congestive heart failure: update 2002 bruce d. hettleman, md dhmc december 2, 2002

Congestive Heart Failure: Update 2002Congestive Heart Failure: Update 2002

Bruce D. Hettleman, MDBruce D. Hettleman, MD

DHMCDHMC

December 2, 2002December 2, 2002

CASE PRESENTATIONCASE PRESENTATION

• 71 yo retired submarine captain is admitted with 71 yo retired submarine captain is admitted with pulmonary edema and an elevated troponin. His pulmonary edema and an elevated troponin. His PMH is notable for advanced CAD and previous MI. PMH is notable for advanced CAD and previous MI. He had CABGX3 in 1990. He had CABGX3 in 1990.

• Echo demonstrated a severely dilated LV with an EF Echo demonstrated a severely dilated LV with an EF of 20% and 3+/4 mitral regurgitation.of 20% and 3+/4 mitral regurgitation.

• EKG showed sinus rhythm at 52 with first degree AV EKG showed sinus rhythm at 52 with first degree AV block and LBBB.block and LBBB.

• Cardiac Cath revealed a patent IMA to the LAD, Cardiac Cath revealed a patent IMA to the LAD, patent SVG to the RCA and a severely diseased patent SVG to the RCA and a severely diseased SVG to the circumflex.SVG to the circumflex.

What should be done once the patient is What should be done once the patient is initially stabilized?initially stabilized?

• 1. Perform urgent repeat bypass surgery and mitral 1. Perform urgent repeat bypass surgery and mitral valve replacement.valve replacement.

• 2.Perform percutaneous intervention (stent) on the 2.Perform percutaneous intervention (stent) on the SVG to the circumflex.SVG to the circumflex.

• 3. Put in a dual chamber pacemaker3. Put in a dual chamber pacemaker

• 4.Maximize medical therapy because he is too high 4.Maximize medical therapy because he is too high a risk for revascularization.a risk for revascularization.

Case Presentation--ContinuedCase Presentation--Continued

• After stenting the SVG to the circumflex his After stenting the SVG to the circumflex his pulmonary edema subsequently responded to pulmonary edema subsequently responded to medical therapy and he was able to ambulate but medical therapy and he was able to ambulate but remained Class III CHF.remained Class III CHF.

• Discharge medications consisted of a Discharge medications consisted of a diuretic,digoxin, beta blocker, ace inhibitor, aspirin, diuretic,digoxin, beta blocker, ace inhibitor, aspirin, plavix and spironolactone.plavix and spironolactone.

• He was given dietary and weight-based diuretic He was given dietary and weight-based diuretic adjustment guidelines.adjustment guidelines.

• Follow-up in CHF Clinic was scheduled for 1 month.Follow-up in CHF Clinic was scheduled for 1 month.

What is the most likely adverse event after What is the most likely adverse event after adding aldactone in the treatment of CHF? adding aldactone in the treatment of CHF?

• 1. Hypotension1. Hypotension

• 2. Breast enlargement2. Breast enlargement

• 3. Yellow vision3. Yellow vision

• 4. Hyperkalemia4. Hyperkalemia

• 5. Worsening CHF5. Worsening CHF

After starting aldactone in Class IV CHF, After starting aldactone in Class IV CHF, when should electrolytes be rechecked?when should electrolytes be rechecked?

• 1. No worries, mate1. No worries, mate

• 2. One week ( big worries, mate)2. One week ( big worries, mate)

• 3. Four weeks3. Four weeks

• 4. Three months4. Three months

Potassium LevelPotassium Level

0

1

2

3

4

5

6

7

8

JNRY 15 JNRY 25 20-Feb 1-Apr

Potassium

Drugs that have shown to prolong life in CHF Drugs that have shown to prolong life in CHF are:are:

• 1. ACE inhibitors1. ACE inhibitors

• 2. Beta Blockers2. Beta Blockers

• 3. Digoxin3. Digoxin

• 4. Aldactone4. Aldactone

• 5. 1,2 and 45. 1,2 and 4

DIG Trial: Effect of Digoxin on Survival in CHFDIG Trial: Effect of Digoxin on Survival in CHF

• NHLBI sponsored study of 7,788 patients with NHLBI sponsored study of 7,788 patients with class II and III CHF and LVEFs class II and III CHF and LVEFs << 45% or > 45% or > 45%45%

