Nuove prospettive nel campo della Resincronizzazione Cardiaca (CRT)

Tullio Agricola

Ospedale Spirito Santo

Pescara

Prevalenza dei ritardi di conduzione inter- o intraventricolari nei pts con scompenso

1 Havranek E, Masoudi F, Westfall K, et al. Am Heart J 2002;143:412-4172 Shenkman H, McKinnon J, Khandelwal A, et al. Circulation 2000;102(18 Suppl II): abstract 22933 Schoeller R, Andersen D, Buttner P, et al. Am J Cardiol. 1993;71:720-7264 Aaronson K, Schwartz J, Chen T, et al. Circulation 1997;95:2660-26675 Farwell D, Patel N, Hall A, et al. Eur Heart J 2000;21:1246-1250

IVCD 15%

IVCD >30%

Popolazione con scompenso in generale1,2

Popolazione con scompenso moderato o severo 3,4,5

IVCD 15%IVCD >30%

Conseguenze Cliniche della Dissincronia Ventricolare

• Movimento anormale della parete del setto interventricolare1

• Ridotto dP/dt3

• Tempo di riempimento diastolico ridotto1,2

• Durata prolungata del rigurgito mitralico (MR)1,2

1 Grines CL, Bashore TM, Boudoulas H, et al. Circulation 1989;79:845-853. 2 Xiao, HB, Lee CH, Gibson DG. Br Heart J 1991;66:443-447. 3 Xiao HB, Brecker SJD, Gibson DG. Br Heart J 1992;68:403-407.

Click to Start/Stop

• In the EuroHeart Failure survey, 36% of those who had LV function assessed had an LVEF ≤ 35% and, of these, 41% had a QRS duration ≥120 ms; 7% had RBBB, 34% had LBBB or other intraventricular conduction delay (IVCD) and 17% had QRS ≥150 ms

• In the Italian Network on CHF (IN-CHF) registry, 1391 patients (25%) had complete LBBB, 336 (6%) had complete RBBB and 339 (6%) had other forms of IVCD.

• The annual incidence of LBBB is about 10% in ambulatory patients with left ventricular systolic dysfunction (LVSD) and chronic HF

Epidemiology, Prognosis, and Pathophysiology of Heart Failure

2013 ESCGuidelines on cardiac pacing and cardiac resynchronization therapy

J Am Coll Cardiol Img. 2013;6(8):924-926. doi:10.1016/j.jcmg.2013.07.002

Normal Heart

LBBB

1. Vena cardiaca Laterale (marginale)

2. Vena cardiaca Postero-laterale

3. Vena cardiaca Posteriore

4. Vena cardiaca Media

5. Vena cardiaca Grande

12

3

4

5

Posizionamento del catetere ventricolare sinistro

La Stimolazione Biventricolare (CRT)

Spontaneo CRT

Modificazione del complesso QRS con la stimolazione biventricolare

Effetto della CRT sulla funzione cardiaca

• Movimento anormale della parete del setto interventricolare1

• Ridotto dP/dt3

• Tempo di riempimento diastolico ridotto1,2

• Durata prolungata del rigurgito mitralico (MR)1,2

1 Grines CL, Bashore TM, Boudoulas H, et al. Circulation 1989;79:845-853. 2 Xiao, HB, Lee CH, Gibson DG. Br Heart J 1991;66:443-447. 3 Xiao HB, Brecker SJD, Gibson DG. Br Heart J 1992;68:403-407.

Click to Start/Stop

1 Nishimura et al. J Am Coll Cardiol. 1995; 25:281.2 Walker et al. Europace 2000;I(suppl D): abstract 212/5. 3 Brecker et al. Lancet. 1992;340:1308.

Ottimizzazione intervallo AV

– Riduce il rigurgito mitralico1,2,3

– Aumenta il tempo di riempimento diastolico

– Migliora il dP/dt del ventricolo sinistro

Effetto della CRT sulla funzione cardiaca

2013 ESCGuidelines on cardiac pacing and cardiac resynchronization therapy

18%

29%

La Stimolazione Biventricolare (CRT)

1. Stimolazione biventricolare è indicata nei pazienti con disfunzione ventricolare sinistra e dissincronia ventricolare (BBSX)

2. Posizionamento di elettrocatetere per il ventricolo sinistro attraverso una vena tributaria del seno coronarico (laterale o postero-laterale)

3. Insuccesso dovuto a: anatomia del CS e dei suoi rami, instabilità dei cateteri, soglie elevate, stimolazione diaframmatica,etc

4. Elevata morbidità e mortalità dell’approccio chirurgico

5. Non responder >30% dei pazienti

Figure 1. Methods, indicating the position of pacing leads and multielectrode arrays.

van Deursen C et al. Circ Arrhythm Electrophysiol. 2009;2:580-587

Copyright © American Heart Association, Inc. All rights reserved.

Figure 2. Three-dimensional reconstruction of electrical activation times in the RV and LV, as measured with epicardial and endocardial electrodes (see Figure 1).

van Deursen C et al. Circ Arrhythm Electrophysiol. 2009;2:580-587

Copyright © American Heart Association, Inc. All rights reserved.

Figure 3. Activation time delays (ms) from the lateral to septal wall, from the base to apex and transmurally across the LV wall, as determined during pacing at the basal lateral wall with a

short AV interval.

van Deursen C et al. Circ Arrhythm Electrophysiol. 2009;2:580-587

Copyright © American Heart Association, Inc. All rights reserved.

Figure 4. Percent increase in electrical LV resynchronization (percent reduction in LV activation time) (A) and LVdP/dtmax (B) during ENDO and EPI-BiV pacing compared with

baseline atrial pacing in the LBBB heart.

van Deursen C et al. Circ Arrhythm Electrophysiol. 2009;2:580-587

Copyright © American Heart Association, Inc. All rights reserved.

