Insuffisance cardiaque et resynchronisationpeut-on mieux faire?

C. LeclercqService de Cardiologie

Centre Cardio-Pneumologique Rennes

Quelles sont les indications de reynchronisation cardiaque?

Eur Heart J 2013; 34: 2281-2329

CRT: NYHA class II, III and ambulatory NYHA class IV and SR

LBBB / Non-LBBB

Eur Heart J 2013; 34: 2281-2329

CRT: NYHA class II, III and ambulatory NYHA class IV and SR

Eur Heart J 2013; 34: 2281-2329

CRT: NYHA class II, III and ambulatory NYHA class IV and SR

Eur Heart J 2013; 34: 2281-2329

Indication for CRT in patients with permanent AF

Class Level

1) Patients with HF, wide QRS and reduced LVEF:

1A) should be considered in chronic HF patients, intrinsic QRS ≥120 ms and LVEF ≤35% who remain in NYHA functional class III and ambulatory IV despite adequate medical treatment (d), provided that a biventricular pacing as close to 100% as possible can be achieved

IIa B

1B) AV junction ablation should be added in case of incomplete biventricular pacing

IIa B

2) Patients with uncontrolled heart rate who are candidates for AV junction ablation. CRT should be considered in patients with reduced LVEF who are candidates for AV junction ablation for rate control.

IIa B

Eur Heart J 2013; 34: 2281-2329

Heart Rhythm 2012;9:1524 –76

is the non response related to a reversible cause ?

• Myocardial ischemia?

• Valvulopathy (AS?)

• COPD?

• Anemia?

• Observance of tt

• Salt excess

• …

• Improvement in patient’s selection?– Avoiding pts with high potential of NR

• COPD++, RV dysfunction with PH, large scar without viability

– Selection of the best patients (NICM, wide QRS, LBBB…)

• Optimization of the LV lead location and pacing programming

• Optimization of medical treatment

• Improvement in optimization of device’s programming

• Remote monitoring

How to increase the rate of responders?

Eur Heart J 2013; 34: 2281-2329

QRS width• COMPANION: •

• CARE-HF:

• Reverse

• Madit-CRT

• RAFT

Zareba. Circulation 2011; 123: 1061-72

Importance of conduction disorders

• QRS duration > 140 ms (men) or 130 ms (women), • QS or rS in leads V1 and V2, • Mid-QRS notching or slurring in 2 of leads V1, V2, V5, V6, I, and aVL.

Redefining the LBBB definition

Strauss. Am j cardiol 2011; 107: 927-34

• Improvement in patient’s selection?– Avoiding pts with high potential of NR

• COPD++, RV dysfunction with PH, large scar without viability

– Selection of the best patients (NICM, wide QRS, LBBB…)

• Optimization of the LV lead location and pacing programming

• Optimization of medical treatment

• Improvement in optimization of device’s programming

• Remote monitoring

How to increase the rate of responders?

Apical versus Non-apical position

Overall population

Apical versus Non-apical position

LBBB population

Location of the LV lead

Singh. Circulation 2011; 123: 1159-1166

Eur Heart J 2013; 34: 2281-2329

LV lead and latest LV activation

Kahn. J Am Coll Cardiol 2012; 59: 1509-18

Eur Heart J 2013; 34: 2281-2329

Baseline

1 ms

150 ms

Dysycnchronous LV

Dysycnchronous LV

LV lead 2LV lead 2

LV lead 2

RV leadRV lead

LV lead 1

RV leadRV lead

LV lead 1LV lead 1

LV lead 3LV lead 3

LV lead 3

RV leadRV lead

Courtesy: P. Ritter

Variable RV and LV Activation in LBBB

Total Ventricular Activation Time: 205 msec RV Activation Time: 130 msecLV Activation Time: 145 msec

LAO 60°LAO 60°

Total Ventricular Activation Time: 157 msec RV Activation Time: 57 msecLV Activation Time: 105 msec

Total Ventricular Activation Time: 189 msec RV Activation Time: 85 msecLV Activation Time: 137 msec

Courtesy: Angelo Auricchio

Hemodynamic improvement with MPP?

Optimization of pacing modalities

Hemodynamic improvement with MPP?

BiV with apical pacing LV

Hemodynamic improvement with MPP?

BiV with basal LV pacing

Hemodynamic improvement with MPP?

BiV with MPP LV pacing

• Improvement in patient’s selection?– Avoiding pts with high potential of NR

• COPD++, RV dysfunction with PH, large scar without viability

– Selection of the best patients (NICM, wide QRS, LBBB…)

• Optimization of the LV lead location and pacing programming

• Optimization of medical treatment

• Improvement in optimization of device’s programming

• Remote monitoring

How to increase the rate of responders?

Medical treatment

Altman. Eur Heart J 2012;33: 2181-8

• Improvement in patient’s selection?– Avoiding pts with high potential of NR

• COPD++, RV dysfunction with PH, large scar without viability

– Selection of the best patients (NICM, wide QRS, LBBB…)

• Optimization of the LV lead location and pacing programming

• Optimization of medical treatment

• Improvement in optimization of device’s programming

• Remote monitoring

How to increase the rate of responders?