• Randomized, controlled, double-blindedRandomized, controlled, double-blinded

• 93% of patients on ACEIs93% of patients on ACEIs

• Superimposable survival curvesSuperimposable survival curves

• 25% reduction with Dig on first CHF 25% reduction with Dig on first CHF hospitalizationhospitalization

Weight of Evidence: ACE Inhibitors

Approximately 7000 patients evaluated in long-termplacebo-controlled clinical trials

Improvement in cardiac function, symptoms, andclinical status; equivocal effects on exercise tolerance

Decrease in all-cause mortality by 20%-25% (P<.001) anddecrease in combined risk of death and hospitalizationby 30%-35% (P<.001)

- Effect shown in SOLVD Treatment, CONSENSUS, andV-HeFT II trials

Garg and Yusuf, 1995.

Weight of Evidence: -Blockade

Traditionally contraindicated in heart failure, due to impaired inotropy, early lack of tolerability, and worsening heart failure

Over 10,000 patients have now been evaluated in long-term placebo-controlled clinical trials;

Improvement in cardiac function and NYHA class; and decrease in mortality and morbidity shown in multiple clinical trials

Effects shown in patients already receiving ACE inhibitors

Improved survival with aldactone in advanced Improved survival with aldactone in advanced CHF--Rales TrialCHF--Rales Trial

Will a permanent pacemaker help this man?Will a permanent pacemaker help this man?

• 1. No, he has no indication for a pacemaker and if 1. No, he has no indication for a pacemaker and if you put one in medicare will send you the bill.you put one in medicare will send you the bill.

• 2. Yes, he should have a VVI back up pacemaker 2. Yes, he should have a VVI back up pacemaker prior to discharge because he has LBBB and may prior to discharge because he has LBBB and may unpredictably develop complete heart block and die.unpredictably develop complete heart block and die.

• 3. Yes, the placement of a routine DDD pacemaker 3. Yes, the placement of a routine DDD pacemaker will reliably improve his hemodynamicswill reliably improve his hemodynamics

• 4.Yes, he ought to have a brand-spankin new 4.Yes, he ought to have a brand-spankin new biventricular resynchronization device because he biventricular resynchronization device because he has LBBB.has LBBB.

Cardiac Resynchronization Cardiac Resynchronization Therapy for Heart FailureTherapy for Heart Failure

Mechanisms, Clinical Outcomes,Mechanisms, Clinical Outcomes,Patient Selection, and ImplantPatient Selection, and Implant

Ventricular Dysynchrony and Cardiac Ventricular Dysynchrony and Cardiac ResynchronizationResynchronization

• Ventricular DysynchronyVentricular Dysynchrony11 – Electrical:Electrical: Inter- or Inter- or

Intraventricular conduction delays typically manifested as left bundle Intraventricular conduction delays typically manifested as left bundle branch block branch block

– Structural:Structural: disruption of myocardial collagen matrix impairing electrical disruption of myocardial collagen matrix impairing electrical conduction and mechanical efficiencyconduction and mechanical efficiency

– Mechanical:Mechanical: Regional wall motion abnormalities with increased workload Regional wall motion abnormalities with increased workload and stress—compromising ventricular mechanicsand stress—compromising ventricular mechanics

• Cardiac ResynchronizationCardiac Resynchronization

– Therapeutic intent of atrial synchronized biventricular pacingTherapeutic intent of atrial synchronized biventricular pacing

• Modification of interventricular, intraventricular, and atrial-ventricular Modification of interventricular, intraventricular, and atrial-ventricular activation sequences in patients with ventricular dysynchronyactivation sequences in patients with ventricular dysynchrony

• Complement to optimal medical therapyComplement to optimal medical therapy

11 Tavazzi L. Tavazzi L. Eur HeartEur Heart J 2000;21:1211-1214 J 2000;21:1211-1214

Animation – Ventricular DysynchronyAnimation – Ventricular Dysynchrony

Click to Start/StopClick to Start/Stop

Cardiac ResynchronizationCardiac Resynchronization


Clinical Consequences of Clinical Consequences of Ventricular DysynchronyVentricular Dysynchrony

• Abnormal Abnormal interventricular interventricular septal wall motionseptal wall motion11

