British Columbia CIHR Research Chair Disclosure CIHR research - PowerPoint PPT Presentation

Professor of Medicine Island Medical Program, University of British Columbia CIHR Research Chair

Disclosure  CIHR research chair (jointly funded by CIHR and Medtronic of Canada)  Research fund (Medtronic of Canada, St. Jude Medical, Biosense-Webster)  Honorarium (Sanofi- Aventis, Boehringer Ingelheim, Medtronic)

Case 1  48 yr old man  Dilated cardiomyopathy  NYHA class II heart failure symptoms  Permanent AF – resistant to cardioversion and Amiodarone  LVEF 25%, LVEDD 55 mm, LA 55 mm  QRS duration 150 ms  LBBB

Medication AF Managed with anticoagulation and good rate control Optimal HF medical therapy  Carvadilol 37.5 mg BID  Digoxin 0.25 mg OD  Rampril 10 mg OD  Spironolactone 25 mg OD  Warfarin – INR 2-3

Which Device Therapy?  ICD  CRT-P  ICD and CRT (CRT-D)

Patients With Reduced LV Ejection Fraction ACC Heart Failure Guidelines 2009 I IIa IIb III For patients who have LVEF less than or equal to 35%, a QRS duration of greater than or equal to 0.12 seconds, and atrial fibrillation, cardiac resynchronization therapy with or without an ICD is reasonable for the treatment of NYHA functional class III or ambulatory class IV heart failure symptoms on optimal recommended medical therapy. Heart Failure Society of America Guidelines 2012 CRT may be considered for some patients with atrial fibrillation More evidence is needed to guide the appropriate use of CRT in patients with AF

Comparative effects of biventricular and RV pacing in HF patients with chronic AF MUSTIC-AF C Leclercq et al EurHeartJ,2002;23:1780 – 1787

Response to CRT in Patients With Sinus Rhythm Versus Chronic AF Molhoek et al AJC 2004 94:1506

Mortality Molhoek et al AJC 2004 94:1506

Outcomes of CRT in Patients with versus Those Without AF: A Systematic Review and Meta-analysis Wilton, HR 2011;8:1088

Outcomes of CRT in Patients with versus Those Without AF: A Systematic Review and Meta-analysis Wilton, HR 2011;8:1088

The Importance of Performing AV Junction Ablation in Patients With AF M Gasparini, JACC 2006;48:734 – 43

Meta-analysis of CRT studies among AF patients with or without AVN ablation P value for the pooled RR 0.001 Wilton, Heart Rhythm 2011;8:1088

AV Nodal Ablation Predicts Survival in Patients with AF Receiving CRT Dong et al , HR 2010;7:1240

AV Nodal Ablation Predicts Survival in Patients with AF Receiving CRT Dong et al , HR 2010;7:1240

AV nodal Ablation Predicts Survival in Patients with AF Receiving CRT Dong et al , HR 2010;7:1240

Importance of Performing AV Junction Ablation in CRT Patients with Permanent AF Baseline Characteristic Gasparini EHJ 2008;29:1644,

Importance of Performing AV Junction Ablation in CRT Patients with Permanent AF Gasparini EHJ 2008;29:1644,

Importance of Performing AV Junction Ablation in CRT Patients with Permanent AF Gasparini EHJ 2008;29:1644,

RAFT – AF data  In the RAFT study, patients with permanent AF were stratified at randomization Primary Outcome Sub-group analysis

Association of % Bi-Ventricular Pacing with Survival in 9,360 CRT-D Patients with AF Ousdigian et al, HRS meeting 2011

CRT for HF patients with Permanent AF  Case-control studies suggest some benefit of CRT, but with less respond rate, less remodeling, and less mortality and morbidity outcomes benefit  Limited randomized trial data  RAFT provided the largest randomized trial data with only a signal of benefit; however, % pacing was low  Planning a large randomized controlled trial

Case 2 65 year old man  CAD – 2 remote MI; PCI – D1 and RCA   Dyslipidemia, Hypertension  LV EF = 28%  HF – NYHA class II; Exertional dyspnea, lethargy, weakness Medications   Metoprolol 37.5 mg BID  Ramipril 10 mg OD ASA 81 mg OD  Lasix 40 mg OD   Sipronolactone 25 mg OD

ECG Sinus Rhythm QRS duration 210 ms

CRT ?  Yes  No  May be

Kaplan-Meier Curves for QRS Morphology in Medicare Patients with CRT-D Bilchick, Circulation 2010;122:2022

Kaplan-Meier Curves for QRS Morphology in Medicare Patients with CRT-D Bilchick, Circulation 2010;122:2022

QRS Morphology and Cardiomyopathy Type in Medicare Patients with CRT-D Mortality rates based on QRS morphology Mortality Hazards Associated with QRS and cardiomyopathy type morphology and cardiomyopathy type Bilchick, Circulation 2010;122:2022

Outcomes in 61 Patients with RBBB in MIRACLE and CONTAK-CD Nery, HR 2010;8:1083

Independent Predictors of Mortality and Hospitalization in CARE-HF Gervais EJHF 2009;11-699

Effectiveness of CRT by QRS Morphology in MADIT-CRT Zareba, Circulation 2011;123:1061

QRS Morphology and Duration on the Effectiveness of CRT  Patients with LBBB derived more benefit from CRT than Non-LBBB  In patients with LBBB, there is a linear relationship between the effectiveness CRT and QRS duration; however there is no distinctive cut-point to differentiate effective versus non-effectiveness  In patients with non-RBBB, QRS duration 160 ms is a good cut-point above which CRT is effective to reduce outcome of death or HF hospitalization