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0 Optimization of AV and VV Delays CRT Program CRM Training and Education 12-09.

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Presentation on theme: "0 Optimization of AV and VV Delays CRT Program CRM Training and Education 12-09."— Presentation transcript:

1 0 Optimization of AV and VV Delays CRT Program CRM Training and Education 12-09

2 1 Follow-up of CRT Patients Discharge 1 mon 3 mon 6 mon 12 mon Every Year Physical Examination Device Control Chest x-ray CPX or Walking Doppler- Echo – –

3 2 Optimization of BiV Pacing A-V Delay V-V Delay

4 3 AV Delay Optimization Ensure BiV pacing Improve diastolic filling Reduce mitral regurgitation Cardiac Output Goals

5 4 AV Delay Optimization AV too long Close to intrinsic PR (fusion) Loss of CRT AV too short Premature mitral valve closure Hemodynamic compromise

6 5 AV Delay Optimization Pulse pressure Empirical Calculation Echocardiography Methods

7 6 AV Delay Optimization Pulse pressure Empirical Calculation Echocardiography Methods

8 7 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

9 8 Pulse Pressure Method IntrinsicBiV Paced Auricchio et al., PACE 1998 P R Aorta LV PEP Time Pressure

10 9 Pulse Pressure Method BiV Pacing Aortic Pressure (mmHg) LV IEGM Time (s)

11 10 AV Delay Optimization Pulse pressure Empirical Calculation Echocardiography Methods

12 11 AV Delay Optimization Intrinsic AV (As-Vs) from IEGM recording Intrinsic QRS width from 12-lead ECG Measurements

13 12 AV Delay Optimization Wide QRS (> 150 ms) AV opt (ms) = 0.70 * A s -V s - 55 Narrow QRS 150 ms AV opt (ms) = 0.70 * A s -V s Empiric Calculation

14 13 AV Delay Optimization QRS = 170 ms; A s -V s = 220 ms AV opt (ms) = 0.70 * = 99 ms QRS = 130 ms; A s -V s = 180 ms AV opt (ms) = 0.70 * 180 = 126 ms Examples

15 14 AV Delay Optimization Aortic Pressure Auricchio et al., Circulation 1999 LV dP/dt max A-V Delay BiV LV RV PR - 30 ms PR - 30 ms

16 15 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

17 16 AV Delay Optimization LV lead in anterior vein RBBB Intrinsic PR > 300 ms AV block II°/III° Limitations of Calculation Methods

18 17 AV Delay Optimization Pulse pressure Empirical Calculation Echocardiography Methods

19 18 AV Delay Optimization Flow Velocity at Mitral Valve Aortic Velocity Time Integral Doppler Echocardiography

20 19 Echocardiography Apical Position 4 Chamber View

21 20 Apical 4-Chamber View

22 21 Apical 4-Chamber View Normal

23 22 Apical 4-Chamber View Normal with CS

24 23 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

25 24 Doppler-Echocardiography Spectral analysis Blood flow velocity

26 25 Mitral Valve Doppler Echo Sample Volume P A R E T LV Ejection Filling ECG Doppler

27 26 Pulsed Wave Doppler Echo 4 Chamber ViewE/A Ratio Mitral Valve

28 27 Pulsed Wave Doppler Echo E A Flow Velocity (cm/s) 50 mm/s ECG

29 28 AV Delay Optimization Transmitral Flow Velocity LV filling pressure E wave Early diastolic passive filling A wave Late diastolic active filling atrial contribution Doppler Echo

30 29 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

31 30 Left Bundle Branch Block QT AA R1 R2 T A EEE P P P AAA

32 31 LBBB: Late MV Closure *IVC = Isovolumic Contraction PQT P AA R1 R2 IVC* A P Aortic Valve Opening AVO MVC Mitral Valve Closure

33 32 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

34 33 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

35 34 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

36 35 PQT P AA R1 R2 QT IVC IVR A MVC P EE E Aortic Flow Aortic Flow Pre Ejection Period (PEP) LBBB: Resynchronization

37 36 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

38 37 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

39 38 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

40 39 Transmitral Flow At short AV delay AV short = 50 ms QA short = 128 ms 128 ms Begin Q E A

41 40 Transmitral Flow At long A-V delay AV long = 160 ms QA long = 48 ms 48 ms Q E A

42 41 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

43 42 AV Delay Optimization Short AVLong AVOptimal AV

44 43 AV Delay Optimization Saxon et al., NASPE 2004

45 44 AV Delay Optimization Long AV 160 ms Short AV 50 ms Optimal AV 100 ms

46 45 AV Delay Optimization Flow Velocity at Mitral Valve Aortic Velocity Time Integral Doppler Echocardiography

47 46 Doppler Echo Apical Five Chamber View

48 47 Doppler Echo Aortic Flow Velocity Kruck, Biamino 1988

49 48 Aortic Flow Velocity LBBB AAA Aortic Flow Aortic Flow Velocity Time

50 49 Aortic Flow Velocity Biventricular Pacing A E AVD Aortic Flow Aortic Flow Velocity Time

51 50 Velocity Time Integral Fehske 1988 Integral = Area under the curve VTI = AVO AVC V * dt (cm)

52 51 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

53 52 AV Delay Optimization Dr. Uhrig, Vivantes Urban Hospital Berlin VTI = 12.7 cmVTI = 20.5 cm Velocity Time Integral

54 53 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

55 54 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 %

56 55 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

57 56 LV dP/dt max LV Pressure (mmHg) dP/dt (mmHg/s) Jansen et al., Am J Cardiol 2006

58 57 Agreement with LV dP/dt max GoodGood to reasonable % Jansen et al., Am J Cardiol 2006

59 58 AV Delay Optimization Empirical Calculation Echocardiography Pulse pressure Methods

60 59 AV Delay Optimization Pulse pressure: hemodynamic testing Calculation: initial programming Doppler Echo: non-responders Summary

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

62 61 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

63 62 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

64 63 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

65 64 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

66 65 V-V Optimization Bordachar et al., JACC 2004 Cardiac OutputMitral Regurgitation Tissue Doppler Imaging – Intra LV delay peak

67 66 41 CHF pts. with CRT-PM V-V Optimization No. of pts. Bordachar et al., JACC ms LV firstRV first

68 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

69 68 V-V Optimization van Gelder et al., Am J Cardiol 2004 AFSR ischemicSR non-ischemic

70 69 V-V Optimization van Gelder et al., JCE 2008 dP/dt max BaselineVV=0QuickOptVV dP/dt 32 HF pts. with CRT, 20 CAD, SR, QRS 170 ms, EF 23%

71 70 Optimizing BiV Pacing

72 71 Optimizing BiV Pacing I V1V1 RV onlyLV onlyBiVBiV LV first

73 72 Optimizing V-V Delay Start with standard setting VV optimization in patients with persistent dyssynchrony Trouble shooting option in clinical non-responders Summary

74 73 Optimization of BiV Pacing A-V Delay V-V Delay


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