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1、Is There a Room to Improve CRT Outcome? From Patient Section to Programming: Mayo Clinic experience,Yong-Mei Cha, MD Mayo Clinic Dalian, 2009,CP1305043-1,Cumuulative patients,Results presented,Cumulative Enrollment in CRT Randomized Trials,PATH CHF,MUSTIC SR,MUSTIC AF,MIRACLE,CONTAK CD,MIRACLE ICD,P
2、ATH CHF II,COMPANION,MIRACLE ICD II,CARE HF,CP1172680-4,CRT,Reverse myocardial remodeling Improve quality of life Improve NYHA class Reduce hospitalizations for heart failure Improve survival,CRT works in 50-70% of patients,Why not every patient response to CRT,QRS morphology and duration Upgrade vs
3、 de novo implantation Etiology of cardiomyopathy Sinus rhythm vs atrial fibrillation Reversibility of LV myocardium LV lead position Percentage of biventricular pacing Device programming,CP1305043-5,Pre-CRT QRS Morphologies N=502,LBBB 50% (254),Paced LBBB 25% (124),RBBB 7% (37),IVCD 11% (53),120 ms
4、7% (34),Dyssynchrony (9) New pacing indication/HF (14) RV-pacing induced HF (3) Advanced HF/borderline QRS (8),Chronic AF 30%,CP1305043-12,Improvement in NYHA Class After CRT,* Significant difference (P0.05) compared to LBBB as a reference group * Significant difference (P0.001) compared to LBBB as
5、a reference group,Improvement in NYHA class,*,*,n=254,n=37,n=124,n=53,n=34,CP1305043-13,Improvement in LVEF (%),*,*,n=254,n=37,n=124,n=53,n=34,* Significant difference (P0.05) compared to LBBB as a reference group * Significant difference (P0.001) compared to LBBB as a reference group,Improvement in
6、 LVEF After CRT,CP1305043-16,Survival After CRT Based on QRS Morphology,Survival estimate (%),Years,No. at risk LBBB 254 208 149 81 47 Paced 124 87 53 37 21 RBBB 37 29 18 7 3 IVCD 53 40 26 11 2 120 ms 34 23 16 8 3,LBBB (n=254, deaths=58) Paced LBBB (n=124, deaths=30) RBBB (n=37, deaths=14) IVCD (n=5
7、3, deaths=14) 120 ms (n=34, deaths=9),P=0.039,Fantoni C, JCE 2005,Fantoni C, JCE 2005,NYHA Class Pre- and Post-CRT,CP1306982-9,* P0.05 or *P0.001 compared to pre-CRT,NYHA class,*,*,De novo n=254,Upgrade n=125,Pre Post,LV Systolic Function: Pre- and Post-CRT,CP1306982-10,* P0.05 or *P0.001 compared t
8、o pre-CRT,Ejection fraction (%),*,*,De novo n=239,Upgrade n=121,Pre Post,Survival After CRT De Novo vs Upgrade groups,CP1306982-16,Survival after CRT (%),63%,Years,De novo 338 272 189 97 49 Upgrade 167 118 76 50 29,De novo,P=0.91,61%,Upgrade,CP1305043-5,Pre-CRT Atrial Rhythm N=502,sinus 66%,AF 34%,I
9、mprovement in NYHA Class After CRT,Improvement in LVEF After CRT,Kaplan-Meier estimate,SR,P=0.78,330 254 183 109 59 172 134 81 38 19,CP1337866-1,AF,Years,Kaplan-Meier estimate,Years,P=0.008,120 90 51 19 7 52 40 26 15 8,CP1337866-3,-AVN-ABL,+AVN-ABL,B,Change in LV End-Systolic Volume After CRT,CP1299
10、428-3,Left ventricular end-systolic volume change (%),Months,Baseline,6,12,24,36,48,SR, V pacing 98%,AF, AVN ablation, V pacing 100%,AF, no AVN ablation, V pacing 88%,Comparison of changes after CRT in patients with DCM and ICM,Survivals in dilated and ischemic cardiomyopathy,Comparison of Changes A
11、fter CRT,CP1306982-8,Biv pacing Biv pacing 99-100% 99% Characteristic n=168 n=138 P NYHA class -0.80.8 -0.60.8 0.015 LV ejection fraction (%) 8.510.8 5.28.8 0.006 LV end-diastolic volume (mL) -27.253.4 -9.541.8 0.006 LV end-systolic volume (mL) -33.545.9 -12.343.7 0.013 Mitral regurgitation* -0.30.7
12、 -0.10.6 0.081 RV systolic pressure (mm Hg) -5.813.6 -4.512.6 0.466,Biventricular Pacing Percentage in All Patients,Koplan BA: JACC, 2009,Patients (no.),Pacing (%),Survival Free from Heart Failure Hospitalization and All-Cause Mortality,Event-free probability,Months post implant,1st quartile: 0-92%
13、(n=467) 2nd quartile: 93-97% (n=474), P=0.0013 (vs Q1) 3rd quartile: 98-99% (n=509), P=0.0004 (vs Q1) 4th quartile: 100% (n=362), P0.0001 (vs Q1),Koplan BA: JACC, 2009,0.5,0.6,0.7,0.8,0.9,1.0,0,2,4,6,8,10,12,75-80%,15%,5%,CAO et al. JCE 2009,Influence of LV Lead Location on Outcomes in the COMPANION
14、 Study,Barold, europace 2009,Measuring VTI,Obtain Doppler velocities across the aortic valve Use the apical long axis view Find the best programmed V-V Delay that provides the largest VTI (SV),LV,LA,Using the Velocity Time Integral (VTI) to Optimize V-V Timing,The volume of blood ejected by the LV e
15、ach beat = Stroke Volume (SV) SV = LVOT area x Velocity Time Integral (VTI) Since LVOT is constant, the larger the VTI the larger the SV,Distribution of Optimized V-V,At implant,6-month,Summary of V-V Timing Results,Sequential biventricular pacing produced the greatest stroke volume in 75% of patients. The median improvements in stroke volume when sequential biventricular pacing were 11.4%, and 9.5% at implant and 6 months respectively.,Cleland: JACC, 2009,