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0 Optimization of AV and VV Delays Lumax 540 CRM Training and Education.

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Presentation on theme: "0 Optimization of AV and VV Delays Lumax 540 CRM Training and Education."— Presentation transcript:

1 0 Optimization of AV and VV Delays Lumax 540 CRM Training and Education

2 1 Optimization of BiV Pacing A-V Delay V-V Delay

3 2 AV Delay Optimization Ensure BiV pacing Improve diastolic filling Reduce mitral regurgitation Cardiac Output Goals

4 3 AV Delay Optimization AV too long Close to intrinsic PR (fusion) Loss of CRT AV too short Premature mitral valve closure Hemodynamic compromise

5 4 AV Delay Optimization Empirical Calculation Echocardiography Pulse pressure Methods

6 5 AV Delay Optimization Aortic Pressure in percent Auricchio et al., Circulation 1999 LV dP/dt max in percent A-V Delay RV LV BiV PR - 30 ms PR - 30 ms

7 6 AV Delay Optimization Example for A s -V s = 220 ms AV opt = (220-30)/2 = 95 ms Calculation Auricchio et al., Circulation AV opt = (PR interval) - 30 ms

8 7 AV Delay Optimization LV lead in anterior vein RBBB Intrinsic PR > 300 ms AV block II°/III° Limitations of Calculation Methods

9 8 AV Delay Optimization Flow Velocity at Mitral Valve Aortic Velocity Time Integral Doppler Echocardiography

10 9 Echocardiography Apical Position 4 Chamber View

11 10 Apical 4-Chamber View

12 11 Doppler-Echocardiography Fd=Doppler frequency f0=Ultrasound frequency (e.g., 2.4 MHz) V=Blood flow velocity =Angle between sound beam and direction of blood flow c=Speed of sound in human tissue (1,530 m/s) Fd = 2 V cos c f0f0

13 12 Doppler-Echocardiography Spectral analysis Blood flow velocity

14 13 Mitral Valve Doppler Echo Sample Volume P A R E T LV Ejection Filling ECG Doppler

15 14 Pulsed Wave Doppler Echo 4 Chamber ViewE/A Ratio Mitral Valve

16 15 Pulsed Wave Doppler Echo E A Velocity (cm/s) Time (50mm/s) ECG

17 16 AV Delay Optimization Transmitral Flow Velocity LV filling pressure E wave Early diastolic passive filling of the left ventricle A wave Late diastolic active filling of the left ventricle atrial contribution Doppler Echo

18 17 Normal Heart Cycle P P AA R A P EEE LVFT S Q T IVRIVCIVRIVC Aortic Flow Aortic Flow Left Ventricular Filling Time Isovolumic Contraction Isovolumic Relaxation

19 18 Left Bundle Branch Block QT AA R1 R2 T A EEE P P P AAA

20 19 LBBB: Late MV Closure *IVC = Isovolumic Contraction PQT P AA R1 R2 IVC* A P Aortic Valve Opening AVO MVC Mitral Valve Closure

21 20 LBBB: Late End of LV Systole PQT P AA R1 R2 IVC Aortic Flow A MVC Aortic Valve Closure P LV Systole Aortic Flow MVC IVC AVO Ejection

22 21 LBBB: Late Start of LV Filling *MVO= Mitral Valve Opening **IVR= Isovolumic Relaxation PQT P A R1 R2 QT IVC IVR* Aortic Flow A MVC MVO* AVOAVC P Aortic Flow A

23 22 LBBB: Fusion of E and A PQT P AA R1 R2 QT A P EE Short LV Filling Time E Aortic Flow Aortic Flow 250 ms at HR 65/min

24 23 PQT P AA R1 R2 QT IVC IVR A MVC P EE E Aortic Flow Aortic Flow Pre Ejection Period (PEP) LBBB: Resynchronization

25 24 Biventricular Pacing P T P AA T A P EEE AVD Aortic Flow Aortic Flow IVC BiV Pro- longed LV Filling Time 325 ms at HR 65/min PEP BiV MVC

26 25 AV Optimization Short AV DelayLong AV Delay Ritter Formula P A QA A wave truncation Forced MVC E P A E Spontaneous MVC QA AV

27 26 AV Delay Optimization Programmed AV Delays AV short = short AV (25% of PR) AV long = long AV (75% of PR) Ritter Formula Ritter et al., PACE 1995 AV opt = AV short + [(AV long - AV short ) - (QA short - QA long )] "The Difference of the Differences" Measured QA Intervals QA short = QA at short AV QA long = QA at long AV

28 27 Transmitral Flow At short AV delay AV short = 50 ms QA short = 128 ms 128 ms Begin Q E A

29 28 Transmitral Flow At long A-V delay AV long = 160 ms QA long = 48 ms 48 ms Q E A