Importance of BiV pacing rate

Hayes D, et al. Heart Rhythm 2011;8:1469 –1475

Survival

Hayes D, et al. Heart Rhythm 2011;8:1469 –1475

AFib

No AFib

Atrial arrhythmias • Atrial arrhythmias are commonly observed in

patients with severe heart failure • Major hemodynamic consequences in CRT patients

due to the loss of atrial contribution to cardiac output and loss of biventricular capture in case of ventricular rapid rate

Arrythmias• Loss of biventricular capture due to

– Atrial arrhythmias • Specific algorithm to overdrive • Consider AV node ablation

Importance of AV node ablation

Upper rate programming

• Some CRT patients have normal SR and AV conduction with during exercise rapid atrial rate

• Programming a too low maximal tracking rate may result in pacemaker Wenckebach or 2:1 with the loss of biventricular capture

• MTR: 70% of (220 – age) bpm and not nominal 120 bpm!!

Exercise test in a CRT patient (I)

Exercise test in a CRT patient (II)

Europace (2009) 11, 931–936

Importance of LV auto-capture

Chronotropic incompetence

CO = HR X SV

Lack of increase in HR will result in HF pts with reduced LVEF in a lack of increase in CO at exercise

Assessment of the profile of HR during exercise is of major importance

If chronotropic incompetence: program the rate response algorithm

Importance of the exercise test

• Usually the device programming is performed at rest, but the assessment of the functioning of the device should be performed also systematically during exercise

• Reasons of disappearance of biventricular capture:

- loss of atrial sensing

- frequent PVCs

- Atrial tachyarrhythmias

- NSVT or SVT

- Spontaneous AV conduction more rapid than the programmed AV delay….

Importance of the exercise testInadequate AV delay

Shorten AV delay

Causes of non response

Mullens. J Am Coll Cardiol 2009; 53: 675-73

Which method to optimize AV delay?

• No optimization : nominal setting (100-150 ms)• Invasive hemodynamic method (dP/dt)• Echocardiographic methods• Finger Plethysmography• Impedance cardiography• Acoustic cardiography• Device-based algorithms• …

Manufacturer SAV (ms)

PAV (ms) Adaptive AV(min. SAV)

VV (ms)

Biotronik Lumax 540 HF

120 150 On 5

Boston ScientificCognis

120 180 Off 0

Medtronic Concerto

100 130 On (70) 0

SorinParadym CRT

125 190 On (80) 0

SJMUnify

150 200 On (100) 0

Long AV delay

(E and A fusion)

Decrease by 20 ms steps

Too short: truncated A-vawe

Optimal AV delayLV filling > 40% RR cycle

The iterative method

DEVICE-BASED methods @ a glance …DEVICE-BASED methods @ a glance …QuickOptQuickOpt

(SJM)(SJM)SmartDelaySmartDelay

(BSC)(BSC)AdaptivCRTAdaptivCRT

(MDT)(MDT)SonRSonR

(Sorin)(Sorin)

Based on IEGMs measures IEGMs measures IEGMs measures Hemodynamic sensor(= contractility)

AVD optimiz. Only @ REST;Paced & sensed

Only @ REST;Paced & sensed

Only @ REST;Paced & sensed

@ REST & under EFFORT;Paced & sensed

VVD optimiz. OK OK OK (LV synchro or BiV)

OK

In-clinic (@ FU) vs Ambulatory (Automatic)

In-clinic In-clinic Ambulatory (every minute)

In-clinic + Ambulatory (Weekly)

Outcomes from trials: SAFETY

OK OK OK OK

Outcomes from trials: EFFICACY

AV & VV opt @ FU visits NOT INFERIOR to clinical practice (0 or 1 echo) clinically @ 1Y (FREEDOM)

AV opt @ FU visits EQUIVALENT to ECHO-guided or Empiric programming, structurally & functionally @ 6M (SMART-AV)

Adaptive-CRT approach isNON-INFERIOR to Echo-optimized BiV, clinically @ 6M (Adaptive-CRT)

AV (weekly) & VV (@ FU visits) optimization by SonR is SUPERIOR to clinical practice, clinically @ 1Y (CLEAR pilot)

Follow-upPatient/device

Clinical responseDevice function

6 mo

Factor identified

Echo optimization

No

1 mo

Yes

Unsatisfactory

Good

Modifysettings

Implantation

Echoscreening

A wave truncation?

No

Echo AVoptimization

Yes

Device algorithmECG

Proposal of Burri / Leclercq / Oliviera

• Improvement in patient’s selection?– Avoiding pts with high potential of NR

• COPD++, RV dysfunction with PH, large scar without viability

– Selection of the best patients (NICM, wide QRS, LBBB…)

• Optimization of the LV lead location and pacing programming

• Optimization of medical treatment

• Improvement in optimization of device’s programming

• Remote monitoring

How to increase the rate of responders?

Optimization of the devices in CRT

Saxon. Circulation 2010;122: 2359 –67

CRT with and without RM

28%

Hindricks. ESC 2013

19%

9%3.4%