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Natale MARRAZZO Francesco SOLIMENE

Quando la CRT-P può bastare?. Natale MARRAZZO Francesco SOLIMENE. European Heart Journal (2008) 29, 2388–2442. Introduction. CRT in NYHA function class IV CRT in NYHA function class I CRT in PERMANENT AFib CRT in conventional PM INDICATION CRT in RENAL FAILURE CRT in ADVANCED AGE.

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Natale MARRAZZO Francesco SOLIMENE

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

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

  3. Introduction • CRT in NYHA function class IV • CRT in NYHA function class I • CRT in PERMANENT AFib • 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 COMPANION CARE-HF

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

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

  7. CRT in NYHA function class III/IV 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

  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 NYHA I MADIT-CRT REVERSE

  12. CRT in NYHA function class I/II Device selection • 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

  13. CRT in NYHA function class I/II 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

  14. CRT and PERMANENT AFib

  15. CRT and PERMANENT AFib

  16. CRT and PERMANENT AFib

  17. CRT and PERMANENT AFib 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

  19. CRT and a conventional PM INDICATION

  20. CRT and a conventional PM INDICATION 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. CRT and RENAL FAILURE PACE 2008; 31:575–579

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

  23. CRT and RENAL FAILURE 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

  24. CRT and RENAL FAILURE 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

  26. CRT and ADVANCED AGE

  27. CRT and ADVANCED AGE

  28. CRT and ADVANCED AGE

  29. CRT and ADVANCED AGE 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

  30. The challenge ofselectingpatientsfor ICD therapy • Cost • Life expectancy • Complications • Inappropriate shocks • Patient’s persective

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