La stimulation biventriculaire (Traitement par Resynchronisation Cardiaque) Indications et Résultats, DIU, Paris 2007
CRT: Results and indications Background Results of CRT Studies Today s classical CRT indications Potential Role of ICD during CRT Particular Indications for CRT
The evolving perspective of HF HF Prevalence Will Double in 30 Years HF Prevalence in Western Europe (Millions) 12 10 8 Ageing population CAD management 6 4 2 5.3 10.6 0 2000 2010 2020 2030 Source: New Medicine Reports 1997 ; 1999 Heart and Stroke Statistical Update, AHA
HF patients die primarily from CV death (mortality by cause in control groups of selected HF trials*) non CV death 18.5% Consensus, Solvd T, Solvd P, Save, Aire, Trace, Rales, Ephesus, Cibis, US Carvedilol, Merit HF, Cibis II, Best, Capricorn, Copernicus, Comet all-cause mortality: 81.5% CV death Publications reporting all-cause mortality, CV death, SCD, death by progression of HF (N= 20 728 pts, control groups, 16 studies)
Care-HF pts also die primarily from CV death non CV death 46/255 (18.1%) Unclassifiable 12/255 (4.7%) CV Death: 197/255 (77.2%)
SCD is the leading cause of CV death (mortality by cause in control groups of selected HF trials*) Other CV death Consensus, Solvd T, Solvd P, Save, Aire, Trace, Rales, Ephesus, Cibis, US Carvedilol, Merit HF, Cibis II, Best, Capricorn, Copernicus, Comet HF Progression 36% Sudden Cardiac Death 42% Publications reporting all-cause mortality, CV death, SCD, death by progression of HF (N= 20 728 pts, control groups, 16 studies)
Functional abnormalities in isolated LBBB LBBB Normal Radionuclide images showing the onset of RV and LV contraction Grines, Circulation 1989
Functional abnormalities in Isolated LBBB IVCT IVRT Grines, Circulation 1989
Rationale for CRT: Abnormal LV segmental contraction
CRT system implantation
CRT-D System Implantation (Right Side) AP view LAO view
Mechanisms of benefit during CRT Systolic function ( increase in CO) Coordination in LV contraction Shorter LV contraction duration Diastolic function Longer LV filling duration Decrease in Mitral regurgitation Effects on neurohormones, Remodelling...
CRT Improves LV Function Without Oxidative Stress MVO2/HR (Relative Units) 0,24 0,22 0,20 0,18 0,16 0,14 P<0.05 Dobutamine LV Pacing 500 600 700 800 900 dp/dt max (mm/hg/s) Nelson et al. Circulation 2000 n=7 Nowak. JACC 2003
Mechanisms of CRT Decrease in Mitral Regurgitation
CRT: Results and indications Background Results of CRT Studies Today s classical CRT indications Potential Role of ICD during CRT Particular indications for CRT
What we know from morbi-mortality trials Cumulative Enrollment in CRT Trials Cumulative Patients 4000 3000 2000 1000 0 Open Studies CARE HF MIRACLE ICD MIRACLE MUSTIC AF MIRACLE ICD II MUSTIC SR COMPANION PATH CHF PATH CHF II CONTAK CD 1999 2000 2001 2002 2003 2004 2005 Results Presented
