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
Popolazione con scompenso in
generale1,2
Popolazione con scompenso
moderato o severo 3,4,5
IVCD >30%
IVCD
>30%
IVCD 15%
IVCD
15%
1
Havranek E, Masoudi F, Westfall K, et al. Am Heart J 2002;143:412-417
Shenkman H, McKinnon J, Khandelwal A, et al. Circulation 2000;102(18 Suppl II): abstract 2293
3 Schoeller R, Andersen D, Buttner P, et al. Am J Cardiol. 1993;71:720-726
4 Aaronson K, Schwartz J, Chen T, et al. Circulation 1997;95:2660-2667
5 Farwell D, Patel N, Hall A, et al. Eur Heart J 2000;21:1246-1250
2
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
Click to Start/Stop
1
Grines CL, Bashore TM, Boudoulas H, et al. Circulation 1989;79:845-853.
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.
2 Xiao,
Epidemiology, Prognosis, and Pathophysiology of
Heart Failure
• 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
2013 ESCGuidelines on cardiac pacing and cardiac resynchronization therapy
Normal Heart
LBBB
J Am Coll Cardiol Img. 2013;6(8):924-926. doi:10.1016/j.jcmg.2013.07.002
Posizionamento del catetere
ventricolare sinistro
3
4
5
2
1
1. Vena cardiaca Laterale
(marginale)
2. Vena cardiaca Posterolaterale
3. Vena cardiaca
Posteriore
4. Vena cardiaca Media
5. Vena cardiaca Grande
La Stimolazione Biventricolare (CRT)
Modificazione del complesso QRS con la stimolazione biventricolare
Spontaneo
CRT
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
Click to Start/Stop
1
Grines CL, Bashore TM, Boudoulas H, et al. Circulation 1989;79:845-853.
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.
2 Xiao,
Effetto della CRT sulla funzione
cardiaca
Ottimizzazione intervallo AV
– Riduce il rigurgito
mitralico1,2,3
– Aumenta il tempo
di riempimento
diastolico
– Migliora il dP/dt
del ventricolo
sinistro
1
Nishimura et al. J Am Coll Cardiol. 1995; 25:281.
Walker et al. Europace 2000;I(suppl D): abstract 212/5.
3 Brecker et al. Lancet. 1992;340:1308.
2
2013 ESCGuidelines on cardiac pacing and cardiac resynchronization therapy
29%
18%
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.
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
Figure Legend:
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.
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
Figure Legend:
Impact of Left Ventricular Pacing at the Best +dP/dTmax Location
Comparison 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.
Date of download:
10/5/2014
Copyright © The American College of Cardiology.
All rights reserved.
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 Implantation
Fluoroscopic 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 Lead
Transseptal 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 volume
LVEF=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