Profilaxia das Complica

1
Limits and Interfaces in Science São Paulo,
November 28-30, 2009.
Implantable Electronic Cardiac Devices for
Prevention of Sudden Cardiac Death and Treatment
of Cardiac Arrhythmias. What are the Limits to
Use It?
Roberto Costa rcosta_at_incor.usp.br
2
Sudden Cardiac Death Current Statistics
Septicemia
Nephritis
SCD is a leading cause of death in the U.S.,
second to all cancers combined.
Alzheimers Disease
Influenza/Pneumonia
Diabetes
Accidents/Injuries
Chronic Lower Respiratory Diseases
Cerebrovascular Disease
Other Cardiac Causes
Sudden Cardiac Arrest (SCA)
All Cancers
0
5
10
15
20
25
National Vital Statistics Report.
20014911. MMWR. 200251123-126.
3
Sudden Cardiac Death Current Statistics
Incidence (cases/year) Survival
Worldwide 3,000,000 lt1
U.S. 450,000 5
W. Europe 400,000 5
Brazil 250,000 NA
American Heart Association. Heart Disease and
Stroke Statistics 2009 Update DATASUS - 2008
Sociedade Brasileira de Cardiologia - 2008
4
Causes of Sudden Cardiac Death
12Other CardiacCause
88ArrhythmicCause
Albert CM. Circulation. 20031072096-2101.
5
Mechanisms of Sudden Arrhythmic Death
Torsades de Pointes13
Bradycardia17
VT62
Primary VF8
Bayés de Luna A. Am Heart J. 1989117151-159.
6
1958 First Antiarrhythmic Devices
7
Antibradycardia Devices Conventional Pacemakers
8
Treatment of Atrioventricular Block Conventional
Pacemakers
Survival
p lt 0,01
Survival (Years)
Rassi A. Not published data
9
Implantable Electronic Cardiac Devices Historical
Aspects
10
Antitachycardia Devices Implantable Cardioverter
Defibrillator
11
Antitachycardia Devices Implantable Cardioverter
Defibrillator
12
Secondary Prevention of Sudden Arrhythmic
Death AVID Study
NEJM 19973371576-83
13
Primary Prevention of Sudden Arrhythmic
Death MADIT II Study
1.0
0.9
0.78
ICD
0.8
Survival Probability
-31
0.7
0.69
Conventional
P 0.007
0.6
0.0
0
1
2
3
4
Years
N of Patients at Risk ICD 742 502
(0.91) 274 (0.84) 110 (0.78)
9 Conventional 490 329 (0.90) 170 (0.78)
65 (0.69) 3
Moss AJ. N Engl J Med 2002346877-883
14
Left Ventricular Dysfunction Electromechanical
Dyssynchrony
Dilated Cardiomyopathy
Normal
Longer
SEPTUM
SEPTUM
BASE
BASE
Relaxed
APEX
APEX
Shorter
Courtesy of Dr Kass, MD, Johns Hopkins
University, Maryland.
15
Left Ventricular Dysfunction Electromechanical
Dyssynchrony
Electromechanical Delay
Normal Activation
Longer
SEPTUM
SEPTUM
BASE
BASE
Relaxed
APEX
APEX
Shorter
Cortesia de D. Kass, MD, Johns Hopkins
University, Maryland.
16
Cardiac Resynchronization Atrio-biventricular
Pacing
LV
RV
17
Cardiac Resynchronization CARE-HF Study Overall
Mortality
HF CF III/IV EFlt0.35 QRSgt130ms
100
75
CRT
Medical Therapy
50
Event-free Survival
25
Plt0.0001
0
0
500
1000
1500
Days
Cleland et al, Eur Heart J 200627(16)1928-32
18
Cardiac Resynchronization CARE-HF Study Sudden
Mortality
Cleland et al, Eur Heart J 200627(16)1928-32
19
Cardiac Resynchronization ICD COMPANION Study
Overall Mortality
12
15
Sobrevida livre de eventos ()
19
N1520
N Engl J Med 2005
20
Implantable Electronic Cardiac Devices Historical
Aspects
21
Remote Transmission of Arrhythmias Therapies
Applied by the Device
22
Clinical and Hemodynamical Diagnosis Analysis of
the Thoracic Impedance
HIGH intrathoracic impedance indicates dry lungs
LOW intrathoracic impedance indicates pulmonary
congestion
Worse
Better
23
Continuous Volemia Evaluation Possibility of a
Precocious Intervention
Adamson PB et al. J Am Coll Cardiol. 2003 41 565
24
Remote Monitoring System
Patient
Transmitter
Wireless transmission
Service center
Data sent to the physician
By landline phone or GSM network
25
Remote Monitoring System

• Device Complications
• Clinical Complications

In-clinic Follow-up
Next evaluation (90-180 days)
26
Remote Transmission of Arrhythmias Atrial
Fibrillation
27
Atrial Fibrillation Incidence
28
Atrial Fibrillation in the Elderly with
Pacemaker Inclusion and Randomization
May 2009 Last statistical analysis
29
Atrial Fibrillation in the Elderly with
Pacemaker Study Design

• Inclusion
• Age 60 years
• Classic indication for AVPM implant or
  replacement

Booked for ambulatory consultation
Surgical procedure
Randomization 11
Control group
months
1
3
18
12
6
24
0-7 days after surgery
30
Atrial Fibrillation in the Elderly with
Pacemaker Episodes Incidence
Event-free Survival
(months)
31
Atrial Fibrillation in the Elderly with
Pacemaker Incidence of new AF episodes after
follow-up
p0,08
P0,045
Time to diagnosys of AF (months)
Remoto
Controle
32
Atrial Fibrillation in the Elderly with
Pacemaker Conducts Established in Extra
Consultations
Conducts in Extra Consultations (23)
33
Cardioverter Defibrillator Number Needed to Treat
NNTx years 100 / ( Mortality in Control Group
Mortality in Treatment Group)
Drug Therapy
amiodarone
ICD Therapy
simvastatin
Metoprolol succinate
captopril
(5 Yr) (2.4 Yr) (3 Yr)
(3 Yr) (3.5 Yr) (1 Yr)
(6 Yr) (2 Yr)
34
Total Comparative Expenses Influence of the
Prevalence
Yearly Expenditures for Medical Procedures
DRG Payment by Procedure Dialysis
54,262 Heart Valves 33,525 ICD
30,394 CRT 25,112 CABG 24,272 Aortic
Aneurysm 17,655 Stent 11,646 Hip / Knee
Replacement 10,365
14.9
16
14
12
10
8.5
Billion
8
6.8
6
4.6
4
2.8
2.0
2
0.6
0.6
0
Dialysis
CABG
Stent
Hip / Knee Replacement
Heart Valves
ICD
Aortic Aneurysm
CRT
Procedure
Weighted DRG payment 2003 with discharges from
2000. HCUPnet. www.ahrq.gov/data/hcupnet.htm Medic
are 2000 Dialysis payment per patient The United
States Renal Data System (USRDS), 2002..
www.usrds.org Weighted DRG payment for 2003
using weighted 2002 industry implants (CRT,
CRTICD), including replacements
35
Limits and Interfaces in Science São Paulo,
November 28-30, 2009.
Implantable Electronic Cardiac Devices for
Prevention of Sudden Cardiac Death and Treatment
of Cardiac Arrhythmias. What are the Limits to
Use It?
Roberto Costa rcosta_at_incor.usp.br