最新：CRT是否还有进步空间？来自Mayo医院的经验英文课件幻灯文档资料.ppt

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1、,Cumuulative patients,Results presented,Cumulative Enrollment in CRT Randomized Trials,PATH CHF,MUSTIC SR,MUSTIC AF,MIRACLE,CONTAK CD,MIRACLE ICD,PATH CHF II,COMPANION,MIRACLE ICD II,CARE HF,CP1172680-4,CRT,Reverse myocardial remodelingImprove quality of lifeImprove NYHA classReduce hospitalizations

2、 for heart failureImprove survival,CRT works in 50-70%of patients,Why not every patient response to CRT,QRS morphology and durationUpgrade vs de novo implantationEtiology of cardiomyopathySinus rhythm vs atrial fibrillationReversibility of LV myocardiumLV lead positionPercentage of biventricular pac

3、ingDevice programming,CP1305043-5,Pre-CRT QRS MorphologiesN=502,LBBB50%(254),Paced LBBB25%(124),RBBB7%(37),IVCD11%(53),120 ms7%(34),Dyssynchrony(9)New pacing indication/HF(14)RV-pacing induced HF(3)Advanced HF/borderline QRS(8),Chronic AF 30%,CP1305043-12,Improvement in NYHA Class After CRT,*Signifi

4、cant difference(P0.05)compared to LBBB as a reference group*Significant difference(P0.001)compared to LBBB as a reference group,Improvement in NYHA class,*,*,n=254,n=37,n=124,n=53,n=34,CP1305043-13,Improvement in LVEF(%),*,*,n=254,n=37,n=124,n=53,n=34,*Significant difference(P0.05)compared to LBBB a

5、s a reference group*Significant difference(P0.001)compared to LBBB as a reference group,Improvement in LVEF After CRT,CP1305043-16,Survival After CRT Based on QRS Morphology,Survival estimate(%),Years,No.at riskLBBB2542081498147Paced12487533721RBBB37291873IVCD534026112120 ms34231683,LBBB(n=254,death

6、s=58)Paced LBBB(n=124,deaths=30)RBBB(n=37,deaths=14)IVCD(n=53,deaths=14)120 ms(n=34,deaths=9),P=0.039,Fantoni C,JCE 2005,Fantoni C,JCE 2005,NYHA Class Pre-and Post-CRT,CP1306982-9,*P0.05 or*P0.001 compared to pre-CRT,NYHA class,*,*,De novon=254,Upgraden=125,PrePost,LV Systolic Function:Pre-and Post-

7、CRT,CP1306982-10,*P0.05 or*P0.001 compared to pre-CRT,Ejection fraction(%),*,*,De novon=239,Upgraden=121,PrePost,Survival After CRTDe Novo vs Upgrade groups,CP1306982-16,Survival after CRT(%),63%,Years,De novo3382721899749Upgrade167118 765029,De novo,P=0.91,61%,Upgrade,CP1305043-5,Pre-CRT Atrial Rhy

8、thmN=502,sinus66%,AF34%,Improvement in NYHA Class After CRT,Improvement in LVEF After CRT,Kaplan-Meier estimate,SR,P=0.78,33025418310959172134 81 3819,CP1337866-1,AF,Years,Kaplan-Meier estimate,Years,P=0.008,1209051197 524026158,CP1337866-3,-AVN-ABL,+AVN-ABL,B,Change in LV End-Systolic Volume After

9、CRT,CP1299428-3,Left ventricular end-systolicvolume change(%),Months,Baseline,6,12,24,36,48,SR,V pacing 98%,AF,AVN ablation,V pacing 100%,AF,no AVN ablation,V pacing 88%,Comparison of changes after CRT in patients with DCM and ICM,Survivals in dilated and ischemic cardiomyopathy,Comparison of Change

10、s After CRT,CP1306982-8,Biv pacing Biv pacing99-100%99%Characteristicn=168n=138PNYHA class-0.80.8-0.60.80.015LV ejection fraction(%)8.510.85.28.80.006LV end-diastolic volume(mL)-27.253.4-9.541.80.006LV end-systolic volume(mL)-33.545.9-12.343.70.013Mitral regurgitation*-0.30.7-0.10.60.081RV systolic

11、pressure(mm Hg)-5.813.6-4.512.60.466,Biventricular Pacing Percentage in All Patients,Koplan BA:JACC,2009,Patients(no.),Pacing(%),Survival Free from Heart Failure Hospitalization and All-Cause Mortality,Event-free probability,Months post implant,1st quartile:0-92%(n=467)2nd quartile:93-97%(n=474),P=0

12、.0013(vs Q1)3rd quartile:98-99%(n=509),P=0.0004(vs Q1)4th quartile:100%(n=362),P0.0001(vs Q1),Koplan BA:JACC,2009,0.5,0.6,0.7,0.8,0.9,1.0,0,2,4,6,8,10,12,75-80%,15%,5%,CAO et al.JCE 2009,Influence of LV Lead Location on Outcomes in the COMPANION Study,Barold,europace 2009,Measuring VTI,Obtain Dopple

13、r velocities across the aortic valveUse the apical long axis viewFind the best programmed V-V Delay that provides the largest VTI(SV),LV,LA,Using the Velocity Time Integral(VTI)to Optimize V-V Timing,The volume of blood ejected by the LV each beat=Stroke Volume(SV)SV=LVOT area x Velocity Time Integr

14、al(VTI)Since LVOT is constant,the larger the VTI the larger the SV,Distribution of Optimized V-V,At implant,6-month,Summary of V-V Timing Results,Sequential biventricular pacing produced the greatest stroke volume in 75%of patients.The median improvements in stroke volume when sequential biventricular pacing were 11.4%,and 9.5%at implant and 6 months respectively.,Cleland:JACC,2009,