Prsentation PowerPoint

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An ICD for every CRT patient ?
JC Deharo, CHU Marseille
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Sudden Cardiac Death in Heart Failure patients
SCD ( of death)
MERIT-HF study, Lancet 1999
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Patients to be treatedfor saving one life
Beta -
ACE Inh
ICD
ICD
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Secondary prevention by the ICD
- 50
Connolly S.J EHJ 2000, 21 2071-2078
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Secondary prevention by the ICD Patients with
the lowest EF benefit the most
From AVID Trial, Domanski, JACC 1999
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Secondary prevention ICM (and NICM)
NYHA class ? III QRS ? 130 ms LV EF ? 35 LV
Diameter ? 55 mm
Malignant ventricular arrhythmia certain or
suspected


CRT
ICD
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ICD / AAD
AVID Trial, NEJM 1997
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Mortality reduction with ICD therapy (Ischemic CM)
Primary prevention
Mortality reduction
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Primary prevention with the ICD The sickest
patients benefit the most
From MADIT Trial, Moss Circulation 2000
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Primary prevention with the ICD Patients with
the larger QRSd benefit the most
MADIT II
N Engl J Med, March 21, 2002
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Primary prevention in ICM
LV EF 35 NYHA class? III QRS ? 130 ms LV
Diameter ? 55 mm
LVEF 30
30 lt LVEF 35 NSVT
EPS inducible
No
Yes
ICD CRT
CRT
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Non ischemic cardiomyopathy Primary prevention ?
DEFINITE NEJM 2004 458 OPT vs ICD NICM LVEF
35 NYHA I III Total ? ? (p0.06)
SCD-HeFT ACC 2004 2521 OPT/Amio/ICD NICMICM L
VEF 35 NYHA II III Total ? ICD
COMPANION NEJM 2004 1520 OPT/CRT/CRT-ICD NICMI
CM LVEF 35 NYHA III IV Total ?
CRT-ICD
AMIOVIRT JACC 2003 101 Amio vs ICD NICM LVEF
35 NYHA I III Total ? ?
CAT Circ. 2003 104 OPT vs ICD Recent
NICM LVEF 30 NYHA II III Total ? ?
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Primary prevention in NICM

No
Yes
CAT AMIOVIRT
DEFINITE
SCD-HeFT COMPANION
NYHA class? III QRS ? 130 ms LV diameter ? 55 mm
Non ischemic CM LVEF 35
ICD CRT

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French recommendations ICD for primary prevention
in NICM
Class II b Non
ischemic CM EF 30
or EF
35 NSVT
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Feasibility

• Implant success 96
• Procedure duration 19284 minutes
• CS lead positioning 7764 minutes
• Implant related complications 12
• CS perforation/dissection 4/84
• CS lead dislodgement 7/84
• Infection 2/84

JACC 2002
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Eligibility for BV Pacing in pts with an ICD
Molhoek, Eur J of Heart Failure 2003
390 ICD
NYHA ? III
QRS gt 120 ms
NYHA II

36 (140)
20 (78)
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Cost concern
x 1.25
ICD candidates MADIT II ?? SCD-HeFT ???
x 3.5
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Conclusion

• ICD in patients indicated for CRT
• Secondary prevention
• Primary prevention in ICM
• (Very low EF, young age ???)
• Primary prevention in NICM
• (Very low EF, young age, heart transplant planed
  ???)