Transcript PowerPoint-Präsentation

13. November 2014
Klinikum Luedenscheid
Germany
Multi Point Pacing (MPP)
A new quadripolar pacing technology to
improve CRT Response
Dr. Dejan Mijic
Department for
Cardiology and Angiology
Klinikum Luedenscheid
Germany
Mile stone CRT Trials
more than 20.000 patients in CRT Trials
Dr. Dejan Mijic
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Challange in CRT: Non-responder rate
Non-responder rate unchanged (about 30%)
Dr. Dejan Mijic
Birnie, Tang et al., Curr Opin Cardiol 2006
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Potential Reasons for Suboptimal
Response
Dr. Dejan Mijic
Mullens, W. et al. J Am Coll Cardiol 2009;53:765-773
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Impact of LV lead location
on CRT-response
Significant improvement:
• NYHA class
• LV reverse remodeling (Δ%LVEDD)
• Event-free survival
Dr. Dejan Mijic
Merchant, F.M. et al. Heart Rhythm. 2010. May; 7(5):639-44
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Multipolar LV lead
- provides more CRT pacing options -
Dr. Dejan Mijic
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Multipolar LV lead
MORE-CRT Study Results
MORE-CRT showed a significant reduction in relative risk of 40.8% in the
quadripolar CRT group
85.97%
N=1069
76.86%
p=0.0001
months
Dr. Dejan Mijic
Boriani et al., presented at ECS 2014
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Intraoperative dp/dt measurement
for detection of the hemodynamic optimal pacing
vector using the Quartet electrode
R.J. male, 11.07.1946, ischemic CM, CAD, EF 20%, SR, LBBB, QRS 180ms.
CRT-D implant 21.03.2010 (Promote Q).
Pat.1 PA
Dr. Dejan Mijic
Pat.1 LAO 40°
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Results dp/dt
Hemodynamics and thresholds of each vector
Intrinsic dp/dt
vector 6 dp/dt
vector 7 dp/dt
dp/dt mmHg
712mmHg
850mmHg (+19,3%)
930mmHg (+30,6%)
LV stimulation
Stimvector
940
threshold
volt
ms
920
900
880
860
Intrinsic
VV 0ms
840
820
VV -20ms
800
780
760
740
720
700
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6 1
Vektor
7
8
9
10
7,5
2,6
2,0
5,0
2,7
1,5
1,2
0,9
4,5
1,7
1,5
0,5
0,5
0,5
0,5
0,5
0,5
0,5
0,5
0,5
Stimulation Vector
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Distribution of LV pacing vectors:
Best and Bad
N=18
dp/dt
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+13,7%
+34,5%
1000
7
900
6
800
5
4
best
700
3
2
600
1
500
bad
0
400
300
200
100
0
Dr. Dejan Mijic
Intrinsic
Bad
Best
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Limitations of conventional BiV CRT
• Traditional CRT with one LV stimulation point in heart failure patients
could reach resynchronisation by even prolonging the ventricular
activation time
• Although clinical problems (e.g. PNS, LV lead implantation failure, LV
lead dislodgement) can be overcome by a quadripolar lead, the
• Non-responder rate remains approximatly 30 %!
Could MultiPoint pacing lead to an additional
hemodynamic effect over
conventional BiV CRT pacing ?
Dr. Dejan Mijic
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TRIP-HF
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multicenter, single-blind, crossover study
40 patients (mean age 70 years, EF 26%)
Stimulation either 1 RV and 2 LV leads (3-V) or 1 RV and 1 LV lead (2-V)
primary end point: quality of ventricular resynchronization (Z ratio)
Dr. Dejan Mijic
Leclercq C, J Am Coll Cardiol 2008;51:1455–62
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TRIP-HF
Dr. Dejan Mijic
Leclercq C, J Am Coll Cardiol 2008;51:1455–62
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Multipoint Pacing – First studies
Muscle Bundle - Microstimulation
Isolated Tissue Slab
Spach MS et al. Circ Res. 1982; 50: 185-191.
Knisley SB and Hill BC. IEEE Trans Biomed Engineer 1995; 42(10):.957-966.
