Se, come e quando l’ottimizzazione è necessaria? How and When Optimization Is Needed?

1. Se, come e quando l’ottimizzazione è necessaria? How and When Optimization Is Needed? M. Cristina Porciani Firenze

2. There is no doubt that CRT has revolutionized treatment for patients with medically resistant LV systolic dysfunction, and abroad QRS • However up to 40% ma not benefit fromdeviceimplantation or even deteriorate • The exactreasonforlackofresponseisstillunclear , butmay due tofactorssuchas minimal preimplantdyssynchrony, inadeguate leadplacement,scarburden, and alsodevicesettingwithinappropiatepacingparametersfor a givenindividual

3. CurrentCRT devices allow manipulation of the AV and VV timings CRT OPTIMIZATION • However, multiple single centre and few multicenter trials have provided controversial data • Whileseveral invasive and non invasive studieshavedemonstratedthatoptimizing AV and VV intervals can acutelyimprovehemodynamicparameters, evidenceabout the croniceffectisscars • In addition, multiple methodologies have been proposed to optimize AV and VV intervals but no consensus has been reached on which methodology should preferably be used.

4. Gras D. PACE 2009

5. CRT OPTIMIZATION AV optimization VV optimization

7. PhysiologicalPrinciples AV Optimization AV optimization

8. Appropriate AVD

9. PhysiologicalPrinciples AV Optimization

10. PhysiologicalPrinciples AV Optimization

11. Evidencefor acute improvementinducedby AV optimization in traditionalpacemakers 15pts with severe HF Nishimuraet al .JACC 1995

12. Evidencefor acute improvementinducedby AV optimization in CRT Average percentage change in systolic parameters as a function of 5 normalized AV delays for each pacing chamber (RV,LV, and BV). Tested AV delays were normalized to the patient’s PR interval minus 30 ms Auricchio A. Circulation 1999

13. Evidencefor acute improvementinduced AV optimization : Echocardiographicmethods

14. Evidencefor acute improvementinduced AV optimization in CRT Relative improvement in the Doppler parameters vs. baseline value after AV optimization Open bars standard settings Hatched bars optimized CRT Solid bars relative variability of the parameters during optimization Stockburger M. et al Europace 2006

15. Whataboutcronicimprovementinduced AV optimization ? Echocardiographyoptimizationofatrioventricular delay was included in several randomized trials in CRT MIRACLE Ritter’s method CARE-HF : iterative method COMPANION: a device-based algorithm

16. Evidenceforlong-termimprovementinducedby AV optimization ECO-Opt AV AV 120ms (n 20 pts) (n 20 pts) *P .05 vs baseline Sawhney NS, HeartRhythm 2004

17. SMART-AV Trial prospectivelyrandomizedptsto a fixed AV(120ms), echooptimized AV and opimized with Smart Delay ( electrogrambasedalgorithm ) in a 1:1:1ratio Pts mean follow-up 5.8±monts Ellenbogen K A Circulation 2010

18. SMART-AV Trial Ellenbogen K A Circulation 2010

19. SMART-AV Trial Ellenbogen K A Circulation 2010

20. Evidenceforlong-termimprovementinducedby AV optimization RetrospectiveStudy 205 pts Mean Follow-up 35 months Kaplan–Meier estimates showing time to the primary endpoint, survival free of cardiac hospitalization Adlbrecht C Eur J Clin Invest 2010

21. Adlbrecht C Eur J Clin Invest 2010

22. 75 Pts non respondersto CRT Mullens W JACC 2009

23. 75 Pts non respondersto CRT Mullens W JACC 2009

24. PhysiologicalPrinciples VV Optimization VV optimization

25. ►Despitesimilar QRS morphologyptswith HF and LBBB maypresentdifferentpattensofventricularasynchrony ►The presenceofscar and slow or blockedconduction areasaffects the timetoachieve a global depolarizationof the ventricle

26. Effectof RV, LV and BiVPacing on depolarisationwavefons RV LV BiV Lambiaseet al. Heart 2004

27. 9 pz 11pz GSCA: Global SystolicContractionAmplitude Sogaard P et al .Circ 2002

28. LVEF% GSCA mm LVEDV ml LVESV ml BaselineSimultaneousSequentialBaselineSimultaneousSequential Sogaard P et al .Circ 2002

29. Echocardiographicmethodsfor V-V optimization

30. Optimizationguidedbyechocardiography Lim SH Europace 2008

31. Optimizationguidedby invasive monitoring Lim SH Europace 2008

32. Long-term benefit of CRT optimization when compared with simultaneous biventricular pacing 121 pts, randomized simultaneous (30) optimized ( 91) Boriani G et al Am H J 2005

33. Leon AR JACC 2005

34. 100 pts 49 non opt 51 opt ◄ Vidal B et al Am J Cardiol 2007

35. 100 pts 49 non opt 51 opt ◄ Vidal B et al Am J Cardiol 2007

36. DECREASE_HF trial three-armrandomized LV pace only, simultaneous and optimized sequential biventricular pacing (1:1:1 ratio). 306 pts Rao RK Circulation 2007

37. CRT OPTIMIZATION AV optimization VV optimization Resultsabout the long term benefit inducedby V-V optimizationappeardiscouragingmainlyfor VV interval

38. Conclusions • Optimization can improvehemodynamicsacutely, but long-term clinical improvements are currently less convincing • Until more definitive evidence is available, however, we must do the best for our patients • It is important to remember that HF pts even a small increase in exercise capacity can make a vast personal difference • Optimization has never been shown to be detrimental so it should certainly be performed in those not receiving benefit with empiric settings, but should also be considered in all other patients