• Reduced dP/dtReduced dP/dt3,43,4

• Reduced pulse Reduced pulse pressurepressure44

• Reduced EF and Reduced EF and COCO44

• Reduced diastolic Reduced diastolic filling timefilling time1,2,41,2,4

• Prolonged MR Prolonged MR durationduration1,2,41,2,4

11 Grines CL, Bashore TM, Boudoulas H, et al. Grines CL, Bashore TM, Boudoulas H, et al. CirculationCirculation 1989;79:845-853. 1989;79:845-853. 2 2 Xiao, HB, Lee CH, Gibson DG. Xiao, HB, Lee CH, Gibson DG. Br Heart J Br Heart J 1991;66:443-447.1991;66:443-447. 33 Xiao HB, Brecker SJD, Gibson DG. Xiao HB, Brecker SJD, Gibson DG. Br Heart J Br Heart J 1992;68:403-407.1992;68:403-407. 44 Yu C-M, Chau E, Sanderson JE, et al. Yu C-M, Chau E, Sanderson JE, et al. CirculationCirculation. 2002;105:438-445.. 2002;105:438-445.

Proposed Mechanisms: Improved Proposed Mechanisms: Improved Intraventricular SynchronyIntraventricular Synchrony

dP/dt dP/dt 1,3,4 1,3,4 EFEF1,51,5 Pulse Pressure Pulse Pressure 3,4 3,4 SV&COSV&CO1, 21, 2

Improved IntraventricularImproved IntraventricularSynchronySynchrony1,21,2

MRMR11

LVESVLVESV11 LA LA PressurePressure11

1 Yu C-M, Chau E, Sanderson J, et al. Yu C-M, Chau E, Sanderson J, et al. CirculationCirculation 2002;105:438-445 2002;105:438-4452 2 SSøgaard P, Kim W, Jensen H, et al. øgaard P, Kim W, Jensen H, et al. CardiologyCardiology 2001;95:173-182 2001;95:173-1823 3 Kass D Chen-Huan C, Curry C, et al. Kass D Chen-Huan C, Curry C, et al. CirculationCirculation 1999;99:1567-73 1999;99:1567-7344 Auricchio A, Ding J, Spinelli J, et al. Auricchio A, Ding J, Spinelli J, et al. J Am Coll CardiolJ Am Coll Cardiol 2002;39:1163-1169 2002;39:1163-11695 5 Stellbrink C, Breithardt O, Franke A, et al. Stellbrink C, Breithardt O, Franke A, et al. J Am Coll CardiolJ Am Coll Cardiol 2001;38:1957- 65 2001;38:1957- 65

Prevalence of Inter- or Intraventricular Prevalence of Inter- or Intraventricular Conduction DelayConduction Delay

11 Havranek E, Masoudi F, Westfall K, et al. Havranek E, Masoudi F, Westfall K, et al. Am Heart JAm Heart J 2002;143:412-417 2002;143:412-41722 Shenkman H, McKinnon J, Khandelwal A, et al. Shenkman H, McKinnon J, Khandelwal A, et al. CirculationCirculation 2000;102(18 Suppl II): abstract 2293 2000;102(18 Suppl II): abstract 229333 Schoeller R, Andresen D, Buttner P, et al. Schoeller R, Andresen D, Buttner P, et al. Am J Cardiol.Am J Cardiol. 1993;71:720-726 1993;71:720-72644 Aaronson K, Schwartz J, Chen T, et al. Aaronson K, Schwartz J, Chen T, et al. CirculationCirculation 1997;95:2660-2667 1997;95:2660-266755 Farwell D, Patel N, Hall A, et al. Farwell D, Patel N, Hall A, et al. Eur Heart JEur Heart J 2000;21:1246-1250 2000;21:1246-1250

IVCD 15%IVCD 15%IVCD >30%IVCD >30%

General HF General HF PopulationPopulation1,21,2

Moderate to SevereModerate to Severe HF Population HF Population3,4,53,4,5

Increased Mortality Rate with LBBBIncreased Mortality Rate with LBBB

• Increased 1-year Increased 1-year mortality with presence mortality with presence of complete LBBB of complete LBBB (QRS > 140 ms)(QRS > 140 ms)

• Risk remains significant Risk remains significant even after adjusting for even after adjusting for age, underlying cardiac age, underlying cardiac disease, indicators of disease, indicators of HF severity, and HF HF severity, and HF medicationsmedications

Baldasseroni S, Opasich C, Gorini M, et al. Baldasseroni S, Opasich C, Gorini M, et al. Am Heart JAm Heart J 2002;143:398- 2002;143:398-405405

