SHA24/055002

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Cardiac Resynchronization Therapy in pediatrics and CHD Waleed Al-Manea , MD King Faisal Hospital And Research Center

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Objectives • • • • •

Introduction Cardiac dyssynchrony -definition Review present criteria for CRT CRT in pediatrics –Experience and challenges KFSH&RC pediatric CRT experience

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

CRT (biventricular) pacemaker • Atrial lead • RV lead • LV lead ( coronary sinus or epicardial )

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Who are the candidates for CRT Current adult guidelines :  Cardiomyopathy with EF less than 35%  Wide QRS more than 120 msec  NYHA class 3-4  Optimal medical therapy

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

QRS Duration • QRS duration qualifying for CRT for NYHA Class III-IV is >120 msec • QRS duration qualifying for CRT for NYHA Class II is >150 msec • Generally broader QRS complexes (>150 msec) has a better clinical response than less broad QRS complexes (120-150 msec) but not true in all cases •

Sipahi I et al. Impact of QRS duration on Clinical Event Reduction with CRT: Meta-analysis of Randomized Clinical Trials. Arch Intern Med.2011(16):1454

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

QRS Morphology • Major patterns: LBBB as compared to non-LBBB (RBBB, IVCD) • LBBB has more benefit from CRT than nonLBBB (RBBB, IVCD) Wojciech Z et al. Effectiveness of CRT by QRS Morphology In the MADIT-CRT. Circulation.2011;123:1061-1072

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Echo • Echocardiography is most popular imaging modality • Different forms of mechanical dyssynchrony: interatrial, atrioventricular, interventricular, LV intraventricular, and intramural • LVEF evaluates global and not regional LV systolic function and does not predict response to CRT Ypenburg C et al. Noninvasive Imaging in CRT-Part1: Selection of Patients. Pacing Clin

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Echo • Echo methods include: M-mode, Doppler longitudinal, radial strain, strain rate, speckle, and real time 3D mode but None has emerged as superior

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

CRT trials • • • • • •

Companion The Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure Care HF Cardiac Resynchronization in Heart Failure Study Madit –CRT Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Miracle Reverse Rethinq

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

LVEF Improvement After CRT (20-30% of CRT recipients are “Nonresponders”)

Auricchio A. Non-Responders to CRT. Circ J.2011;75:521-527

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

What is so special on CRT in CHD? -Lack of prospective, randomized data - Heterogeneous anatomic and functional substrates ( Systemic LV / RV / single ventricle ) - Different implantation approaches -transvenous - epicardial - hybrid

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Available larger CRT studies in pediatric/congenital heart disease Design: Retrospective, non-randomized Dubin AM et al. J Am Coll Cardiol 2005 - multi-center -N = 103 - Cecchin F et al. JCE 2009 - single-center - N = 60 - Response definition: ≼ 10 % proportional in EF and/or in NYHA class Janousek J et al. Heart 2009 - multi-center - N = 109

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

CRT in Children • 4 year old boy s/p VSD closure in June 2002

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

• Cardiac function deteriorated after 2 years

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Post CRT

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

CRT PRE

POST

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Post CRT

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

CRT in Children KFSH Experience Objective : We aim to describe our experience with CRT in children and patients with CHD and poor ventricular function .

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

METHODS • Retrospective Review of 23 patients • Median age Age was 8.1 Years (6 months-16years).

• Mean follow up time 22 months ( 6 months – 9 years).

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

• All pts had symptomatic CHF and ventricular dilatation • EF range between 13-48% .

• QRS ranging between 150-190 msec.

• All had evidence of ventricular dyssynchrony by 2 dimensional echocardiography ( and recently dyssnchrony assessment done better with 3-D echo)

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Patient population 18 pt (80%) with congenital heart disease

CHD 80%

CHD

CHB

LBBB

4 patients (15%)with complete heart block 1 (5%)patient with idiopathic LBBB

LBBB 5%

CHB 15%

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

18 pts with CHD 7 pts with TOF 3 D-TGA and VSD 3 L-TGA 2 AV canal 1 DORV 1 ASD 1 single ventricle

L-TGA 19%

D-TGA+VSD 19%

TOF 31%

SV 6%

DORV 6%

ASD 6%

AV Canal 13%

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

CRT –P Implantation : 18 epicardial .

4 mixed .

1 transvenous .

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

17 Patients showed improvement ( 75%)

PRE Electrical remodeling Radiological parameter

POST

165 ms ( 150-190 ms) 140 ms (110-190ms).

68%

( 55-87%)

63% (52-78 %).

(Cardio-Thoracic ratio)

Ejection Fraction

17 %

(13-48%)

28%

(24-58%)

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

Conclusion – CRT is a promising mode of therapy for a subgroup of pediatric patients with poor ventricular function – Epicardial LV/LA lead implant is safe and possibly provide comparable results to the transvenous approach , with less complications – More studies are needed to identify those who will benefit the most from this mode of therapy

Management of Arrhythmias After Repair of CHD, M Alfayyadh MD

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