Outcomes and Follow-up of CRT patients Randomized Controlled Trials on CRT Study (n randomized) MIRACLE (453) MUSTIC SR (58) MUSTIC AF (43) PATH CHF (41) MIRACLE ICD (369) CONTAK CD (490) COMPANION (1520) PATH CHF II (89) MIRACLE ICD II (186) CARE HF (814) NYHA III, IV III, IV 120 Normal No Published + Exercise III, IV 130 Capacity: Normal 6 Yes MW, Published Peak VO2 + LV II-IVfunction: 120 Normal EF, MR Yes Published + Reverse III, IV 120 remodeling: Normal NoLV Published EDV, ESV + III, IV 120 Normal Both Published + III, IV QRS 130 III >150 Normal NYHA III >200* Class, AF 120 Sinus CRT Improves: Normal Normal Normal ICD? No No No Yes No Status Published Published Published Quality of life score (MLWHF), Hospitalization, II 130 Mortality Published Published Results + + + + + LVEF 35% for all trials * RV paced QRS
CRT Improves Exercise Capacity Average Change in 6 Minute Walk Distance Average Change in Peak VO 2 m 60 40 20 0-20 -40 MIRACLE * MUSTIC SR * CONTAK CD * MIRACLE ICD ml/kg/min 3 2 1 0 MIRACLE * MUSTIC SR * CONTAK CD * * 0 MIRACLE ICD Control CRT Control CRT Abraham et al., 2003 * P < 0.05
6 Min. WT: + 13/20% QoL (MLWHF): + 30% NYHA: - 0.5/0.8 NO CRT CRT Miracle ICD
Comparison with Drug Trials: Digoxin, ACE-I and Beta-blocker Therapies Change from baseline in 6 minute walk distance Change from baseline in CPX Duration Change from baseline in QoL (MLWHF) Score 40 90 * 5 meters 30 20 10 0-10 -20-30 Dig (1) * BB (2) CRT (6) seconds 60 30 0-30 * Dig (1) Control ACE (3) CRT (6) Treatment Improvement score 0-5 -10-15 -20 ACE (4) NS BB (5) CRT (6) * P.05 P.01 P.001 1 NEJM 1993;329:1-7 (RADIANCE) 2 Circulation 1996;94:2793-2799 (PRECISE) 3 JAMA 1988;259:539-544 4 Am J Cardiol 1993;71:1106-1107 (SOLVD Treatment) 5 J Cardiac Failure 1997;3:173-179 6 NEJM 2002;346:1845-53 (MIRACLE)
Effects of CRT on Hospitalization Rate MUSTIC Monthly rate of hospitalisations for CHF (Randomisation to M 12) MIRACLE Total Days Hospitalized for Heart Failure 0,14 0,12 0,10 0,08 0,06 0,04 0,02 0 / 7 CR - CR + 363 Control N=225 77% p = 0.012 83 CRT N=228
Euro 10 000 9 000 8 000 7 000 6 000 5 000 4 000 3 000 2 000 1 000 0 Karolinska Study Hospital costs per patient 9 301 before implant Differenz: 7.647 1 654 after implant Costs for CRT: 8.019/Patient. Costs for the device balance the saved money within one year. Braunschweig F. Eur J Heart Failure 2:399-406 (2000)
COMPANION: Primary Endpoint All cause Mortality + Hospitalization Bristow et al. NEJM. 2004; 350: 2140-50 Companion reinforces previous results of CRT trials
COMPANION : Mortality and HF hospitalization Death: 24% Hosp: 76%
Cardiac Resynchronisation in Heart Failure: CARE-HF Baseline Evaluation Randomization (1:1) OMT CRT (CRT+OMT) Minimum 18 Month Follow-up 813 patients, 82 centers,12 countries, FU: 29.4 M NYHA class III/IV, LVSD: EF 35%; EDD > 30mm/hm QRS 150 ms or Echo if QRS 120-149 ms Primary composite endpoint: All-cause mortality or unplanned hosp. for a major CVS event (time to first event analysis, Hosp adjudicated by a blinded EP committee)