30 29 AV Delay Optimization Result Programmed AV Delays AV short = 50 ms AV long = 160 ms Measured QA Intervals QA short = 128 ms QA long = 48 ms AV opt = AV short + [(AV long - AV short ) - (QA short - QA long )] "The Difference of the Differences" AV opt = 50 + [(160-50)-( )] = 50 + ( ) AV opt = 80 ms

31 30 AV Delay Optimization Short AVLong AVOptimal AV

32 31 AV Delay Optimization Doppler Echocardiography Flow Velocity at Mitral Valve Aortic Velocity Time Integral

33 32 Doppler Echo Apical Five Chamber View

34 33 Doppler Echo Aortic Flow Velocity Kruck, Biamino 1988

35 34 Aortic Flow Velocity LBBB AAA Aortic Flow Aortic Flow Velocity Time

36 35 Aortic Flow Velocity Biventricular Pacing A E AVD Aortic Flow Aortic Flow Velocity Time

37 36 Velocity Time Integral Fehske 1988 Integral = Area under the curve VTI = AVO AVC V * dt (cm)

38 37 Velocity Time Integral ECG Velocity (m/s) Time v max Ejection time v mean V max = 1.58 m/s V mean = 1.09 m/s ET= 288 ms VTI= V mean * ET VTI= 0.31 m

39 38 AV Delay Optimization Dr. Uhrig, Vivantes Urban Hospital Berlin VTI = 12.7 cmVTI = 20.5 cm Velocity Time Integral

40 39 VTI Method Fehske 1988 Derived Parameters Stroke Volume SV= VTI * A VTI=Velocity Time Integral A=Aortic Valve Area Cardiac Output CO=SV * HR HR=Heart Rate

41 40 VTI Method Objective Identify optimal AV delay at max. VTI Procedure CW Doppler of aortic outflow tract Decrement AV delay by 20 ms down to 80 ms Limitations Doppler signal quality Breathing modulations Intrinsic error %

42 41 AV Delay Optimization 30 Pts. after CRT implantation NYHA III-IV, LVEF < 35%, SR BiV on atrial sensed beats AV optimization on LV dp/dt max Comparison to Ritter formula, diastolic filling time (DFT), LV VTI, E/A VTI Jansen et al., Am J Cardiol 2006

43 42 LV dP/dt max LV Pressure (mmHg) dP/dt (mmHg/s) Jansen et al., Am J Cardiol 2006

44 43 Compliance with LV dP/dt max. measurements Good Good to reasonable % Jansen et al., Am J Cardiol 2006

45 44 AV Delay Optimization Empirical Calculation Echocardiography Pulse pressure Methods

46 45 Pulse Pressure Method Objective Identify AV delay that provides maximal difference between systolic and diastolic blood pressure Procedure Arterial line to measure central aortic pressure accurately

47 46 Pulse Pressure Method IntrinsicPaced Auricchio et al., PACE 1998 P R Aorta LV PEP Time Pressure

48 47 Pulse Pressure Method BiV Pacing Aortic Pressure (mmHg) LV IEGM Time (s)

49 48 AV Delay Optimization Pulse pressure: hemodynamic testing Calculation: initial programming Doppler Echo: non-responders Summary

50 49 Optimization of BiV Pacing A-V Delay V-V Delay

51 50 V-V Delay Optimization LV first ASAS RV P AV LV P RV P VV AV RV first ASAS VV = 0 ASAS RV P AV LV P

52 51 V-V Optimization 41 pts. with CHF after CRT-PM AV delay optimization RV-/LV pre-activation: 0, 12, 20, 40, 80 ms Endpoints: Cardiac output, mitral regurgitation from echo Bordachar et al., JACC 2004

53 52 V-V Optimization Echocardiographic Parameters M-mode: septal-to-posterior wall motion delay (SPWMD) Doppler: Interventricular mechenical delay (IVMD) Tissue Doppler: Intra LV delay onset (LV onset) Intra LV delay peak (LV peak) SD from 12 segments intra LV delay peak (SD LV peak)) Delayed longitudinal contraction (DLC) Bordachar et al., JACC 2004

54 53 V-V Optimization Bordachar et al., JACC 2004 Parameter Correlation to Hemodynamics Cardiac Output Mitral Regurgitation LV peak SD LV peak LV onset DLC SPWMD IVMD

55 54 41 CHF pts. with CRT-PM V-V Optimization No. of pts. Bordachar et al., JACC ms LV firstRV first

56 DCM pts. with CRT (Doppler Echo) V-V Optimization LV first 80 RV first At Implant 3 months No. of pts. Delurgio et al., NASPE 2002 ms

57 56 V-V Optimization van Gelder et al., Am J Cardiol 2004 AF SR ischemic SR non-ischemic

58 57 Optimizing BiV Pacing

59 58 Optimizing BiV Pacing I V1V1 RV onlyLV onlyBiVBiV LV first

60 59 Optimizing V-V Delay Start with standard setting VV optimization in patients with persistent dyssynchrony Trouble shooting option in clinical non-responders Summary

61 60 Optimization of BiV Pacing A-V Delay V-V Delay


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