11.911.9

5.55.5

16.116.1

7.37.3

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55

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1515

2020

All CauseAll Cause Sudden CardiacSudden Cardiac

All patients N=5517All patients N=5517

LBBB N=1391LBBB N=1391HRHR** 1.70 1.70

(1.41-2.05)(1.41-2.05)

HR HR ** 1.58 1.58(1.21-2.06)(1.21-2.06)

Cause of DeathCause of Death

1-Y

ear

Mo

rtal

ity

(%)

1-Y

ear

Mo

rtal

ity

(%)

* HR = Hazard Ratio* HR = Hazard Ratio

Proposed Mechanisms of Proposed Mechanisms of Cardiac ResynchronizationCardiac Resynchronization


Improved Intraventricular Improved Intraventricular SynchronySynchrony

Improved Atrioventricular Improved Atrioventricular SynchronySynchrony

Improved Interventricular Improved Interventricular SynchronySynchrony

Yu C-M, Chau E, Sanderson J, et al. Yu C-M, Chau E, Sanderson J, et al. CirculationCirculation 2002;105:438- 2002;105:438-445445

Summary of Proposed MechanismsSummary of Proposed Mechanisms

Yu C-M, Chau E, Sanderson J, et al. Yu C-M, Chau E, Sanderson J, et al. CirculationCirculation 2002;105:438-445 2002;105:438-445

IntraventricularIntraventricularSynchronySynchrony

AtrioventricularAtrioventricularSynchronySynchrony

InterventricularInterventricularSynchronySynchrony

LALAPressurePressure

LV DiastolicLV DiastolicFillingFilling

RV StrokeRV StrokeVolumeVolume

LVESVLVESV LVEDVLVEDV

Reverse RemodelingReverse Remodeling


MRMR dP/dt, dP/dt, EF, EF, COCO(( Pulse Pressure)Pulse Pressure)

Achieving Cardiac ResynchronizationAchieving Cardiac ResynchronizationMechanical Goal: Atrial-synchronized bi-ventricular pacingMechanical Goal: Atrial-synchronized bi-ventricular pacing

• Transvenous ApproachTransvenous Approach– Standard pacing lead in RAStandard pacing lead in RA– Standard pacing or defibrillation lead in RVStandard pacing or defibrillation lead in RV– Specially designed left heart lead placed in a left ventricular Specially designed left heart lead placed in a left ventricular

cardiac vein via the coronary sinuscardiac vein via the coronary sinus

Right AtrialRight AtrialLeadLead

Right VentricularRight VentricularLeadLead

Left VentricularLeft VentricularLeadLead

CRT Improves Quality of Life Score and CRT Improves Quality of Life Score and NYHA Functional ClassNYHA Functional Class

QoLQoL NYHANYHA

PATH-CHFPATH-CHF1 1 (n=41)(n=41) ++ ++

InSync (Europe)InSync (Europe)2 2 (n=103)(n=103) ++ ++

InSync ICD (Europe)InSync ICD (Europe)3 3 (n=84)(n=84) ++ ++

MUSTICMUSTIC4 4 (n=67)(n=67) ++

MIRACLEMIRACLE5 5 (n=453)(n=453) ++ ++

MIRACLE ICDMIRACLE ICD6 6 (n=364)(n=364) ++ ++

1 Auricchio A. Stellbrink C, Sack S., et al. Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol J Am Coll Cardiol 2002;39:2026-2002;39:2026- 2033 203322 Gras D, Leclercq C, Tang A, et al. Gras D, Leclercq C, Tang A, et al. Eur J Heart FailureEur J Heart Failure 2002;4:311-320 2002;4:311-32033 Kuhlkamp V. Kuhlkamp V. JACCJACC 2002;39:790-797 2002;39:790-7974 4 Linde C, Leclercq C, Rex S, et al. Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol J Am Coll Cardiol 2002;40:111-118 2002;40:111-118

5 Abraham W, Fisher W, Smith A, et al.Abraham W, Fisher W, Smith A, et al. N Engl J Med.N Engl J Med. 2002;346:1845-1853 2002;346:1845-185366 Leon A. Leon A. NASPE Scientific Sessions – Late BreakingNASPE Scientific Sessions – Late Breaking Clinical Trials. Clinical Trials. May 2002; Medtronic Inc. data on fileMay 2002; Medtronic Inc. data on file