Care-HF: Baseline Characteristics Age [yr] - median (IQR) Male (%) NYHA IV (%) Ischaemic heart disease (%) Treatment (%) ACEIs / ARBs Beta blockers Furosemide Eq 80 mg/day Digitalis Spironolactone Control n = 404 66 (59 to 72) 293 (73%) 27 (6.7%) 142 (35%) 383 (95%) 298 (73%) 177 (44%) 181 (45%) 238 (59%) CRT n = 409 67 (60 to 73) 304 (74%) 23 (5.6%) 167 (41%) 387 (95%) 288 (71%) 175 (43%) 165 (40%) 219 (54%)
SAE Groupings Care-HF: Serious Adverse Events Patients with Procedure or device related Adverse Event (Assessed by Independent Expert) Procedure related death Lead problems Coronary sinus dissection Pocket complications Patients with Other Serious Adverse Events (Investigator Reported) Myocardial Isch & MI Worsening HF Atrial arrhythmia Ventricular arrhythmia Respiratory infection AVB or bradycardia Control 1 6 0 1 84 263 41 54 101 27 CRT 1 27 12 9 70 191 64 58 85 17 P value P = 0.99 P < 0.001 P < 0.001 P = 0.012 P = 0.21 P < 0.0001 P = 0.02 P = 0.74 P = 0.15 P = 0.12
CARE-HF: Improved NYHA, QoL, LVEF Euro Qualit of Life Score NYHA Class 0,8 0,70 0,6 0,4 0,2 Daniel 0,0 Gras NYHA Class at 90 days p<0.001 3,0 2,5 2,1 2,0 1,5 1,0 0,5 0,0 2,7 Euro QoL Score at 90 days p<0.001 0,63 CRT Control 0,35 0,3 0,25 0,2 0,15 0,1 0,05 0 Mean LVEF at 18 Months p<0.001 31,9% CRT 25,0% Control Patients in the CRT group had a lower NYHA class and a higher Euro Quality of Life score at 90 days. Mean LV ejection fraction was higher on average in the CRT group compared with the medical therapy alone group. Cleland et al. New England Journal of Medicine. 2005; 352: 1539-49
Care-HF: Changes in LVES volume & LVEF Volume (ml) 250 210 170 241 233 233 194 221 164 202 149 Ejection Fraction (%) 40 30 20 10 26 25 27 30 28 34 30 36 130 Baseline 3 months P<0.0001 18 months P<0.0001 29 months P<0.0001 0 Baseline 3 months P<0.0001 18 months P<0.0001 29 months P<0.0001 Control Group CRT Group Control Group CRT Group LV End-Systolic Volumes LV ejection Fraction
Changes in IVMD (ms) and MRI in Care HF Time (ms) 50 40 30 49 50 48 47 28 28 49 29 LA area index (%) 20 10 24 23 23 23 21 19 19 19 20 Baseline 3 months P<0.0001 18 months P<0.0001 29 months P<0.0001 0 Baseline 3 months P<0.0001 18 months P=0.004 29 months P=0.015 Control Group CRT Group Control Group CRT Group Interventricular Mechanical Delay Mitral Regurgitation index
CARE-HF: Primary endpoint All-cause Mortality or Unplanned Hosp. for Major CVS Event Event-free Survival 1.00 0.75 0.50 0.25 No statistical significant heterogeneity in subgroups HR 0.63 (95% CI 0.51 to 0.77) Death : 20% Hospitalizations : 80% CRT P <.0001 Medical Tx 0.00 Number at risk CRT Medical Tx 0 500 1000 1500 409 323 273 166 68 7 404 292 232 118 48 3 Days Cleland. N Engl J Med. 2005;352
