1

Optimization of AV and VV Delays

CRT Program

CRM Training and Education

12-09

3

Optimization of BiV Pacing

A-V Delay

V-V Delay

4

AV Delay Optimization

Ensure BiV pacing

Improve diastolic filling

Reduce mitral regurgitation

Cardiac Output

Goals

5

AV Delay Optimization

AV too long

Close to intrinsic PR (fusion)

Loss of CRT

AV too short

Premature mitral valve closure

Hemodynamic compromise

6

AV Delay Optimization

Pulse pressure

Empirical Calculation

Echocardiography

Methods

7

AV Delay Optimization

Pulse pressure

Empirical Calculation

Echocardiography

Methods

9

Pulse Pressure Method

Intrinsic BiV Paced

Auricchio et al., PACE 1998

P R

Aorta

LV

PEP

Time

Pressure

P Vp Time

Pressure

10

Pulse Pressure Method

BiV Pacing

AorticPressure(mmHg)

LV IEGM

Time (s) 0 1 2 3 4 5 6 7 8 9

60

85

110

11

AV Delay Optimization

Pulse pressure

Empirical Calculation

Echocardiography

Methods

15

AV Delay Optimization

Aortic Pressure

Auricchio et al., Circulation 1999

LV dP/dtmax

A-V Delay A-V Delay

BiV

LV

RV

-8

-4

0

4

8

12

16

0

PR - 30 ms

-12

-6

0

6

12

18

24

0 PR - 30 ms

16

AV Delay Optimization

Example for As-Vs = 220 ms

AVopt = (220-30)/2 = 95 ms

Calculation

Auricchio et al., Circulation 1999

2AVopt =

(PR interval) - 30 ms

18

AV Delay Optimization

Pulse pressure

Empirical Calculation

Echocardiography

Methods

19

AV Delay Optimization

Flow Velocity at Mitral Valve

Aortic Velocity Time Integral

Doppler Echocardiography

21

Apical 4-Chamber View

26

Mitral Valve Doppler Echo

SampleVolume

P

A

R

E

T

LV EjectionFilling

ECG

Doppler

27

Pulsed Wave Doppler Echo

4 Chamber View E/A Ratio

Mitral Valve

28

Pulsed Wave Doppler Echo

EA

FlowVelocity

(cm/s)

50 mm/s

ECG

29

AV Delay Optimization

Transmitral Flow Velocity LV filling pressure

E waveEarly diastolic passive filling

A waveLate diastolic active filling atrial contribution

Doppler Echo

31

Left Bundle Branch Block

Q T

A A

R1 R2 R1 R2

T

AE EE

P P P

A A A

32

LBBB: Late MV Closure

*IVC = Isovolumic Contraction

P Q T P

A A

R1 R2 R1 R2

IVC* A

P

IVC*

Aortic Valve Opening AVO

MVCMitral Valve Closure

33

LBBB: Late End of LV Systole

P Q T P

A A

R1 R2 R1 R2

IVC

AorticFlow

A

MVC

Aortic Valve Closure

P

LV Systole

AorticFlow

MVC

IVC

AVO

Ejection

34

LBBB: Late Start of LV Filling

* MVO = Mitral Valve Opening** IVR = Isovolumic Relaxation

P Q T P

A

R1 R2 R1 R2

Q T

IVC IVR*

AorticFlow

A

MVC MVO*

AVO AVC

P

AorticFlow

A

35

LBBB: Fusion of E and A

P Q T P

A A

R1 R2 R1 R2

Q T

A

P

E E

ShortLV

FillingTime

E

AorticFlow

AorticFlow

250 ms at HR 65/min

36

P Q T P

A A

R1 R2 R1 R2

Q T

IVC IVRA

MVC

P

E EE

AorticFlow

AorticFlow

Pre Ejection Period (PEP)

LBBB: Resynchronization

37

Biventricular Pacing

PT

P

A A

T

A

P

E EE

AVD

AorticFlow

AorticFlow

IVC IVC

BiV

Pro-longed

LV FillingTime

325 ms at HR 65/min

PEP

BiV BiV

MVC MVC

38

AV Optimization

Short AV Delay Long AV Delay

“Ritter Formula”

P

A

QA

A wave truncation

ForcedMVC

E

P

AE

SpontaneousMVC

QA

AV AV

39

AV Delay Optimization

Programmed AV Delays

AVshort = short AV (25% of PR)

AVlong = long AV (75% of PR)

Ritter Formula

Ritter et al., PACE 1995

AVopt = AVshort + [(AVlong - AVshort) - (QAshort - QAlong)]

"The Difference of the Differences"

Measured QA Intervals

QAshort = QA at short AV

QAlong = QA at long AV

40

Transmitral Flow

At short AV delay

AVshort = 50 ms

QAshort = 128 ms

128 ms

Begin Q

EA

41

Transmitral Flow

At long A-V delay

AVlong = 160 ms

QAlong = 48 ms

48 ms

Q

E A

42

AV Delay Optimization

Result

Programmed AV Delays

AVshort = 50 ms

AVlong = 160 ms

Measured QA Intervals

QAshort = 128 ms

QAlong = 48 ms

AVopt = AVshort + [(AVlong - AVshort) - (QAshort - QAlong)]

