CARDIAC RESYNCHRONIZATION THERAPY Jeffrey J. Shultz, MD Cardiac Electrophysiology Park Nicollet...
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Cardiac Resynchronization Therapy
Cardiac Resynchronization TherapyJeffrey J. Shultz, MDCardiac ElectrophysiologyPark Nicollet Heart and Vascular CenterCase: DK 69 y/o male2006 - Aortic valve replacement and CABG. (No h/o MI)LVEF remained approximately 45%LBBB (ECG to be shown)NYHA Class ICarvedilol 25 mg BID, Lisinopril 20 mg daily, HCTZ, Coumadin, ASA, Amlodipine, Lipitor2014 Episodic dyspnea, LVEF down to 35%Lasix and spironolactone addedJan 2015 - Progressive DOE, NYHA Class III, Stress test = inferior ischemia and LVEF=20%Feb 2015 Cor Angio = non-occlusive CAD. Rx = Med Mgmt.June 2015 Remains NYHA Class III, LVEF=30%, Referred for Bi-V ICD
DK 69 y/o male
Congestive Heart Failure - Magnitude of the ProblemEstimated 5.1 million in US / 23 million worldwide (2006)Exact numbers difficult due to varying inclusion criteriaSteep rise in incidence with age3-4-fold increase in hospitalizations from 1971-1999Increase in Mortality attributable to CHF from 5.8/1000 in 1970 to 16.4/1000 in 1993$32 billion spent on treatment of CHF in US / yearDeatHs due to coronary heart disease
NHLBI 2012Hospitalizations due to CHF
NHLBI 2012Age-related CHF Incidence(#/1000)
leMaleFemaleBleumink, et.al. EHJ 2004
1. Framingham Heart Study (1948 1988) in Atlas of Heart Diseases.2. American Heart Association. Heart Disease and Stroke Statistics2003 Update.
Systolic versus Diastolic CHFSystolic HF-REFImpaired contractility / ejectionLVEF 50%Approximately 1/3 CHF prevalenceCommon conditions HTN, elderly without HF-PEF, HCM, constrictive/ restrictive CMLimited therapeutic options
HF-pef vs hf-ref mortality
Brouwers et.al, EHJ 2013
1. The Criteria Committee of the New York Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, Mass: Little, Brown & Co; 1994:253-256
Weapons against Systolic CHFPrevention Education and management of CAD risk factorsAggressive treatment of UA/STEMI/Non-STEMIMedical therapy ACE-Is/ARBs, -blockers, aldosterone antagonists, diureticsDietary / Fluid restrictionsAggressive outpatient monitoring programsCardiac Resynchronization Therapy (CRT)What is Dyssynchony?3 types of dyssynchronyAV Delay between atrial and ventricular contraction (AV block)Interventricular Delay between right and left ventricular activation (LBBB)Intraventricular - normal ventricular activation sequence is disrupted, resulting in discoordinated contraction of the LV segmentsCRT can help with all threeLeft Bundle Branch Block- Currently best measure of left ventricular dyssynchrony- QRS duration > 120; preferably > 150 for CRT
HOW DO WE MEASURE DYSSYNCHRONY?CRT DevicesCRT-D Implantable Defibrillator capable of Bi-Ventricular Pacing (Most common)CDT-P Pacemaker capable of Bi-Ventricular Pacing (Has no ability to treat ventricular tachyarrhythmias)
Coronary venous anatomy
Pressure Products CSG Worley Sheath
Coronary venous anatomy
LV lead placement
Dong et.al; Europace 2012
CRT Indications - 2012Class 1 - LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration greater than or equal to 150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT.Class 2a LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT.LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS duration greater than or equal to 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT.Atrial fibrillation and LVEF less than or equal to 35% on GDMT if a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRTPatients on GDMT who have LVEF less than or equal to 35% and are undergoing new or replacement device placement with anticipated requirement for significant (>40%) ventricular pacing.
CRT Indications - 2012Class 2bLVEF less than or equal to 30%, ischemic etiology of heart failure, sinus rhythm, LBBB with a QRS duration of greater than or equal to 150 ms, and NYHA class I symptoms on GDMTLVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with QRS duration 120 to 149 ms, and NYHA class III/ambulatory class IV on GDMTLVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS duration greater than or equal to 150 ms, and NYHA class II symptoms on GDMTClass 3NYHA class I or II symptoms and non-LBBB pattern with QRS duration less than 150 msComorbidities and/or frailty limit survival with good functional capacity to less than 1 year.