Care-HF: All-Cause Mortality Event-free Survival 1.00 0.75 0.50 0.25 HR 0.64 (95% CI 0.48 to 0.85) CRT (20%) P =.0019 Medical Therapy (29.7%) 0.00 Number at risk CRT Medical Therapy 0 500 1000 1500 409 376 351 213 89 8 404 365 321 192 71 5 Days
CRT impacts on Mortality & Hospitalization rates 100 Survival 10 Annual survival (%) 75 50 25 CRT Hospitalization 1 Hospitalizations / year 0 I II III IV NYHA CLASS.1
Care-HF extension phase Cross Over Control Group (n= 404) Main Study 19 prior to Primary EP (5%) 50 in total (12.4%) Extension Phase 45 (11.1%) One lost to follow-up Total 95 (23.5%) Implant Failures CRT Group (n = 409) Main Study 19 (4.6%) Extension Phase None Total 19 (4.6%)
CARE-HF Extension Study Effect of CRT on All-Cause Mortality 1.00 Hazard Ratio 0.60 (95% CI 0.47 to 0.77; P<0.0001) 0.75 CRT Survival 0.50 Mean Follow-up Medical Therapy Number at risk 0.25 CRT Medical therapy Mean Follow-up 36.4 months (range 26.1 to 52.6) CRT Deaths = 101 (24.7%) Medical Therapy Deaths = 154 (38.1%) 0.00 0 400 800 1200 1600 Time (days) 409 383 358 338 209 85 404 372 331 298 178 63 9 6
CARE-HF Extension Study Time to Death from Worsening Heart Failure 1.00 Survival 0.75 0.50 Hazard Ratio 0.55 (95% CI 0.37 to 0.82; P=0.003) CRT Medical Therapy 0.25 0.00 CRT = 38 HF deaths (9.3%) Medical Therapy = 64 HF deaths (15.8%) 0 400 800 1200 1600 Time (days)
CARE-HF Extension Study Time to Sudden Death 1.00 CRT Survival 0.75 0.50 Hazard Ratio 0.54 (95% CI 0.35 to 0.84; P=0.006) Medical Therapy 0.25 0.00 CRT = 32 sudden deaths (7.8%) Medical Therapy = 54 sudden deaths (13.4%) 0 400 800 1200 1600 Time (days)
CRT: Results and indications Background Results of CRT Studies Today s classical CRT indications Potential Role of ICD during CRT Particular indications for CRT
CRT in Clinical Practice ACC/AHA; HFSA; CCS; ESC Guidelines 2005 CRT: Indication Class I, Level A
Impact of CRT on PCWP Start pacing Stop pacing pcw Hemodynamics of CRT: beat-to-beat reduction of pcw and v-wave
Acute hemodynamic evaluation is not necessary Acute hemodynamic changes do not correlate with long term effect of CRT Mitral regurgitation (%) 40 35 30 25 20 15 10 MR LVEF LV volumes Ejection fraction (%) 45 40 35 30 220 200 180 160 140 120 5 25 100 0 Yu Circulation 2002 Baseline 1 w k 1 mo 3 mo off-imm 20 off-1w k off-4w k 80 Left ventricular volume (m baseline 1 wk 1mo 3 mo off-imm off-1wk off-4wk Immediate effect Delayed effect baseline 1 w k 1 mo 3 mo off-imm off-1w k off-4w k
CRT provides LV reverse remodeling effect Sogaard P, et al; J Am Coll Cardiol 2002
Today s classical CRT indications 1. Cardiomyopathy (Ischemic or not): EF<35%, EDD>55 mm 2. NYHA functional class III/IV 3. OMT (6 weeks) : ACEI, Diur., Bb., Spiron. 4. Ventricular Asynchrony QRS > 150 ms QRS < 150 ms: Echo criteria (Care-HF) 1. Aortic Pre-ejection delay > 140 ms 2. Interventricular mechanical delay > 40 ms 3. LV segmental post systolic contraction + 4. Intra LV asynchrony + 5. AV asynchrony