"The Difference of the Differences"

AVopt = 50 + [(160-50)-(128 - 48)]

= 50 + (110 - 80)

AVopt = 80 ms

43

AV Delay Optimization

Short AV Long AV Optimal AV

46

AV Delay Optimization

Flow Velocity at Mitral Valve

Aortic Velocity Time Integral

Doppler Echocardiography

47

Doppler Echo

Apical Five Chamber View

48

Doppler Echo

Aortic Flow Velocity

Kruck, Biamino 1988

49

Aortic Flow Velocity

LBBB

A A A

AorticFlow

AorticFlow

Velocity

Time

50

Aortic Flow Velocity

Biventricular Pacing

AE

AVD

AorticFlow

AorticFlow

Velocity

Time

51

Velocity Time Integral

Fehske 1988

Integral = Area under the curve

VTI =

AVO

AVC

V * dt

(cm)

53

AV Delay Optimization

Dr. Uhrig, Vivantes Urban Hospital Berlin

VTI = 12.7 cm VTI = 20.5 cm

Velocity Time Integral

54

VTI Method

Fehske 1988

Derived Parameters

Stroke VolumeSV = VTI * AVTI = Velocity Time

IntegralA = Aortic Valve Area

Cardiac OutputCO = SV * HRHR = Heart Rate

56

AV Delay Optimization

30 Pts. after CRT implantation NYHA III-IV, LVEF < 35%, SR

BiV on atrial sensed beats AV optimization on LV dp/dt max

Comparison to Ritter formula, diastolic filling time (DFT), LV VTI, E/A VTI

Jansen et al., Am J Cardiol 2006

57

LV dP/dt max

LVPressure(mmHg)

dP/dt(mmHg/s)

Jansen et al., Am J Cardiol 2006

58

Agreement with LV dP/dt max

Good Good to reasonable

%

Jansen et al., Am J Cardiol 2006

0

67

43

97

57

87

73

100

0

20

40

60

80

100

Ritter DFT LV VTI E/A VTI

59

AV Delay Optimization

Empirical Calculation

Echocardiography

Pulse pressure

Methods

60

AV Delay Optimization

Pulse pressure: hemodynamic testing

Calculation: initial programming

Doppler Echo: non-responders

Summary

61

Optimization of BiV Pacing

A-V Delay

V-V Delay

62

V-V Delay Optimization

LV first

AS

RVP

AV

LVP LVPRVP

VV VV

AV

RV first

AS

VV = 0

AS

RVP

AV

LVP

63

V-V Optimization

41 pts. with CHF after CRT-PM

AV delay optimization

RV-/LV pre-activation: 0, 12, 20, 40, 80 ms

Endpoints: Cardiac output, mitral regurgitation from echo

Bordachar et al., JACC 2004

64

V-V Optimization

Echocardiographic Parameters

M-mode: septal-to-posterior wall motion delay (SPWMD)

Doppler: Interventricular mechenical delay (IVMD)

Tissue Doppler:

Intra LV delay onset (LV onset)

Intra LV delay peak (LV peak)

SD from 12 segments intra LV delay peak (SDLV peak))

Delayed longitudinal contraction (DLC)

Bordachar et al., JACC 2004

65

V-V Optimization

Bordachar et al., JACC 2004

Parameter

Correlation to Hemodynamics

CardiacOutput

Mitral Regurgitation

LV peak

SD LV peak

LV onset

DLC

SPWMD

IVMD

-0.67

-0.67

-0.64

-0.48

-0.41

-0.24

0.68

0.68

0.63

0.51

0.24

0.06

67

41 CHF pts. with CRT-PM

V-V Optimization

No. of pts.

Bordachar et al., JACC 2004

0

2

4

6

8

10

8040200204080 12 12 ms

LV first RV first

68

166 DCM pts. with CRT (Doppler Echo)

V-V Optimization

0

20

40

60

LV first

80

RV first

40200204080

At Implant

3 months

No. of pts.

Delurgio et al., NASPE 2002

ms

69

V-V Optimization

van Gelder et al., Am J Cardiol 2004

AF SR ischemic SR non-ischemic

70

V-V Optimization

van Gelder et al., JCE 2008

dP/dtmax

Baseline VV=0 QuickOpt VVdP/dt

32 HF pts. with CRT, 20 CAD, SR, QRS 170 ms, EF 23%

71

Optimizing BiV Pacing

72

Optimizing BiV Pacing

I

V1

RV only LV only BiV BiV LVfirst

73

Optimizing V-V Delay

Start with standard setting

VV optimization in patients with persistent dyssynchrony

Trouble shooting option in clinical non-responders

Summary

74

Optimization of BiV Pacing

A-V Delay

V-V Delay