PRESENTATION NAME

Non Apical RV pacing in CRTdr. Beny Hartono SpJP, FIHADr.dr.Muh.Munawar SpJP,FIHA,FACC,FESC,FSCAI,FAPSIC,FASCC,FCAPSC

Referat

RD Robin H Wibowo

OutlineBackgroundRationaleThe Evidence ConclusionRD Robin H WibowoBackground

RD Robin H WibowoCardiac resynchronization therapy (CRT), also known as biventricular pacing or multisite ventricular pacing, involves simultaneous pacing of the right ventricle (RV) and the left ventricle (LV). To this end, a coronary sinus lead is placed for LV pacing in addition to a conventional RV endocardial lead (with or without a right atrial [RA] lead). (See Permanent Pacemaker Insertion.) he basic goal of CRT is to restore LV synchrony in patients with dilated cardiomyopathy and a widened QRS, which is predominantly a result of left bundle branch block, in order to improve the mechanical functioning of the LV3BackgroundCRT is currently only successful in about two thirds of heart failure patientsThe optimal location of the RV lead is still a matter of debate. RD Robin H Wibowo4BackgroundRV apex has been the preferred site due to the ease of placement, stability, reliability, and lead design. Conventional lead placement in the apex of the right ventricle can induce cardiac dyssynchrony and thus increase morbidity and mortality.RD Robin H Wibowo5 RationaleAcute and long-term effects of RV apical pacing

Changes in electrical activation and mechanical activation Metabolism/perfusion Changes in regional perfusion Changes in oxygen demandRemodeling Asymmetric hypertrophy Histopathological changes Ventricular dilation Functional mitral regurgitation Hemodynamics Decreased cardiac output Increased LV filling pressures Mechanical function Changes in myocardial strain Interventricular mechanical dyssynchrony Intraventricular mechanical dyssynchrony

RD Robin H WibowoJ Am Coll Cardiol. 2009;54:764-7767CRT in HF

Freemantle N et al Eur J Heart Fail 2006;8:433

MortalityHospitalizationNormal conduction

RD Robin H Wibowo

Ramanathan et al mapped the earliest cardiac electrical activation sequences, finding a general cardiac electrical activation sequence common to humans which involves earliest epicardial activation in the right paraseptal region and multiple breakthroughs aligned parallel to the course of the left anterior descending coronary artery.4 (Figure 2)The septo-parietal target zone for non-apical RV septal pacing is proposed on this anatomical-physiological basis.

Fig. 2 Left Inset:Noninvasive ventricular isochrones (activation sequences) using electrocardiographic imaging to image epicardial potentials-Location of earliest activation site in the RV right paraseptal zone within 25msec of QRS onsetelliptical areas of activation can be observed in many subjects parallel to the LAD coronary artery course.Right Inset: RV breakthrough shown as an intense potential negative minimum at the corresponding right paraseptal zone illustrated adjacent.4

9The anatomyRD Robin H Wibowo

3ACadaveric RV RAO dissection showing both inlet and outlet (infundibulum) and septomarginal trabeculations. The proposed course of the lead with the Mond stylet in place has been shown in red. SVC and IVC=superior and inferior vena cava; AA=ascending aorta; MPA=Main pulmonary artery; CS=coronary sinus.3BEndocardial view of the TVOT and high septum showing the septoparietal trabeculations (stars) arising from the septomarginal trabeculation (SMT). Underlying crisscross architecture of myocardial strands allows good lead anchoring. TV=tricuspid valve; MPM and APM= medial and anterior papillary muscles; SC=supraventricular crest; SMT=septomarginal trabeculation3CReconstructed 64 slice cardiac CT view of the RVOT showing the exact course of the Mond stylet from SVC to RA to septum/SPT.1D Two versions of the Mond stylet available with demonstrated primary and secondary curves.

10Angiographic differentiation RD Robin H Wibowo

11 The EvidenceRD Robin H WibowoREVERSE Sub-analysis of the active group (CRT-ON), the precise locations of the LV and RV lead tips based on postoperative AP and lateral chest XrayInternational, multicentre, double- blinded randomized 12-month clinical fup Echocardiographic responsesThe death Heart failure (HF) hospitalizationsRD Robin H WibowoOnly a few studies have examined the role of RV lead position in the efficacy and outcome of cardiac resynchronization therapy (CRT).

