pre-crt to guide CRT implant 50 pts retrospectivelyenrolled underwent standard CRT implant Response to CRT: LVESV reduction >15% at 6 month follow-up
METHODS: IMAGING GROUP 1. Standard clinical and echo evaluation: HF specialist 2. CMR imaging: Radiologist and Imaging cardiologist 3. 2D-STE assessment of longitudinal myocardial strain: Imaging cardiologist 4. CRT team (HF specialist, Imaging cardiologist, Electrophysiologist) discussion: Target area 5. CRT Implant: Electrophysiologist
IMAGING GROUP: IDENTIFICATION OF TARGET AREA STEP 1: exclusion of the scar area (area with delayed-enhancement >75%) In patients with non-ischemic cardiomyopathy, area with subepicardial fibrosis, even though non-transmural was also identified and discharged.
a) b) c) Scar Transmurality (%) d) Scar Map Transmural Scar Area Azienda Ospedaliera CARDIAC MRI Universitaria - Ferrara Roma 2015
IMAGING GROUP: IDENTIFICATION OF TARGET AREA STEP 2: 2D ST-Longitudinal strain bull s eye of timings, identification of the most delayed area between non-fibrotic segments
LONGITUDINAL ADVANTAGES OVER THE RADIAL: Timing (ms) 1.MORE REPRODUCIBLE 2.COMPREHENSIVE ASSESSMENT OF THE LV, (AND NOT ONLY OF THE MID-VENTRICLE PORTION) 3.POLAR PLOT MAPS WHICH ARE EASY TO INTERPRET, AVOIDING MEASUREMENTS AND FACILITATING THE COMMUNICATION BETWEEN THE CRT TEAM
IMAGING GROUP: IDENTIFICATION OF TARGET AREA STEP 3: The target area for LV lead position was then defined as the most delayed non-fibrotic area
Ischemic 23 (46%) 24 (48%) Baseline characteristics Imaging-guided Standard practice p value (n = 50) (n = 50) Age (years) 67.3 ± 9.7 65.6 ± 8.4 0.37 Gender (male/female) 37/13 38/12 1 NYHA class 0.19 II, n (%) 29 (58%) 25 (50%) III, n (%) 17 (34%) 24 (48%) IV, n (%) 4 (8%) 1 (2%) QRS duration (ms) 156 ± 24 154 ± 30 0.70 LBBB, n (%) 27 (54%) 26 (52%) 1 Etiology, n (%) 1 Non-ischemic 27 (54%) 26 (52%)
RESULTS IMAGING STANDARD
CRT RESPONSE 15-30% = RESPONDER 0-15% = NON- RESPONDER %ΔESV >30% = SUPER RESPONDER 6m ESV > baseline ESV = NEGATIVE RESPONDER
RESULTS IMAGING STANDARD
TARGET AREA TARGET AREA IS NOT STANDARD BUT IT IS IDEAL AND UNIQUE IN EVERY SINGLE PATIENT!!!
RESULTS WHEN LV LEAD POSITION IS MATCHED WITH TARGET AREA CRT RESPONSE IS HIGHER!!!
Case report:, 60 yrs Cardiologic history: Dilated cardiomyopathy, BBSn, NYHA III, EF 25% No lesion in coronary artery
ΔQRS= -30 msec PRE EF= 25% POST EF= 45%
STUDY LIMITATIONS Non randomized study Control group is retrospective Small sample size CMR limitations (claustrophobia, renal insufficiency, allergics) PROOF OF CONCEPT STUDY
Conclusions Mutlimodality Imaging is: Useful for characterization of myocardial substrate Important for planning implantation strategy Helpful for device setting Crucial for the improvement of response and prognosis
Heart Failure Electrophysiology CRT patient Cardiac Imaging
Traditional Approach to HF Patient HF Clinic EP lab implant Imaging
NEW Approach to HF Patient HF Clinic EP lab implant Imaging Follow up
Thanks!