Diapositiva 1

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Quando la CRT-P può bastare?
Natale MARRAZZO Francesco SOLIMENE
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European Heart Journal (2008) 29, 23882442
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Introduction

• CRT in NYHA function class IV
• CRT in NYHA function class I
• CRT in PERMANENT AFib
• CRT in conventional PM INDICATION
• CRT in RENAL FAILURE
• CRT in ADVANCED AGE

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CRT in NYHA function class III/IV
Impact of CRT therapy on morbidity
COMPANION
CARE-HF
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CRT in NYHA function class III/IV
Impact of CRT therapy on mortality
COMPANION
CARE-HF
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CRT in NYHA function class III/IV
Ambulatory patients in NYHA function class IV
COMPANION
Primary time to all-cause death or hospitalization
Secondary time to all-cause death
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CRT in NYHA function class III/IV
Key issues

• LV dilatation no longer required
• Class IV patients should be ambulatory
• Reasonable expectation of survival with good
  functional status for 1 y for CRT-D
• Evidence is strongest for patients with typical
  LBBB
• Similar level of evidence for CRT-P and CRT-D

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CRT in NYHA function class I/II
Clinical evidence
MADIT CRT
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CRT in NYHA function class I/II
Clinical evidence
REVERSE
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CRT in NYHA function class I/II
Clinical evidence
REVERSE
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CRT in NYHA function class I/II
NYHA I
MADIT-CRT
REVERSE
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CRT in NYHA function class I/II
Device selection

• In favour of implantation of CRT-D
• Predominantly or exclusively implanted CRT-D
• Younger age, lower comorbidity and longer life
  expectancy
• In favour of implantation of CRT-P
• Survival advantage with CRT-D was not shown
• LVEF increase to gt 35 (NO ICD indication in HF)
• Higher risk of device-related complications with
  CRT-D

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CRT in NYHA function class I/II
Key issues

• MADIT-CRT and REVERSE demonstrate reduced
  morbidity
• In REVERSE and in MADIT-CRT NYHA I pts had been
  previously symptomatic
• Improvement primarily seen in pts with QRS 150
  ms and/or typical LBBB.
• In MADIT-CRT, women with LBBB demonstrated a
  particularly favourable response
• Survival advantage not established
• In MADIT-CRT the extent of reverse remodelling
  was concordant with and predictive of improvement
  in clinical outcomes

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CRT and PERMANENT AFib
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CRT and PERMANENT AFib
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CRT and PERMANENT AFib
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CRT and PERMANENT AFib
Key issues

• Approximately one-fifth of CRT implantations in
  Europe are in
• patients with permanent AF
• NYHA class III/IV symptoms and an LVEF of 35
  are well-established indications for ICD
• Frequent pacing is defined as 95 pacemaker
  dependency
• Evidence is strongest for patients with an LBBB
  pattern
• Insufficient evidence for mortality
  recommendation

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CRT and a conventional PM INDICATION
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CRT and a conventional PM INDICATION
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CRT and a conventional PM INDICATION
Key issues

• In patients with a conventional indication for
  pacing, NYHA III/IV symptoms, an LVEF of 35,
  and a QRS width of 120 ms, a CRT-P/CRT-D is
  indicated
• RV pacing will induce dyssynchrony
• Chronic RV pacing in patients with LV
  dysfunction should be avoided
• CRT may permit adequate up-titration of
  b-blocker treatment

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CRT and RENAL FAILURE
PACE 2008 31575579
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CRT and RENAL FAILURE
PACE 2008 31575579
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CRT and RENAL FAILURE
Retrospective study on n239 ICD pts (all 1-ary
prev) CR-dysf creatin.gt2mg/dl or under
dialysis FU 1815 months Mortality in CR-dysf
48.6 Mortality in controls 8.2
Cuculich P al. PACE 2007
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CRT and RENAL FAILURE
Key issues

• RF is associated with an increased risk for
  all-cause mortality, largely explained by an
  increased risk for pump-failure death
• High creatinine remaines an independent
  predictor of mortality in CRT recipients
• RF pts despite ICD implantation extract little,
  if any, survival benefit from this therapy

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CRT and ADVANCED AGE
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CRT and ADVANCED AGE
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CRT and ADVANCED AGE
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CRT and ADVANCED AGE
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CRT and ADVANCED AGE
Key issues

• HF is predominantly a disorder of older adults
• Very few pts over age 75 were enrolled in the
  major ICD trials
• None of the CRT trials included pts in this age
  range
• With respect to ICDs high procedural
  complication rates , short life expectancy, high
  risk of dying from causes other than SCD
• ICD is unlikely to be favorable for most pts

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(No Transcript)
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• The challenge of selecting patients for ICD
  therapy
• Cost
• Life expectancy
• Complications
• Inappropriate shocks
• Patients persective