HIL 26.11.13. CRT

Kardiale Resynchronisation
CHF-Lunch vom 26.11.2013
PD Dr. Beat Schär
[email protected]
CHF
Todesursachen
70%
60%
50%
40%
pump failure
sudden
other
30%
20%
10%
0%
NYHA II NYHA III NYHA IV
N=110
N=232
N=27
MERIT - HF. Lancet. 1999;353:2001-07.
Prävalenz und Prognose von
Electrical Dyssynchrony
LBBB More Prevalent with
Impaired LV Systolic Function
Increased All-Cause Mortality
with Wide QRS at 45 Months (3)
P < 0.001
Preserved 8%
LVSF (1)
Impaired
LVSF (1)
49%
34%
24%
Mod/Sev
HF (2)
38%
1. Masoudi, et al. JACC. 2003;41:217-223.
2. Aaronson, et al. Circulation. 1997;95:2660-2667.
QRS
< 120 ms
QRS
≥ 120 ms
3. Iuliano, et al. AHJ. 2002;143:1085-1091.
Bedeutung des LSB bei CHF
Baldasseroni Am Heart J 2002
CRT Anwendung bei der CHF
Maggioni et al. Eur J Heart Fail 2010
Normale elektrische Aktivierung
90 ms
150 ms
ECG
RA / RV
LA / LV
A
V
A
V
Elektrische Aktivierung beim LSB
160 ms
ECG
150 ms
150 ms
RA / RV
+80
230 ms
LA / LV
Prolonged left-sided AV-Interval
Folgen des LSB bei CHF
-
-
-
verzögert erregte lateraler Wand
Kontraktion damit erst, wenn das Septum bereits wieder
in Relaxation begriffen ist
relevante Funktionseinbusse des Ventrikels
(mechanische Dyssynchronie)
weitere Verminderung der LVEF
Mitralinsuffizienz
Erhöhung der Fülllungsdrücke
„Krankheit“ per se oder Folge einer Kardiopathie?
Case presentation
Mr. U.L.; 9.9.1956
(Former) security officer in large Swiss bank
Until summer 2009 patient is fine
10/2009 pulmonary infection
Progressing dyspnea and reduced physical capacity
End of 11/2009 hospitalisation for CHF
MRI compatible with myocarditis, LVEF 16%
Discharge with Carvedilol 2x3.125mg, Ramipril 3.75mg, Nitropatch, Torasemid 10mg
1/2010: Dyspnea II-III (can walk slowly 300m or 2 flights of stairs,
then severe dyspnea)
3/2010: Dyspnea slightly better, LVEF in echo 21%,
Therapy now Carvedilol 2x12.5mg, Ramipril 5mg, Torasemid 5mg
Problem:
orthostatic symptoms, weight gain, when diuretics stopped.
1/2011
Walking for 2 hours possible
Gentle inclination leads to sudden dyspnea
Carvedilol 2x25mg, Ramipril 2x5mg, Spironolactone 25mg
LVEF 30%, trace MI, PAP 35mmHg
7/2012
Dyspnea slightly worse
Patient not satisfied with situation
From his point of view no ameloriation after CRT
LVEF 31%
7/2013
Dyspnea much better NYHA I
Patient satisfied with situation, has bought a young dog
Dilatrend 2x25mg, Ramipril 2x2.5mg, Inspra 25mg
Benefit einer optimalen medikamentösen
Therapie
SOLVD
CONSENSUS
-16 to -31%
CIBIS II
COPERNICUS
- 35%
RALES
- 22%
Digoxin
Diuretics
Hydralazine
CARE-HF
ACE Inhib.
-40%
ß-blockers
+ ACE Inhib.
Adapted from Ellenbogen KA et al.; J Am Coll Cardiol 2005;46:2199 –203
ß-blockers
+ ACE Inhib.
+ Aldosterone
antagonists
ß-blockers
+ ACE Inhib.
+ Aldost. antag.
+ CRT
CARE-HF
Primary endpoint: death from any cause or unplanned hospitalization
159 (39%)
224 (55%)
Cleland, NEJM 2005;352:1539
CRT reduziert Sudden Cardiac Death
(CARE-HF Extension Study)
-46%
Hazard Ratio 0.54
(95% CI 0.35 to 0.84; P=0.006)
1.00
CRT
Medical
Therapy
...but not at the beginning
0.75
Survival
Mean Follow-up
0.50
0.25
0.00
CRT = 32 sudden deaths (7.8%)
Medical Therapy = 54 sudden deaths (13.4%)
0
400
800
Time (days)
Cleland et al.; Eur Heart J. 2006 Aug;27(16):1928-32
1200
1600
MADIT CRT
1820 pts NYHA I or II
QRS width > 130 ms
CRT-D vs ICD (3:2)
Primary end point:
heart failure event or death
Mean follow-up: 28 months
Moss A et al., N Engl J Med 2010
MADIT CRT
Primary endpoint driven by
reduction of HF admission
NB outpatient iv diuretic qualified
Annual mortality rate:
3% both groups (ns)
Moss A et al., N Engl J Med 2010
Subgruppenanalyse
Moss A et al., N Engl J Med 2010
MADIT CRT
LSB und nicht-LSB
http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/CirculatorySystem
DevicesPanel/ucm204585.htm
CRT-Outcome bei Nicht-LSB pattern
335 CRT patients (LBBB 204, RBBB 38, IVCD 27)
Rickard J et al., PACE 2010
ALTITUDE survival study
CRT-D
1y: 88%
5y: 54%
CRT-P
1y: 82%
5y: 48%
Saxon LA et al., Circulation 2010
Reverse remodelling
Reverse remodelling: Persistent effect of CRT
Ejection fraction (%)
70
60
50
40
30
20
10
0
9
8
7
6
5
4
3
2
1
(n
(n
(n
(n
(n
(n
(n
(n
=8
=8
=1
=2
=3
=5
=7
=1
)
)
3)
8)
3)
7)
7)
22
)
)
78
43
=1
=1
(n
(n
BL
)
time (years)
S Frey…. B Schaer i.p.
Reverse remodelling nur mit CRT?
= LVESV
Einfluss von Komorbiditäten
Theuns/Schaer, Europace 2010
CRT-D im Langzeitverlauf
49 Patienten des USB
Follow-up mindestens 5 Jahre
80% Primärprävention
65% nicht-ischämische Kardiopathie
At implant
During Follow-up
NYHA IV
NYHA III
NYHA II
NYHA I
NYHA class II
10
0
4
5
1
NYHA class III
29
0
13
11
5
NYHA class IV
8
1
3
3
1
Bossard/Schaer Swiss Medical Weekly in press
«Mortalität» 8%
ICD-Therapien: 28%; nur 8% für FVT >220 oder FV
LVEF Verbesserung von 23% auf 37%, davon 47% auf > 35%
Nachteile
Aggregatswechsel: mean nach 54 Monate
10 Patienten mit Phrenicus-Stimulation
14 major complications
(sonde defekt[4], sonde disloziert[7], infektion [2], thrombose [1])
CRT-P oder CRT-D
20‘000 oder 45‘000 CHF
Primäre/Sekundäre Prävention
Ischämische/Nicht-ischämische Kardiopathie
Alter
Komorbiditäten
«Ziele» des Patienten
In der Schweiz 2011: 238 CRT-P und 307 CRT-D
Cave: USA RBBB not reimbursed!