Figure 5. Left, Example from a study of pressure-volume diagrams of the LV during ENDO (black) and EPI BiV pacing (gray line) and their related baseline states (broken lines).

van Deursen C et al. Circ Arrhythm Electrophysiol. 2009;2:580-587

Copyright © American Heart Association, Inc. All rights reserved.

Figure 8. A, Percent decrease in Tpeak-Tend (left) and percent decrease in dispersion of repolarization during EPI and ENDO-BiV pacing.

van Deursen C et al. Circ Arrhythm Electrophysiol. 2009;2:580-587

Copyright © American Heart Association, Inc. All rights reserved.

Date of download: 10/5/2014

Copyright © The American College of Cardiology. All rights reserved.

From: Optimizing Hemodynamics in Heart Failure Patients by Systematic Screening of Left Ventricular Pacing Sites: The Lateral Left Ventricular Wall and the Coronary Sinus Are Rarely the Best Sites

J Am Coll Cardiol. 2010;55(6):566-575. doi:10.1016/j.jacc.2009.08.045

Distribution of LV Pacing Sites and Catheter Position(A) Predetermined left ventricular (LV) pacing site used during the study. The LV cavity was divided into 9 zones: 4 basal, 4 mid-cavity (inferior, lateral, anterior, and septal aspects), and 1 apex. One site was epicardial in a lateral branch of the coronary sinus (CS), and 1 site was endocardial just facing the CS pacing site. (B) Catheter position during the study.

Figure Legend:

Date of download: 10/5/2014

Copyright © The American College of Cardiology. All rights reserved.

From: Optimizing Hemodynamics in Heart Failure Patients by Systematic Screening of Left Ventricular Pacing Sites: The Lateral Left Ventricular Wall and the Coronary Sinus Are Rarely the Best Sites

J Am Coll Cardiol. 2010;55(6):566-575. doi:10.1016/j.jacc.2009.08.045

Impact of Left Ventricular Pacing at the Best +dP/dTmax LocationComparison of hemodynamic change when the pacing site is defined by the site associated with the greatest improvement of +dP/dTmax. AV = atrioventricular; CS = coronary sinus; ESP = end-systolic pressure; PP = pulse pressure.

Figure Legend:

Vantaggi della LVEP

1. Potenziale accesso a tutte le regioni del ventricolo sinistro

2. Propagazione più rapida dell’impulso elettrico nell’endocardio con altrettanto più rapida ripolarizzazione

3. Più fisiologica stimolazione del VS con preservazione dell’attivazione transmurale e della sequenza di ripolarizzazione

4. Possibilità di un migliore controllo degli indici di contrattilità

5. La CRT classica presenta più del 30% di non responder. Nelle limitate casistiche con LVEP i risultati sono migliori.

From: Left Ventricular Endocardial Stimulation for Severe Heart Failure

J Am Coll Cardiol. 2010;56(10):747-753. doi:10.1016/j.jacc.2010.04.038

Fluoroscopic Views During Transseptal ImplantationFluoroscopic views from a recipient of an atriobiventricular cardiac resynchronization therapy system, with the left ventricular endocardial lead implanted transseptally. (A) The septum was punctured with a needle preformed to reach the fossa ovalis. The proximal segment of a guidewire was then placed in the left atrium. (B) A sheath was introduced into the left atrium along the guidewire, and the stimulation lead was advanced through the sheath.

Svantaggi della LVEP

• Complicanze tromboemboliche

• Complicanze legate all’eparina durante la procedura

• Interazione con la valvola mitrale

• Rischi di eventuale estrazione

From: Left Ventricular Endocardial Stimulation for Severe Heart Failure

J Am Coll Cardiol. 2010;56(10):747-753. doi:10.1016/j.jacc.2010.04.038

Transseptal Passage of a Left Ventricular Endocardial LeadTransseptal passage of a left ventricular endocardial lead (arrow) and absence of adhesion at the level of the mitral valve (green star), in a cardiac resynchronization therapy recipient who died suddenly from a ventricular tachyarrhythmia.

Tecniche di Impianto

Approccio Transettale Ventricolare

Approccio Transaortico

ALSYNC: LV Endocardial Pacing Could Help in CRT Nonresponse

• In a 138-patients not suitable for or not responder to traditional CRT

• Safety and efficacy study of LV endocardial-lead CRT

• 16 centers in Europe and two in Canada • About two-thirds of the group showed some kind of

functional or reverse-remodeling response characteristic of standard CRT over at least six months of follow-up.

Prof John Morgan (Southampton University Hospitals Trust, UK) Heart Rhythm Society 2014 Scientific Sessions

Rates of Achieving Functional, Reverse-Remodeling Improvements in ALSYNC

End Points All Patients (%) Patients With Prior Failed CRT Implant (%)

Patients With Prior CRT Nonresponse (%)

LVESV >15% improvement

55 57 47

LVEF >5-point improvement

64 65 61

NYHA class >1 class improvement

60 63 52

Mitral regurgitation >1 class improvement

33 29 43

LVESV=left ventricular end-systolic volumeLVEF=left ventricular ejection fraction

CONCLUSIONI

• Studi sperimentali su modelli animali ed umani hanno dimostrato il beneficio emodinamico della stimolazione endocardica LV rispetto a quella epicardica nei pazienti candidati alla CRT

• I pazienti candidati alla stimolazione LV endo sono i non responders o coloro nei quali è fallito il tentativo di impianto di un catetere epicardico in maniera convenzionale.

• Esistono diversi modi per ottenere una stimolazione endocardica del ventricolo sinistro, specialmente se la tecnologia leadless diventasse disponibile