Patient selection for CRT Echo parameters consideration (Q to Pulmonary Ejection = 120 ms) (Q to Aortic Ejection = 230 ms) ( 1 ) Prolonged aortic pre-ejection delay ( 2 ) Interventricular Mechanical Delay = 110 ms
Patient selection for CRT Echo Parameters Under Consideration QRS-LLW: 590 ms QRS-E: 530 ms OVERLAP (3) LV late systolic contraction
Echocardiographic criteria to select pts for CRT S E S A Just prove it!! DESIRE and PROSPECT trials E A Courtesy of G Habib
Mr Seg, 63 years, DCM, NYHA Class III
Me Seg, 63 ans, CMD
1. AV Dyssynchrony : LVFT < 40% Cardiac Cycle DFT at Baseline: 280 ms DFT during CRT: 400 ms
Clinical Case: LVEF: 25%, SR, LBBB (QRS 160 ms), NYHA III/OMT
Complex forms of ventricular asynchrony Advanced CRT: RV septal, Dual-site LV pacing
CRT & reduced RV function: Interaction at 18 M 0 LVESV Control CRT 302/40 291/53 LVEF P=0.003 15 from baseline (cm 3 ) -20-40 -60-80 -14,4-52,1-76,4-41,7 2,1 4,9 10,3 4,0 10 5 from baseline (%) -100 TAPSE >14 mm P=0.002 TAPSE 14 mm 302/40 291/53 Control CRT 0 TAPSE: Tricuspid Annular plane systolic excursion
Dual site RV Pacing to optimize CRT
Typical non responder to CRT: 84 Yo, ICM, NYHA IV, RV dysfunction
CRT: Results and indications Background Results of CRT Studies Today s classical CRT indications Potential Role of ICD during CRT Particular indications for CRT
ESC Guidelines 2005 1 Indications for ICD in HF Previous Cardiac Arrest, SVT: I, A ICM, LVEF < 30-35%, after 40 days of MI: I, A NYHA III-IV, LVEF < 35%, QRS > 120 ms: IIa, B 1.European Heart Journal 2005;26:115-1140 2.Madit 1 & 2: Moss NEJM 1996, 2002 3.Definite: Kadish NEJM 2004 4. Salukhe Circulation 2004 5. Desai Jama 2004 6. SCDHefT: Bardy NEJM 2005
MADIT II Survival Results ICM + LVEF < 30% 1.0 Probability of Survival 0.9 0.8 0.7 0.6 P = 0.007 Conventional Defibrillator 0.0 0 1 2 3 4 No. At Risk Year Defibrillator 742 502 (0.91) 274 (0.94) 110 (0.78) 9 Conventional 490 329 (0.90) 170 (0.78) 65 (0.69) 3 Moss AJ. N Engl J Med. 2002;346:877-83.
International Perspective of the evolving Role of CRT Sudden Cardiac Death despite CRT 40 30 20 10 0 36 35 COMPANION CRT-P arm CARE-HF Sudden death as % of total mortality Sudden deaths account for ~35% of mortality in CRT-P
Time to SCD in Care HF and Companion 1.00 CRT Survival 0.75 0.50 Hazard Ratio 0.54 (95% CI 0.35 to 0.84; P=0.006) Medical Therapy 0.25 0.00 CRT = 32 sudden deaths (7.8%) Medical Therapy = 54 sudden deaths (13.4%) 0 400 800 1200 1600 Time (days)
CARE-HF, COMPANION, SCD-HeFT: Mode of Death OPT CRT-P CRT-D ICD CARE-HF (29.4mth) COMPANION (16.6mth) SCD-HeFT (45.5mth) Mortality 16,0% 14,0% 12,0% 10,0% 8,0% 6,0% 4,0% 2,0% 0,0% 9,4% 7,1% SCD 13,9% 8,1% 7,8% PUMP FAILURE 5,8% 2,9% SCD 11,0% 8,6% 8,7% PUMP FAILURE 11,6% SCD 4,6% 7,8% 8,7% PUMP FAILURE Cause of death JM Cleland JGF. N Engl J Med. 2005;352:1539-49. Bristow MR. N Engl J Med. 2004;350:2140-50. Bardy GH. N Engl J Med. 2005;352:225-237. Packer DL. Heart Rhythm 2005. May;2 (1suppl):AB20-2.
