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Se, come e quando l’ottimizzazione è necessaria? How and When Optimization Is Needed? M. Cristina Porciani Firenze.

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Presentation on theme: "Se, come e quando l’ottimizzazione è necessaria? How and When Optimization Is Needed? M. Cristina Porciani Firenze."— Presentation transcript:

1 Se, come e quando l’ottimizzazione è necessaria? How and When Optimization Is Needed? M. Cristina Porciani Firenze

2  There is no doubt that CRT has revolutionized treatment for patients with medically resistant LV systolic dysfunction, and abroad QRS  However up to 40% ma not benefit from device implantation or even deteriorate  The exact reason for lack of response is still unclear, but may due to factors such as minimal preimplant dyssynchrony, inadeguate lead placement,scar burden, and also device setting with inappropiate pacing parameters for a given individual

3 However, multiple single centre and few multicenter trials have provided controversial data  While several invasive and non invasive studies have demonstrated that optimizing AV and VV intervals can acutely improve hemodynamic parameters, evidence about the cronic effect is scars  In addition, multiple methodologies have been proposed to optimize AV and VV intervals but no consensus has been reached on which methodology should preferably be used. Current CRT devices allow manipulation of the AV and VV timings CRT OPTIMIZATION

4 Gras D. PACE 2009

5 AV optimization VV optimization CRT OPTIMIZATION

6

7 AV optimization Physiological Principles AV Optimization

8 AppropriateAVD

9 Physiological Principles AV Optimization

10 Physiological Principles AV Optimization

11 AV Delay60ms100ms120ms CO(lt/min)3,4 ± 1 3,9 ± 1,1● 3,8 ± 0,9 FT (ms)316 ± 110●293 ± 75295 ± 99 Nishimura et al.JACC 1995 15pts with severe HF Evidence for acute improvement induced by AV optimization in traditional pacemakers

12 Auricchio A. Circulation 1999 Evidence for acute improvement induced by AV optimization in CRT Average percentage change in systolic parameters as a function of 5 normalized AV delays for each pacing chamber (RV,LV, and BV). Tested AV delays were normalized to the patient’s PR interval minus 30 ms

13 Evidence for acute improvement induced AV optimization : Echocardiographic methods

14 Open bars standard settings Hatched bars optimized CRT Solid bars relative variability of the parameters during optimization Relative improvement in the Doppler parameters vs. baseline value after AV optimization Stockburger M. et al Europace 2006 Evidence for acute improvement induced AV optimization in CRT

15 Echocardiography optimization of atrioventricular delay was included in several randomized trials in CRT MIRACLE Ritter’s method CARE-HF : iterative method COMPANION: a device-based algorithm What about cronic improvement induced AV optimization ?

16 Sawhney NS, Heart Rhythm 2004 * P.05 vs baseline ECO-Opt AV AV 120ms (n 20 pts) (n 20 pts) Evidence for long-term improvement induced by AV optimization

17 SMART-AV Trial prospectively randomized pts to a fixed AV(120ms), echo optimized AV and opimized with Smart Delay ( electrogram based algorithm ) in a 1:1:1 ratio Ellenbogen K A Circulation 2010 980 Pts mean follow-up 5.8±monts

18 SMART-AV Trial Ellenbogen K A Circulation 2010

19 SMART-AV Trial Ellenbogen K A Circulation 2010

20 Adlbrecht C Eur J Clin Invest 2010 Retrospective Study 205 pts Mean Follow-up 35 months Evidence for long-term improvement induced by AV optimization Kaplan–Meier estimates showing time to the primary endpoint, survival free of cardiac hospitalization

21 Adlbrecht C Eur J Clin Invest 2010

22 Mullens W JACC 2009 75 Pts non responders to CRT

23 Mullens W JACC 2009 75 Pts non responders to CRT

24 VV optimization Physiological Principles VV Optimization

25 ► Despite similar QRS morphology pts with HF and LBBB may present different pattens of ventricular asynchrony ► The presence of scar and slow or blocked conduction areas affects the time to achieve a global depolarization of the ve ntricle

26 Effect of RV, LV and BiV Pacing on depolarisation wavefons Lambiase et al. Heart 2004 RV LV BiV

27 Sogaard P et al.Circ 2002 GSCA: Global Systolic Contraction Amplitude 9 pz 11pz

28 Baseline Simultaneous Sequential LVEF%GSCA mm LVEDV ml LVESV ml Sogaard P et al.Circ 2002

29 Echocardiographic methods for V-V optimization

30 Lim SH Europace 2008 Optimization guided by echocardiography

31 Lim SH Europace 2008 Optimization guided by invasive monitoring

32 Long-term benefit of CRT optimization when compared with simultaneous biventricular pacing 121 pts, randomized simultaneous (30) optimized ( 91) Boriani G et al Am H J 2005

33 Leon AR JACC 2005

34 Vidal B et al Am J Cardiol 2007 100 pts 49 non opt 51 opt ◄

35 Vidal B et al Am J Cardiol 2007 100 pts 49 non opt 51 opt ◄

36 Rao RK Circulation 2007 DECREASE_HF trial three-arm randomized LV pace only, simultaneous and optimized sequential biventricular pacing (1:1:1 ratio). 306 pts

37 AV optimization VV optimization CRT OPTIMIZATION Results about the long term benefit induced by V-V optimization appear discouraging mainly for VV interval

38 Conclusions Optimization can improve hemodynamics acutely, but long- term clinical improvements are currently less convincing  Until more definitive evidence is available, however, we must do the best for our patients  It is important to remember that HF pts even a small increase in exercise capacity can make a vast personal difference  Optimization has never been shown to be detrimental so it should certainly be performed in those not receiving benefit with empiric settings, but should also be considered in all other patients

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