++ Statistically significant improvement with CRT (p Statistically significant improvement with CRT (p 0.05) 0.05) Not statistically significant or No statistical analysis performed on dataNot statistically significant or No statistical analysis performed on data

Blank Blank Indicates test neither performed nor reported Indicates test neither performed nor reported

CRT Improves Exercise CapacityCRT Improves Exercise Capacity

1 Auricchio A. Stellbrink C, Sack S., et al. Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol J Am Coll Cardiol 2002;39:2026-2002;39:2026- 2033 203322 Gras D, Leclercq C, Tang A, et al. Gras D, Leclercq C, Tang A, et al. Eur J Heart FailureEur J Heart Failure 2002;4:311-320 2002;4:311-320

33 Kuhlkamp V. Kuhlkamp V. JACCJACC 2002;39:790-797 2002;39:790-7974 4 Linde C, Leclercq C, Rex S, et al. Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol J Am Coll Cardiol 2002;40:111-118 2002;40:111-118

5 Abraham W, Fisher W, Smith A, et al.Abraham W, Fisher W, Smith A, et al. N Engl J Med.N Engl J Med. 2002;346:1845-1853 2002;346:1845-185366 Leon A. Leon A. NASPE Scientific Sessions – Late BreakingNASPE Scientific Sessions – Late Breaking Clinical Trials. Clinical Trials. May 2002; Medtronic Inc., data on fileMay 2002; Medtronic Inc., data on file

6 Min Walk6 Min Walk Peak VOPeak VO22

ExerciseExerciseTimeTime

PATH-CHFPATH-CHF1 1 (n=41)(n=41) ++ ++

InSync (Europe)InSync (Europe)2 2 (n=103)(n=103) ++

InSync ICD (Europe)InSync ICD (Europe)3 3 (n=84)(n=84) ++

MUSTICMUSTIC4 4 (n=67)(n=67) ++

MIRACLEMIRACLE5 5 (n=453)(n=453) ++ ++ ++

MIRACLE ICDMIRACLE ICD6 6 (n=364)(n=364) ++ ++++ Statistically significant improvement with CRT (p Statistically significant improvement with CRT (p 0.05) 0.05) Not statistically significant or No statistical analysis performed on dataNot statistically significant or No statistical analysis performed on data


CRT Improves Cardiac Function/StructureCRT Improves Cardiac Function/Structure

1 Auricchio A. Stellbrink C, Sack S., et al. Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol J Am Coll Cardiol 2002;39:2026-2002;39:2026- 2033 203322 Gras D, Leclercq C, Tang A, et al. Gras D, Leclercq C, Tang A, et al. Eur J Heart FailureEur J Heart Failure 2002;4:311-320 2002;4:311-32033 Kuhlkamp V. Kuhlkamp V. JACCJACC 2002;39:790-797 2002;39:790-7974 4 Linde C, Leclercq C, Rex S, et al. Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol J Am Coll Cardiol 2002;40:111-118 2002;40:111-118

5 Abraham W, Fisher W, Smith A, et al.Abraham W, Fisher W, Smith A, et al. N Engl J Med.N Engl J Med. 2002;346:1845-1853 2002;346:1845-185366 Young J. Young J. ACC Scientific Sessions – Late BreakingACC Scientific Sessions – Late Breaking Clinical Trials III. Clinical Trials III. March 2002; Medtronic Inc., March 2002; Medtronic Inc., data on file data on file

++ LVESV, LVESV, ++ LVEDV LVEDV ++ MIRACLE ICDMIRACLE ICD6 6 (n=362)(n=362)

++ LVEDD, LVEDD, ++ LVEDV, LVESV LVEDV, LVESV ++ ++MIRACLEMIRACLE5 5 (n=453)(n=453)

LVEDD,LVESDLVEDD,LVESD Filling Time Filling Time MUSTICMUSTIC4 4 (n=67)(n=67)

++ Filling Time Filling Time ++InSync ICD (Europe)InSync ICD (Europe)3 3 (n=84)(n=84)

++ Filling Time Filling Time ++InSync (Europe)InSync (Europe)2 2 (n=103)(n=103)

++ LVEDP LVEDP ++ LV dP/dt LV dP/dtmaxmax

PATH-CHFPATH-CHF1 1 (n=41)(n=41)

