1. CRT Overview
This lecture is intended to give a basic overview of HF to include:
-General knowledge of the cardiac cycle and how a normal heart should function
-The incidence and prevalence of HF
-The patient outcomes with respect to mortality and hospitalization
-The description of the classic HF patient
-NYHA class and Stages, distribution of population, and modes of death
-The decompensation of the HF patient and the treatments provided
-Where CRT fits into the HF continuum

2. CRT : Cardiac Resynchronization Therapy
Heart Failure 환자에 적용
2005년 8월 1일부터 보험 급여
CRT-P : CRT Pacemaker (Low power)
CRT-D : CRT + ICD (High power)

3. 2005 Hear Failure Guidelines Recommendations for Device Therapy
CRT Indication
2005 Hear Failure Guidelines Recommendations for
Device Therapy
LVEF less than or equal to 35% (<35%)
Sinus rhythm
NYHA Functional Class III or Ambulatory Class IV symptoms
Despite recommended, optimal medical therapy
And who have cardiac dysynchrony, which is currently defined as a QRS duration greater than 120ms (>120ms)

4. CRT Indication What is Heart Failure?
“Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.”
ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

5. CRT Indication Large K9 Heart
(approximately the size of normal human heart)
Heart from MIRACLE study patient

6. Ventricular Dysynchrony and Cardiac Resynchronization
Electrical: Inter- or Intraventricular conduction delays typically manifested as left bundle branch block
Structural: disruption of myocardial collagen matrix impairing electrical conduction and mechanical efficiency
Mechanical: Regional wall motion abnormalities with increased workload and stress—compromising ventricular mechanics
Cardiac Resynchronization
Therapeutic intent of atrial synchronized biventricular pacing
Modification of interventricular, intraventricular, and atrial-ventricular activation sequences in patients with ventricular dysynchrony
Complement to optimal medical therapy
1 Tavazzi L. Eur Heart J 2000;21:

7. The Donkey Analogy
Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…

8. Digitalis Compounds
Like the carrot placed in front of the donkey

9. Diuretics, ACE Inhibitors
Reduce the number of sacks on the wagon

10. ß-Blockers
Limit the donkey’s speed, thus saving energy

11. Cardiac Resynchronization Therapy
Increase the donkey’s (heart) efficiency

12. Atrial-synchronized bi-ventricular pacing
LV Lead Implant
Atrial-synchronized bi-ventricular pacing
☞ Transvenous Approach
▶ Standard pacing lead in RA
▶ Standard pacing or defibrillation lead in RV
▶ Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus

13. Selecting Vein for CRT Lead Placement
LV Lead Implant
Selecting Vein for CRT Lead Placement
Target: Left ventricular free wall
(Lateral, Poster-lateral, Antero-lateral) 1,2,3
A. Lateral (marginal) cardiac vein
B. Postero-lateral cardiac vein
C. Posterior cardiac vein
D. Middle cardiac vein
E. Great cardiac vein E A A B B C D E C D
1. Ansalone et al. JACC. 2002;39:
2. Butter et al. CIRCULATION. 2001;104:
3. Auricchio et al. AJC. 1999;83:136D-142D
LAO View

14. LV Lead Implant

15. Left heart Delivery System

16. CS Cannulation
Use extreme care when passing the guide catheter through vessels
Due to the relative stiffness of the catheter, damage to the walls of the vessels may include dissections or perforations

17. Attain Balloon Catheter
Balloon occludes most coronary sinuses – inflates to 10 mm
Balloon can be inflated and deflated several times
Contrast solution can be injected through catheter

18. CS Anatomy
AP View
LAO View

19. Coronary Sinus Lead Attain OTW LV Lead 4 Fr. Lead Body
Unipolar, Polyurethane
5.8 mm2 tapered annular electrode
Steroid eluting
Silicone-Sealed Lead Tip
Two distal curves
Over-The-Wire Lead Body Advancement with Stylet or Guide Wire (<0.018”)
Standard IS-1 connector
Steroid collar
Electrode
Tip seal
Guide wire

20. CS Branch Selection
Advance lead near the cardiac vein ostium
3. Advance lead over the wire into the cardiac vein
Steer guide wire tip deep into cardiac vein

21. LV Lead Implant
LV Lead Placement (with guide wire)