REVERSE and RAFT (2012)REVERSE (REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction) and RAFT (Resynchronization/Defibrillation in Ambulatory Heart Failure) trials showed that Cardiac Resynchronization Therapy (CRT-D) reduced Heart Failure (HF) Hospitalization or All-Cause Death. Looked at patients with;NYHA Class IILeft Bundle Branch BlockLeft Ventricular Ejection Fraction 30% QRS duration 130 ms
REVerse and raft - results REVERSE: Reduction of Worsened Clinical Composite Responsefrom 18% with CRT OFF versus 5% with CRT ON (p = 0.004) (Figure 1) REVERSE: 73% reduction in Time to First HF Hospitalization or All-Cause Death with CRT (p = 0.004) (Figure 2) RAFT: 42% reduction in Time to First HF Hospitalization or All-Cause Death with CRT-D (p < 0.0001)
Reverse - results
Expanded CRT indications with reverse and raft31NYHA III/IV**NYHA IIQRS DurationProlongedLBBB***, QRS 130 msLVEF 35% 30%Optimal Medical TherapyYesYesApproved Device(s)CRT-P, CRT-DCRT-D onlyIn this slide, the one column shows the FDA-approved labeling that Medtronic (and other manufacturers) received for NYHA Functional Class III and Ambulatory Class IV patients. In comparison, the FDA-approved labeling for Medtronic CRT-D devices in the NYHA Class II patients requires a left bundle branch block, a QRS duration of greater than or equal to 130 ms, an ejection fraction of less than or equal to 30%, and optimal medical therapy. Note that the labeling is only for CRT-D and not CRT-P.
31Block HF trial 2013Objective: To determine if biventricular pacing with CRT is superior to right ventricular only pacing in patients with;Class I or IIa pacing indicationNYHA class I, II, or IIILVEF 300 msec with pacing at 100 BPMBlock hf - results
Updated recommendations - April 2014
AV block (prolonged 1st degree, 2nd or 3rd degree)NYHA Class I, II, III heart failureLVEF 50%Optimal medical therapy (OMT)DK 68 y/o maleUnder went implant of CRT-D on 6/17/15ECG to be shownSaw PMD on 7/21/15 Feel great! No dyspnea or DOE.Seen in Cardiology 9/2/15 NYHA Class I-IIEcho LVEF = 30% but LV chamber size noted to be smallerDK 69 y/o male
DK 68 y/o male post CRT-D
CRT RespondersApproximately 70% response rate30-40% will have objective improvement in LVEFCharacteristics of respondersLBBB with QRS duration > 150 msecQRS to LV pacing site > 110 msec100% LV pacingCommon causes for being a non-responderReduced LV pacing lead dislodgement, atrial fibrillation, PVCsPoor LV lead position anatomy, lead dislodgementProgramming issues suboptimal AV delay or V-V timing
Potential Implant ComplicationsBleeding / hematoma / bruisingInfectionCardiac perforationPneumothoraxLead dislodgementDiaphragm / Phrenic Nerve stimulationVenous thrombosisVascular injuryBrachial plexus injuryRenal failureArrhythmia inductionCVA / MI / DeathPhrenic Nerve Stimulation
Post-Op carePain reliefMonitor typical post-op vital signsMonitor wound intact, no bleeding, limited swelling at site or armMonitor for pneumothorax / pericardial effusion / tampanade sudden chest pain, dyspnea, hypotension, neck vein distentionWatch for loss of capture / change in pacing complex / over- and undersensingMonitor for Diaphragm pacingConclusionsCHF remains a major clinical problem and is responsible for significant CV mortality and repeat hospitalizationsCRT has proven to be a significant adjunct to CHF medical therapy resulting in improved in survival and decreased hospitalizationsCRT can be performed with high rate of success and low rate of complicationsApprox 70% will respond to CRT and LVEF will improve in approx 30-40%.Looking for better ways to identify dyssynchrony and target dyssynchronyLV lead positioning limited by anatomy, scar, diaphragm pacing