1. Natale MARRAZZO Francesco SOLIMENE Quando la CRT-P può bastare?

2. European Heart Journal (2008) 29, 2388–2442

3. Introduction CRT in NYHA function class IV  CRT in NYHA function class IV CRT in NYHA function class I  CRT in NYHA function class I CRT in PERMANENT AFib  CRT in PERMANENT AFib CRT in conventional PM INDICATION  CRT in conventional PM INDICATION  CRT in RENAL FAILURE  CRT in ADVANCED AGE

4. CRT in NYHA function class III/IV Impact of CRT therapy on morbidity COMPANIONCARE-HF

5. CRT in NYHA function class III/IV Impact of CRT therapy on mortality COMPANIONCARE-HF

6. CRT in NYHA function class III/IV Ambulatory patients in NYHA function class IV Primary time to all-cause death or hospitalization Secondary time to all-cause death COMPANION

7. Key issues  LV dilatation no longer required  Class IV patients should be ambulatory  Reasonable expectation of survival with good functional status for 1 y for CRT-D  Evidence is strongest for patients with typical LBBB  Similar level of evidence for CRT-P and CRT-D CRT in NYHA function class III/IV

8. CRT in NYHA function class I/II Clinical evidence MADIT CRT

9. CRT in NYHA function class I/II Clinical evidence REVERSE

10. CRT in NYHA function class I/II Clinical evidence REVERSE

11. CRT in NYHA function class I/II MADIT-CRT REVERSE NYHA I

12. CRT in NYHA function class I/II In favour of implantation of CRT-D ♥ Predominantly or exclusively implanted CRT-D ♥ Younger age, lower comorbidity and longer life expectancy In favour of implantation of CRT-P ♥ Survival advantage with CRT-D was not shown ♥ LVEF increase to > 35% (NO ICD indication in HF) ♥ Higher risk of device-related complications with CRT-D Device selection

13. Key issues  MADIT-CRT and REVERSE demonstrate reduced morbidity  In REVERSE and in MADIT-CRT NYHA I pts had been previously symptomatic  Improvement primarily seen in pts with QRS ≥150 ms and/or typical LBBB.  In MADIT-CRT, women with LBBB demonstrated a particularly favourable response  Survival advantage not established  In MADIT-CRT the extent of reverse remodelling was concordant with and predictive of improvement in clinical outcomes CRT in NYHA function class I/II

14. CRT and PERMANENT AFib

17. Key issues  Approximately one-fifth of CRT implantations in Europe are in patients with permanent AF  NYHA class III/IV symptoms and an LVEF of ≤35% are well- established indications for ICD  Frequent pacing is defined as ≥95% pacemaker dependency  Evidence is strongest for patients with an LBBB pattern  Insufficient evidence for mortality recommendation

18. CRT and a conventional PM INDICATION CRT and a conventional PM INDICATION

20. Key issues  In patients with a conventional indication for pacing, NYHA III/IV symptoms, an LVEF of ≤35%, and a QRS width of ≥120 ms, a CRT- P/CRT-D is indicated  RV pacing will induce dyssynchrony  Chronic RV pacing in patients with LV dysfunction should be avoided  CRT may permit adequate up-titration of b-blocker treatment

21. PACE 2008; 31:575–579 CRT and RENAL FAILURE CRT and RENAL FAILURE

22. PACE 2008; 31:575–579 CRT and RENAL FAILURE CRT and RENAL FAILURE

23. Retrospective study on n=239 ICD pts (all 1-ary prev) CR-dysf = creatin.>2mg/dl or under dialysis FU: 18±15 months Mortality in CR-dysf: 48.6% Mortality in controls: 8.2% Cuculich P & al. PACE 2007 CRT and RENAL FAILURE CRT and RENAL FAILURE

24. Key issues  RF is associated with an increased risk for all-cause mortality, largely explained by an increased risk for pump- failure death  High creatinine remaines an independent predictor of mortality in CRT recipients  RF pts despite ICD implantation extract little, if any, survival benefit from this therapy

25. CRT and ADVANCED AGE CRT and ADVANCED AGE

29. Key issues  HF is predominantly a disorder of older adults  Very few pts over age 75 were enrolled in the major ICD trials  None of the CRT trials included pts in this age range  With respect to ICDs: high procedural complication rates, short life expectancy, high risk of dying from causes other than SCD  ICD is unlikely to be favorable for most pts

31. The challenge of selecting patients for ICD therapy ♥ Cost ♥ Life expectancy ♥ Complications ♥ Inappropriate shocks ♥ Patient’s persective