Strategy to reduce mortality in HF pts treated by CRT 1 Year Mortality ACE-I, Beta-blockade, ACE-I Spironolactone & Beta Blockade Reduce Mortality 16% 12% 8% 4% 0% Reduce mortality 15,6% 12,4% 11,5% 7,8% SOLVD-T MERIT-HF + CIBIS II Placebo Adapted from McMurray JJV; Heart 1999 Treatment Further reduction expected from CRT/ICD in selected HF patients Further Reduction with CRT + ICD for Higher Risk Patients HF Mortality Sudden Cardiac Death CRT ICD Care-HF Madit, Companion, SCD-HeFT With respect to «clinical» contra indication to ICD
«Clinical» Contra-Indication to ICD in HF Pts Physiological: Age > 80-85, Psychological pbs... Class IV + other disease Advanced RV dysfunction, High PVR Comorbidities Renal dysfunction: creatinine clearance < 30 ml/mn Severe liver impairment Advanced other disease (diabetes )
Effect of Starting Age and Device Longevity on Cost per QALY Base case Incremental Cost Per QALY Gained 80,000 70,000 5 Years 60,000 50,000 40,000 8 Years 30,000 20,000 10,000 0 55 60 65 70 75 Age at Starting Treatment 7 Years CRT-D vs CRT-P CRT-D vs MT CRT-P vs MT Freemantle, ESC 2006 CRT+MT vs MT CRT+ICD+MT vs CRT + MT CRT+ICD+MT vs MT
CRT: Results and indications Background Results of CRT Studies Today s classical CRT indications Potential Role of ICD during CRT Particular indications for CRT
Patient selection for CRT: particular cases 1. Origin of the DCM: impact in clinical outcome? 2. NYHA class II: candidates for CRT? 3. Is long QRS duration required for CRT? 4. RBBB versus LBBB outcome? 5. Do patients with Chronic AF benefit from CRT? 6. Role of CRT in candidates for cardiac pacing?
Patient selection for CRT: particular cases 1. Origin of the DCM: impact in clinical outcome? YES 40 20-20 -40-60 -80 ml 0 Left Ventricular End Diastolic Volume 2,5-16,6 6,6 0 0,5 1 1,5 2 2,5 P=0.016 Ischemic P<0.001 P<0.001 Non-Ischemic Control 106 77 CRT 99 98-46,7 Impact of CRT in ischemic versus non ischemic pts
Interaction Between CRT & Ischemic Etiology from baseline (cm 3 ) 0-20 -40-60 -80-100 Control LVESV CRT -6,9-26,4-49,0-84,4 P=0.01 LVEF P=0.003 11,2 6,0 2,9 1,5 Control CRT 15 10 5 0 from baseline (%) Non-ischemic etiology Ischemic etiology
Possible Reasons for Failure of CRT: ICM CRT-D combined to optimal revascularization
MIRACLE ICD II Study 6 Min Walk, QoL, NYHA (Circulation 2004) m 450 400 350 300 Distance Walked in 6 Minutes Base P=0.59 6 Mo 50 40 30 20 10 Quality of Life Score (MLWHF) Base P=0.49 6 Mo Proportion of Patients NYHA Class at 6 Months 70% P=0.05 60% 50% 40% 30% 20% 10% 0% I II III IV Control (n=96) CRT (n=81) Control (n=98) CRT (n=82)
MIRACLE ICD II Study Improvements in Cardiac Volumes and Dimension suggest that CRT Improves Cardiac Function and Structure cm 3 400 350 Left Ventricular End Diastolic Diameter P=0.04 cm 3 400 350 Left Ventricular End Systolic Diameter P=0.01 % 30 28 Left Ventricular Ejection Fraction P=0.02 300 300 26 24 250 250 22 200 Base 6 Mo 200 Base 6 Mo 20 Base 6 Mo Control (n=85) CRT (n=69) Abraham, Circulation 2004
