Transcript Diapositiva 1 - Gastaldi Congressi s.r.l

Se, come e quando l’ottimizzazione è
necessaria?
How and When Optimization Is Needed?
M. Cristina Porciani
Firenze
There is no doubt that CRT has revolutionized treatment for patients with
medically resistant LV systolic dysfunction, and abroad QRS
 However up to 40% ma not benefit from device implantation or even
deteriorate
The exact reason for lack of response is still unclear , but may due to factors
such as minimal preimplant dyssynchrony, inadeguate lead placement,scar
burden, and also device setting with inappropiate pacing parameters for a given
individual
Current CRT devices allow
manipulation of
the AV and VV timings
CRT OPTIMIZATION
RNW 2 – TTT
4 July 2002
For Internal use only
However, multiple single centre and few multicenter trials
have provided controversial data
While several invasive and non invasive studies have
demonstrated that optimizing AV and VV intervals can acutely
improve hemodynamic parameters, evidence about the
cronic effect is scars
 In addition, multiple methodologies have been proposed to
optimize AV and VV intervals but no consensus has been
reached on which methodology should preferably be used.
Gras D. PACE 2009
CRT OPTIMIZATION
AV optimization
VV optimization
Physiological Principles
AV Optimization
AV optimization
Appropriate
AVD
Physiological Principles
AV Optimization
Physiological Principles
AV Optimization
Evidence for acute improvement induced by AV optimization
in traditional pacemakers
AV Delay
60ms
100ms
120ms
CO(lt/min)
3,4 ± 1
3,9 ± 1,1●
3,8 ± 0,9
FT (ms)
316 ± 110●
293 ± 75
295 ± 99
15pts with
severe HF
Nishimura et al .JACC 1995
Evidence for acute improvement induced by AV optimization in CRT
Average percentage change in systolic parameters as a function of 5
normalized AV delays for each pacing chamber (RV,LV, and BV).
Tested AV delays were normalized to the patient’s PR interval minus
30 ms
Auricchio A. Circulation 1999
Evidence for acute improvement induced AV optimization :
Echocardiographic methods
Evidence for acute improvement induced AV optimization in CRT
Relative improvement in the Doppler parameters vs. baseline value
after AV optimization
Open bars standard settings
Hatched bars optimized CRT
Solid bars relative variability of the parameters during optimization
Stockburger M. et al Europace 2006
What about cronic improvement induced AV optimization ?
Echocardiography optimization of atrioventricular delay was
included in several randomized trials in CRT
MIRACLE Ritter’s method
CARE-HF : iterative method
COMPANION: a device-based algorithm
Evidence for long-term improvement induced by AV optimization
*P
.05 vs baseline
ECO-Opt AV
(n 20 pts)
AV 120ms
(n 20 pts)
Sawhney NS, Heart Rhythm 2004
SMART-AV Trial prospectively randomized pts to
a fixed AV(120ms), echo optimized AV and opimized
with Smart Delay ( electrogram based algorithm ) in a 1:1:1 ratio
980 Pts
mean follow-up 5.8±monts
Ellenbogen K A Circulation 2010
SMART-AV Trial
Ellenbogen K A Circulation 2010
SMART-AV Trial
Ellenbogen K A Circulation 2010
Evidence for long-term improvement induced by AV optimization
Retrospective Study
205 pts
Mean Follow-up 35 months
Kaplan–Meier estimates showing time to the primary
endpoint, survival free of cardiac hospitalization
Adlbrecht C Eur J Clin Invest 2010
Adlbrecht C Eur J Clin Invest 2010
75 Pts non responders to CRT
Mullens W JACC 2009
75 Pts non responders to CRT
Mullens W JACC 2009
Physiological Principles
VV Optimization
VV optimization
►Despite similar QRS morphology pts with HF and LBBB may
present different pattens of ventricular asynchrony
►The presence of scar and slow or blocked
conduction
areas affects the time to achieve a global depolarization of the
ventricle
Effect of RV, LV and BiV Pacing on depolarisation wavefons
RV
LV
BiV
Lambiase et al. Heart 2004
9 pz
11pz
GSCA: Global Systolic Contraction Amplitude
Sogaard P et al .Circ 2002
LVEF%
GSCA mm
LVEDV ml
Baseline
LVESV ml
Simultaneous
Sequential
Baseline
Simultaneous
Sequential
Sogaard P et al .Circ 2002
Echocardiographic methods for V-V optimization
Optimization guided by echocardiography
Lim SH Europace 2008
Optimization guided by invasive monitoring
Lim SH Europace 2008
Long-term benefit of CRT optimization when compared
with simultaneous biventricular pacing
121 pts, randomized
simultaneous (30)
optimized ( 91)
Boriani G et al Am H J 2005
Leon AR JACC 2005
100 pts
49 non opt
51 opt
◄
Vidal B et al Am J Cardiol 2007
100 pts
49 non opt
51 opt
◄
Vidal B et al Am J Cardiol 2007
DECREASE_HF trial three-arm randomized
LV pace only, simultaneous and optimized sequential
biventricular pacing (1:1:1 ratio).
306 pts
Rao RK Circulation 2007
CRT OPTIMIZATION
AV optimization
VV optimization
Results about the long term benefit induced by
V-V optimization appear discouraging mainly for VV
interval
Conclusions
Optimization can improve hemodynamics acutely, but longterm clinical improvements are currently less convincing
Until more definitive evidence is available, however, we must
do the best for our patients
 It is important to remember that HF pts even a small
increase in exercise capacity can make a vast personal
difference
Optimization has never been shown to be detrimental so it
should certainly be performed in those not receiving benefit
with empiric settings, but should also be considered in all
other patients