Patient selection for CRT Yahya Al Hebaishi Electrophysiology Division/Heart Failure Unit PSCC, Riyadh
Reviwed, Edited & presented by Dr.Adil Osman Ahmed MRCP(UK) ,Saudi Board of Cardiology, CCDS(IBHRE( DivisionO EP & Pacing Prince Sultan Cardiac center Riyadh
Patient selection for CRT Introduction Clinical predictors of response Role of imaging modalities Electrocardiographic Predictors of CRT response Major society guidelines Summary
Heart Failure: Scope of Problem Prevalence Worldwide, 22 million1 United States, 5 million2
Incidence Worldwide, 2 million new cases annually1 United States, 500,000 new cases annually2 Primary reason for 12 to 15 million office visits and 6.5 million hospital days each year in US 1 World Health Statistics, WHO, 1995 2 AHA, 2002 Heart and Stroke Statistical Update
Heart Failure: Saudi Arabia ~450,000 (1.7%) of population Age over 45 years expected to double by 2020
Atrial fib (33% v 17%) and LBBB (33% v 11%) rates lower in KSA HFpEF less common in KSA Present with more advanced disease NYHA Cl III & IV (60% vs 30%) KSA - DM, IHD and HTN also very common
K. AlHabib et al. Eur J of Heart Failure, 2011
Heart Failure: Role of CRT LeftBundle Bundle Branch Block MoreMore Prevalent with Left Branch Block Prevalent Impaired LV Systolic Function with Impaired LV Systolic Function Preserved LVSF (1) Impaired LVSF (1) Moderate/Severe HF (2)
8%
24%
38% 1. Masoudi, et al. JACC 2003;41:217-23 2. Aaronson, et al. Circ 1997;95:2660-7
Prognosis with Ventricular Dyssynchrony
45 months mortality One year mortality 11% QRS < 120 msec
34% QRS < 120 msec
49% QRS > 120 msec
16% QRS > 120 msec
Baldasseroni S, et al. Eur Heart J 2002;23:1692-98 N=5,517 Luliano et al, AHJ 2002; 143: 1085-91
Device Based Clinical Trials INSYNC ICD RHYTHM ICD N 126 N 103
MUSTIC N 60
PAVE N 360
PATH-CHF I & II N 200
1995
1996
VIGOR CHF N 84
1997
1998
1999
MIRACLE N 536 INSYNC I, II, III N 600
VECTOR N 201
2000
2004
2008
MIRACLE ICD CARE HF N 1000 N 800
CONTAK CD COMPANION N 1100 N 2200
REVERSE MADIT-CRT RAFT
Not all patients benefit from CRT Although most treated patients show a benefit from CRT, about 30% of patient dose not respond to CRT Co-morbidities Myocardial scar LV lead position Patient selection
Clinical predictors of CRT response Female sex Non ischemic CM BMI <30 kg/m(2) Smaller baseline left atrial volume Left ventricular volume? JJAm Cardiol. AmColl Collend-diastolic Cardiol.2012 2012Jun Jun19;59(25):2366-73 19;59(25):2366-73 Less MR Less co-morbidities ESRD PHTN
J Am Coll Cardiol. 2012 Jun 19;59(25):2366-73 Circulation 2011 Oct 4;124(14):1527-36 Europace 2012 Nov;14(11):1608-14
Imaging role
Tissue Doppler
Echo and CRT response: PROSPECT trial
Circulation. 2008 May 20;117(20):2608-16.
Echo parameters in PROSPECT trial
Echo parameters in PROSPECT trial
Interobserver and Intraoperator Variability Summary
Circulation. 2008;117: 2608-2616.
Echo parameters in PROSPECT trial
NO Single Echo Measure of Dyssnchrony may be recommended to improve patient selection for CRT
PROSPECT trial: ECG remains the standard
Patient selection for CRT: MRI and SPECT
ECG remains the gold standard test for CRT patient selection QRS duration QRS morphology LV activation patterns Patient rhythm P wave morphology and the PR interval
Narrow QRS and CRT response RethinQ study
Beshai JF, RethinQ Study Investigators Engl J Med. 2007;357(24):2461.
Narrow QRS and CRT response RethinQ study
Beshai JF, RethinQ Study Investigators N Engl J Med. 2007;357(24):2461.
QRS duration and CRT response QRS 120-149ms
Sipahi I, Carrigan TP et al Arch Intern Med. 2011;171(16):1454.
QRS duration and CRT response QRS 120-149ms
Sipahi I, Carrigan TP et al Arch Intern Med. 2011;171(16):1454.
QRS duration and CRT response
Sipahi I, Carrigan TP et al Arch Intern Med. 2011;171(16):1454.
QRS duration and CRT response
Sipahi I, Carrigan TP et al Arch Intern Med. 2011;171(16):1454.
LV activation and CRT response
Sweeney MO, et al , Circulation. 2010;121(5):626.
LV activation and CRT response
Sweeney MO, et al , Circulation. 2010;121(5):626.
LV activation and CRT response
Sweeney MO, et al , Circulation. 2010;121(5):626.
LV activation and CRT response
Sweeney MO, et al , Circulation. 2010;121(5):626.
LV activation and CRT response
Sweeney MO, et al , Circulation. 2010;121(5):626.
LV activation and CRT response
Sweeney MO, et al , Circulation. 2010;121(5):626.
LV activation and CRT response
Gold, M. R., et al. European Heart: 32, Issue: 20, Pages: 2516 to 2524, October 14, 2011
LV activation and CRT response
Gold, M. R., et al. European Heart: 32, Issue: 20, Pages: 2516 to 2524, October 14, 2011
QRS morphology and CRT response
Zareba et al Circulation. 2011;123:1061-1072
QRS morphology and CRT response
American heart journal 2012, 163(2):260-267 e263
QRS morphology and CRT response
American heart journal 2012, 163(2):260-267 e263
Patient rhythm Major clinical trials of resynchronization included mainly patients in sinus rhythm A meta-analysis of 1,164 patients in five studies showed that Patients in AF had a significant improvement after CRT, with similar or improved ejection fraction as sinus rhythm patients, but the functional improvement was less
P-wave morphology and the PR interval Significant interatrial delay may results in left atrial contraction during LV systole, which may negatively affect CRT outcome. Septal lead? A long native PR interval may permit a more physiological AV delay programming. Subgroup analysis of patients in the COMPANION trial demonstrated that randomization to CRT was associated with a reduction in the endpoint, but the strength of the association was greater for those with prolonged PR
Summary
Summary Clinical & ECG criteria remains the gold standard method for selection of patients for CRT. Echo has a role in defining the LV function but the current parameters do not distinguish those who will benifit from those who will not benifit from CRT. New Echo modalities & new Imaging modalities e.g MRI, Nuclear , CT & cardiac mapping may have a role in the future.
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