13REVERSEthe apex was preferred in 78% of recipients of CRT-D.Ultimately placed at the apex in 68%, and in the septum or elsewhere in 32% of patientsNo significant differences of clinical and echoNo recommendations regarding the placement of the RV lead

RD Robin H Wibowothe RV stimulation site seemed to have an effect on the pattern and degree of LV dyssynchrony in CRT candidates. 6 The design and results of this international, multicentre, double- blinded randomized REVERSE trial evaluated prospectively the impact of the RV lead tip position on the long-term outcome of CRT. The REVERSE trial made no recommendations regarding the placement of the RV lead, though the apex was preferred in 78% of recipients of CRT-D to optimize the stability of the lead and of the energy required to defibrillate. The RV lead was ultimately placed at the apex in 68%, and in the septum or elsewhere in 32% of patients. No significant differences were observed between an RV apical vs. non-apical lead placement with respect to the clinical and echocardiographic responses or clinical outcomes. 5 These observations are concordant with those made in a relatively large observational study published recently.7 They do not support the use of alternate RV stimulation sites for CRT, though this remains to be definitively addressed in a randomized trial.

14Data comparisonRD Robin H WibowoIn a single-blind prospective randomization of 53 patients to RV septal versus RV apical lead positioning guided by RV mapping to obtain maximal electrical separation (MES) between the LV and RV leads, Miranda et al elegantly show at 3 months that the RV-LV MES was greatest in septal locations and corresponded to a greater percentage of CRT responders, as judged by EF 6-minute walk test, with no adverse safety issues.8

In a randomized design in 33 patients with classical CRT indications, Rnn et al could not show a difference between apex and RVOT RV lead positioning in endpoints of EF, QoL, peak oxygen uptake, BNP, or 6-minute walk.10

15Data comparisonRD Robin H Wibowo16SEPTAL CRTProspective, multicenter, European, single-blind, randomized controlled trialNon inferiority hypothesis Primary end point: Changes in the LVESV between baseline and 6 monthsSecondary end points: the % of echo-responders defined by a reduction in the LVESV > 15% at 6 months the implant success rate of the RV lead the proportion of patients experiencing 1 MAE including deaths from all causesSerious cardiac Adverse EventProcedure related o rdevice-related MAE

17Study Flowchart

1 Year MortalityRD Robin H Wibowo

First multicenter randomized prospective trial comparing RV apical and RV septal pacing in CRT-D recipients Septal CRT demonstrates the non-inferiority of RV septal pacing when compared to conventional RV apical pacing in CRT patients No = in LVESV reduction between baseline and 6 months Similar percentage of echo-responders (50%) No difference in implant success rate No statistical = for the safety and efficacy endpoints: Total mortality: 3.0% vs.3.8% (p=0.749) MAE : 34.8% vs. 39.7% (p=0.446)

19SEPTAL CRTNo = in the percentage of echo-responders, i.e. reduction in LVESV > 15% at 6 months, 50% in both groups, p = 0.99 No = in the implant success rate: 90.0% in the Septum randomized group 86.8% in the Apex randomized group Low implant success rate mostly due to the lack of defibrillation testing (n = 27) 2 patients crossed over due to failure of fulfilling the RV implantation criteria in each group

SEPTAL CRT conclusionFirst multicenter randomized prospective trial comparing RV apical and RV septal pacing in CRT-D recipients Septal CRT demonstrates the non-inferiority of RV septal pacing when compared to conventional RV apical pacing in CRT patients No = in LVESV reduction between baseline and 6 months Similar percentage of echo-responders (50%)No difference in implant success rate No statistical = for the safety and efficacy endpoints: Total mortality: 3.0% vs.3.8% (p=0.749) MAE : 34.8% vs. 39.7% (p=0.446)

ConclusionsNon apical RV pacing, may offer a physiologically beneficial, if not safer and superior alternative to RV apical pacing.

RD Robin H WibowoCOI was the only independent predictorassociated with good midterm outcome for active-xation atrial and ventricular leads 22Future directionsthe ideal choice for pacing with significant dependency in patients may be between physiologically optimised biventricular pacing versus anatomically optimised selectivesite RV pavingRD Robin H WibowoIflead measurements at implant showed no orsmaller ST-segment elevation in bipolar EGMor a high pacing threshold was obtained 10minutes after xation, strong consideration shouldbe given to reposition the lead,

23GraciasRD Robin H Wibowo

24Endpoint, Desain, dan Temuan Utama Studi Acak Terkontrol yang Mengevaluasi CRT pada Gagal Jantung

CRT algorithm

RD Robin H Wibowo