CARDIAC RESYNCHRONISATION

THERAPY (CRT)

FOR CHRONIC CONGESTIVE HEART

FAILURE (CHF)

WHY ? WHEN ?

Laurent SABBAH

Cardiology Unit, Necker Hospital, Paris

29/04/2014

2

3

Prevalence : 2 - 3 % of population in Europe (1)

12 % > 60 years old in France % (2)

1rst hospitalisation cause after 60 years

5 years mortality : 50 % depending on NYHA class

(1) Dickstein K, Cohen-Solal A & alii. ESC guidelines for the diagnosis and treatment of acute and chronic

heart failure 2008. European Heart Journal

(2) Prévalence et prise en charge de l’insuffisance cardiaque en France - Enquête RS2002-2 février 2002 -

Réseau Sentinelle

CHF: EPIDEMIOLOGY

NYHA

II III IV

Annual Mortality (%) 5 - 15 20 - 50 30 -70

Sudden death mortality 50 - 80 30 - 50 5 - 30

CLASSICAL TREATMENT

DRUG THERAPY > 2NYHA

6

DRUG THERAPY > 2NYHA

7

Transplantation

ICD +/- CRT LV A D

8

Electrical dyssynchrony LBBB

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9

QRS DURATION AND EF

3471 subjects with heart failure

Shenkman, H. J. et al. Congestive heart failure and QRS duration: establishing prognosis study. Chest 122 (2002).

EF

< 4

5%

10

Prevalence and Prognosis of

Ventricular dyssynchrony

LBBB More Prevalent with

Impaired LV Systolic Function

38%

24%

8%

Mod/Sev HF (2)

Impaired LVSF (1)

Preserved LVSF (1)

1. Masoudi, et al. JACC. 2003;41:217-223.

2. Aaronson, et al. Circulation. 1997;95:2660-2667.

Increased All-Cause Mortality with Wide QRS at 45 Months (3)

34%

49%

QRS

< 120 ms

QRS

≥ 120 ms

3. Iuliano, et al. AHJ. 2002;143:1085-1091.

P < 0.001

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QRS DURATION AND SURVIVAL

60%

70%

80%

90%

100%

0 60 120 180 240 300 360

Jours

Su

rvie

QRS duration (ms)

<90

90-120

120-170

170-220

>220

VEST study (1999)

Dilated CM NYHA>2

3654 ECG scanned

1year mortality

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Single blind study . 66 patients

NYHA III FEVG 23+/- 7%+ QRS >150 ms+ rsr

2 groups

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Double blind randomised study . 453 NYHA III-IV, EF< 35% QRS > 130ms

CRT for all , stimulation or not Followed for 6 months: Functional criterias

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CRT Improves Exercise Capacity

* P < 0.05 Abraham et al., 2003

Average Change in 6

Minute Walk Distance

-40

-20

0

20

40

60

MIR

ACLE

MUST

IC S

RCO

NTA

K CD

MIR

ACLE

ICD

m

Control CRT

**

*

Average Change in Peak

VO2

00

1

2

3

MIR

ACLE

MUST

IC S

RCO

NTA

K CD

MIR

ACLE

ICD

ml/kg

/min

Control CRT

*

*

*

*

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CRT Improves Quality of Life and

NYHA Functional Class

* P < 0.05 Abraham et al., 2003

Average Change in Score

(MLWHF)

-20

-15

-10

-5

0

MIR

ACLE

MUST

IC S

R

CONTA

K CD

MIR

ACLE

ICD

Control CRT

* * * *

NYHA: Proportion

Improving 1 or More Class

0%

20%

40%

60%

80%

MIRACLE CONTAK

CD

MIRACLE

ICD

Control CRT

**

*

16

First mortality evaluation study

813 patients NYHA>3 QRS>120MSEC

EF : 25%

CRT VS drug therapy

Follow up : 3 years

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Care hf Primary Endpoint (All-cause Mortality or Unplanned Hosp. for Major CVS Event)

CRT : 159 pts (39%)

3 48 118 232 292 404 Medical Therapy

7 68 166 273 323 409 CRT

Number at risk 0 500 1000 1500

0.00

0.25

0.50

0.75

1.00

HR 0.63 (95% CI 0.51 to 0.77)

Ev

ent-

free

Su

rviv

al

Days

P < .0001

Medical : 224 pts

Therapy (55 %)

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COMPANION (2004)

N:1520, NYHA> III, EF < 36%, QRS > 120 ms + SR

Optimal drug therapy ( ODT) Vs ODT + CRT Vs ODT + CRTD

Bristow, M. R. et al. CRT with or without an ICD in advanced CHF

N. Engl. J. Med. 350, 2140–2150 (2004).

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Moderate HF: NYHA 2 or 3. n : 1800

EF <30% + QRS>120 msec : CRTD VS DAI alone

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>1800 patients . follow up : 4.5 years

Moderate HF : 86 % NYHA 2 . EF <30 %

ICD VS CRTD

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Goldenberg et al.

Nejm

Mars 2014

Results at 7 years

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NARROW QRS + ECHOGRAPHIC DYSSYNCHRONY ?

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RIGHT BBB ?

MADIT-CRT

Recommandations

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CHF + NYHA III+ SINUS RYTHM

CHF + NYHA II+ SINUS RYTHM

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CHF + NYHA III + AF RYTHM

CHF + NYHA II OR III + PM INDICATION

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CHF+ NYHA>2+OPTIMAL DRUG THERAPY

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