OtherOther MRMRLVEFLVEF

++ Statistically significant improvement with CRT (p Statistically significant improvement with CRT (p 0.05) 0.05) Not statistically significant or No statistical analysis performed on dataNot statistically significant or No statistical analysis performed on data


11 Gras D, Leclercq C, Tang A, et al. Gras D, Leclercq C, Tang A, et al. Eur J Heart FailEur J Heart Fail 2002;4:311-320 2002;4:311-3202 Auricchio A. Stellbrink C, Sack S., et al. Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol J Am Coll Cardiol 2002;39:2026-20332002;39:2026-20333 3 Linde C, Leclercq C, Rex S, et al. Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol J Am Coll Cardiol 2002;40:111-118 2002;40:111-118

NYHANYHA QoLQoL 6 Minute6 Minute

WalkWalk

Peak VOPeak VO22

InSync European InSync European and Canadian Studyand Canadian Study1 1

(n=67, followed to 12 months)(n=67, followed to 12 months) ++ ++ ++

PATH-CHF StudyPATH-CHF Study22

(n=29, followed to 12 months)(n=29, followed to 12 months)

++ ++ ++

++

MUSTIC StudyMUSTIC Study33

(n=42 in sinus rhythm group, (n=42 in sinus rhythm group, n=33 in atrial fibrillation group n=33 in atrial fibrillation groupfollowed to 12 months)followed to 12 months)

++ ++ ++

Cardiac Resynchronization OutcomesCardiac Resynchronization OutcomesSustained for at least 12 monthsSustained for at least 12 months

++ Statistically significant improvement with CRT (p Statistically significant improvement with CRT (p 0.05) 0.05) No statistically significant improvement with CRT No statistically significant improvement with CRT

Blank Indicates test neither performed nor reportedBlank Indicates test neither performed nor reported

Step 1: Cannulate CSStep 1: Cannulate CSAttain LDS Model 6216AAttain LDS Model 6216A

• Use extreme care when passing the Use extreme care when passing the guide catheter through vesselsguide catheter through vessels

• Due to the relative stiffness of the Due to the relative stiffness of the catheter, damage to the walls of the catheter, damage to the walls of the vessels may include dissections or vessels may include dissections or perforations perforations

Step 2: Perform Venograms Step 2: Perform Venograms

Varying Patient Anatomy Varying Patient Anatomy 1,2,31,2,3

2. Neri et al. 2. Neri et al. Europace Europace 2000;I :D95 Abstract 88/22000;I :D95 Abstract 88/2

1. Potkin et al. 1. Potkin et al. Am J Cardiol Am J Cardiol 1987;60:1418-14211987;60:1418-1421

3. Hill et al.3. Hill et al. EuropaceEuropace 2000;I:D238 Abstract 2000;I:D238 Abstract 167/2167/2

Photos Courtesy of Dr. Daniel GrasPhotos Courtesy of Dr. Daniel Gras

Cardiac Venous AnatomyCardiac Venous Anatomy

CS Os

Middle Posterior

Postero-lateral

Great

Lateral

Antero-lateral

Anterior

Step 2: Perform VenogramsStep 2: Perform Venograms

Lead in Lateral Cardiac VeinLead in Lateral Cardiac Vein

Step 2: Perform VenogramsStep 2: Perform Venograms

Step 4: Place LeadStep 4: Place LeadAttain OTW Model 4193Attain OTW Model 4193


Step 4: Place LeadStep 4: Place LeadAttain OTW Model 4193Attain OTW Model 4193

Courtesy ofCourtesy ofDr. Daniel GrasDr. Daniel Gras


LAO View: LAO View: Tracking Over the WireTracking Over the Wire


Courtesy ofCourtesy ofDr. Daniel GrasDr. Daniel Gras

Step 4: Place Leads Step 4: Place Leads Attain LV Model 2187 Attain LV Model 2187

Video compliments of Video compliments of Dr. Vince PaulDr. Vince Paul


Biventricular Pacing is indicated for the Biventricular Pacing is indicated for the reduction of CHF symptoms in patients with:reduction of CHF symptoms in patients with:

• 1. Stable Class III-IV CHF1. Stable Class III-IV CHF

• 2. QRS> 130 ms2. QRS> 130 ms

• 3.EF <35%3.EF <35%

• 4. Optimal medical therapy4. Optimal medical therapy

congestive heart failure: update 2002 bruce d. hettleman, md dhmc december 2, 2002

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