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Selected Site vs. Multipoint Pacing in
Healthy Individuals
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Selected Site vs. Multipoint Pacing in
Myocardial Scar
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MultiPoint™ Pacing Potential Benefits
Pacing from TWO LV sites (“Multipoint LV stimulation”)
– Capture a larger area
• Engage areas around scar tissue
– Improve pattern of depolarization
and repolarization
– Improve hemodynamics
– Improve resynchronization
Dr. Dejan Mijic
LVp
LVd
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MultiPoint™ Pacing:
Flexible Programming Options
Pacing Sequences and Delays
LV First
LVp
Delay 1
5-80 ms
Delay 2
5-50 ms
LV1
LV2
RV
LVd
LVp
RV
LVp
LVd
RV
RV
LV1
LV2
RV
LVd
LVp
RV
LVp
LVd
LVd
RV
Group
A
B
C
D
LV1
Cathode
Anode
P4
D1
M2
RVc
P4
M2
RVc
M2
M3
P4
RVc
M2
P4
RVc
Dr. Dejan Mijic
RV First
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Case Report
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73-year-old obese female with dilative cardiomyopathy
Hypertension
SR, LBBB, QRS duration = 170 ms
Ejection fraction = 15-20%
Mitral insufficiency II°
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Case Report
Measured dp/dt (mmHg)
Non-biV Pacing Selected biV Site Pacing Multi Point Pacing
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Case Report
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Effect of SSP and MPP on dp/dt compared to
instrinsic sinus rhythm (n=3)
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Clinical Studies: MultiPoint™ Pacing
MultiPoint Pacing improves acute contractility
measurements 1,2
Methods:
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N=19
•
Measurements of acute haemodynamic
response (LV-dP/dt) of MPP and biv
pacing
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Four different MPP configurations with
cathode in the LV and RV coil as anode
were used
Dr. Dejan Mijic
Results:
• Most common optimal configuration in MPP was
most distal and proximal electrode
• In 84% two or more MPP configurations increased
significantly LV dp/dt compared with BiV pacing
• 89% of pts. showed an acute increase of LV dp/dt
Thibault et al. Europace 2013
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Clinical Studies: MultiPoint™ Pacing
Effects of MPP on mechanical dyssynchrony
Methods:
• n=52
• Acute pacing protocol consisting of BiV
simultaneous pacing and a set of 8 MPP
interventions covering a range of LVLV
and LVRV delay combinations
• Max. VVV-time: 85ms
Results:
• In 63% of patients at least one MPP
intervention exibited a significant
reduction (>20%) of dyssynchrony
Dr. Dejan Mijic
Rinaldi et al. JCF 2013
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Clinical Studies: MultiPoint™ Pacing
Acute pressure-volume loops in MPP-CRT patients
Methods:
• Acute PV loops measurements in n=44 pt
• Measurements performed:
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Distal BiV (CONV)
Proximal BiV (CONV)
Anatomic MPP (D1-P4)
Electric MPP (conduction delay)
Results:
• Compared to the best CONV vector MPP
improved (regardless of HF etiology):
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–
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•
Dr. Dejan Mijic
LV dP/dtmax (p<0.001)
Stroke volume (p=0.003)
LV EF (p=0,003)
MPP D1/P4 showed the best results
Pappone et al., Heart Rhythm 2014; 11:394-401
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Clinical Studies: MultiPoint™ Pacing
12 months response to MPP compared with
conventional BiV Pacing
Dr. Dejan Mijic
Pappone et al., Heart Rhythm 2014
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Clinical Studies: MultiPoint™ Pacing
12 months response to MPP compared with
conventional BiV Pacing
Responder Definition:
ESV reduction > 15%
Dr. Dejan Mijic
Pappone et al., Heart Rhythm 2014
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More CRT MPP Study
MOre REsponse on Cardiac Resynchonization Therapy
(CRT) with MultiPoint Pacing
“The purpose of this clinical investigation is to assess the impact of the
Multi Point Pacing (MPP) feature at 12 months in the treatment of patients
not responding to standard Cardiac Resynchronization Therapy (CRT)
after 6 months.”
Prospective, randomized, multicenter design
Type:
Enrollment Target: 1256 Qualified Patients
Duration:
Investigation Timelines: Approx. 42 months
Patient timelines: Participation 6 – 12 months, depending on
CRT response
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More CRT MPP Study
Project Flow Chart
(follow up of qualified subjects)
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Take home messages…
•
Multi-point pacing using a quadripolar electrode is associated with
- high procedural success, lead stability/LV capture, reduction of PNS
- numerous programmable configurations
- which can have an impact on shorter LV activation
- which can result in better hemodynamics (A-VTI, dp/dt, TDI)
•
Although only small patient numbers were investigated, there is a certain consistency in the
results that multi-point pacing can improve CRT and reduce non-responder rate
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Data from multi-point pacing with multipolar LV lead are promising but there is a demand for
more automatic adjustment of optimal AV/VV delays
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At least patients who do not respond to conventional BIV pacing should be considered for
multipoint pacing
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Multipoint pacing today is still under continuing investigation, further prospective trials (MoreCRT MPP) will show the potential benefit of MPP over conventional BiV pacing in CHF
patients
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Thank you for your attention
MPP Programming Strategy
V1
Delay 1
V2
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NOT Easy…a bit more difficult than programming conventional BiV
More Options…means more flexibility
Now, how do we program?
Two sides: SIMPLE or STRESSED?
Stick with the principles of MPP or consider “optimizing” MPP?
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Principles of MPP
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V3
Capture larger area, improve resulting homogeneous/uniform propagation
Simple way of programming MPP
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Delay 2
Two electrodes with the most anatomical separation with min delays
“Optimization” of MPP
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Requires electrical or hemodynamic feedback
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•
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Electrical: QRSd, RV-LV conduction
Hemodynamics: non-invasive, invasive
Long-term performance of “optimization”
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