Recommendations for CRT are based on the results of controlled trials: 158 < QRS < 176 Study (n) NYHA QRS Rhythm Results MUSTIC SR (58) III >150 Sinus + MUSTIC AF (43) III >200* AF + MIRACLE (453) III, IV 130 Sinus + PATH CHF (41) III, IV 120 Sinus + MIRACLE ICD (369) III-IV 130 Sinus + CONTAK CD (227) II-IV 120 Sinus + MIRACLE ICD II (186) II 130 Sinus + PATH CHF II (89) III, IV 120 Sinus + COMPANION (1520) III, IV 120 Sinus + CARE HF (814) III, IV 120 Sinus +
Patient selection for CRT: particular cases 4. RBBB versus LBBB LBBB aspect Common finding in DCM Conduction disturbances at distal Purkinje system RBBB aspect 1. and «hemifascicular LBBB» aspect (left axis deviation) 2. and severe RV dilatation/dysfunction
Patient selection for CRT 5. Role of CRT in AF Pts: Mustic trial ml/kg/min 18.0 17.0 16.0 15.0 14.0 13.0 12.0 12.7 = + 12.9 % p = 0.04 12.8 15.7 13.0 12.2 13.9 13.8 BiV-RV RV-BiV 11.0 10.0 Baseline Rando CO1 CO2 Results Baseline 1 Year 2 Year Heart Rate 75±15 76 ± 7 71 ± 12 NYHA 3 ± 0 2.2 ± 0.5 2.2 ± 0.5 6MWT 325 ± 82 370 ± 87 362 ± 99 Peak VO2 13 ± 4 14 ± 3.5 NA QOL 45 ± 23 31 ± 17 32 ± 20 LVEF (%) 26 ± 7.7 30 ± 8 NA
Patient Selection for CRT: Particular Cases LV Function Changes in MUSTIC AF Patients Rand n=67 BIV-CO n=48 BIV 9M n=45 BIV 12M n=43 LVEDD (mm) 74±10 69±11*** 68±10*** 67±12*** LVESD (mm) 63±10 58±12*** 56±11*** 57±12*** MR area (cm 2 ) 7.8±7.8 5.6±8.3 4.9±4.6** 4.3±4.0** DFT (ms) 375±136 430±137* 471±154** 425±129*
PAVE trial (Post AV nodal ablation Evaluation study) «Ablate and pace» for AF, NYHA I-III, 6min HWT<450m, Mean QRS ~ 100ms, LVEF ~ 45% m 100 75 50 25 Change in 6-min HWT P=0.03 LVEF (%) 50 40 30 Change in LVEF P=0.03 0 6 weeks 6 months 20 Preimplant 6 months RV (n= 106) BV (n=146) Doshi, ACC 2004
Impact of CRT in Patients with AF Gasparini JACC 2006
Patient selection for CRT: particular cases 6. CRT in candidates for cardiac pacing? On evaluation CRT in PM pts N QRS (ms) NYHA Peak VO2 (ml/min/kg) QOL LVEF (%) Leclercq 1 20 Leon 2 23 NA Bakker 3 60 NA 1. Compare 2. Prevent 3. Combat 4. Block-HF 5. X-Change HF 1- C. Leclercq. Am Heart J 2000;140:862-70 2- A. Leon. J Am Coll Cardiol 2002;39:1258-63 3- C. Bakker. PACE 2002;25:1166-71
CRT: Results and indications (Conclusions) Cardiac asynchrony is deleterious on hemodynamics CRT improves: NYHA Class, QOL score, Exercise Capacity (6MW, Peak VO2), LV function (EF, MR), Reverse Remodeling, Hospitalization, Mortality Classical CRT indications: Drug refractory NYHA III-IV, SR, QRS > 120 ms CM (ischemic or not): EF < 35%, EDD > 55 mm Additional CRT indications Chronic AF, Classical PM indications (Biopace) Future: NYHA II (Predict, Raft, Madit CRT), Investigation of Asynchrony at Echo (Desire, Prospect)