Impact of BiVentricular Pacing on Heart Failure Patients, Slides of Medicine

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Cardiac Resynchronization

Therapy

BiVentricular Pacing

Cardiac Dysynchrony

►Some Heart failure patients will suffer from

dysynchrony. It is thought that this

dysynchrony can further impair their overall

cardiac function. IF the ventricles beat

together, the thought is that there will be

less regional loading disparities.

►As upgraded, ICD’s, with coronary sinus

leads have the capability of pacing both

ventricles, we should see which patients

benefit from BiV pacing.

MIRACLE ICD

► Multicenter InSync

Randomized Clinical

Evaluation

► JAMA 2003

► Small study, using a

survey to look at

symptoms.

► Not powered to detect

a mortality difference.

MIRACLE ICD

COMPANION

►1527 patients

 NYHA III or IV (ischemic or nonischemic)

 QRS >

►Assigned to one of three groups

 Pharamcologic therapy alone

 Above + CRT

 Above + CRT + ICD

►Primary endpoint: composite of death or

hospitalization for any cause.

Companion Results

► After 12 months

 68% composite end point in pharacological group.

 56% in BIV alone

 56% in ICD + BIV group.

► Secondary endpoint (death from any cause)

 Pharmacological 19%

 BIV (hazard ration of .76, CI of .58 to 1.01, p 0.059) –

near significant

 BIV ICD: 36% reduction, Hazard ratio .64, CI .48 to .86,

P0.

CARE HF

► CArdiac REsynchronization in Heart Failure

Study

► Looked at the effect on mortality and

morbitity by CRT in patients with evidence of

dysyncrhony and heart failure. THIS STUDY

IS WITHOUT DEFIBRILLATORS.

 NYHA Class III or IV

 LVEF < 35%

 QRS > 150, or 120 w/ other signs of dyssynchrony

by echo.

► NEJM: 2005

CARE HF

• Not a blinded study.
• Primary end point was MACE
• Secondary endpoint all casue mortality
• @ 28 months
  • Reduction in MACE in 39 vs 55%
  • This benefit does increase over time
  • Also a reduction in overall mortaliyt of

20% vs 30%. Biggest finding is that

this drop was found to mostly be in less

deaths from worsening heart failure.

Shows the benefits of Bi Ventricular pacing

and CRT alone in survival in HF.

CARE HF Hemodynamic, Echocardiographic, and Biochemical Assessments

Cleland, J. et al. N Engl J Med 2005;352:1539-

CRT guideline

► Class I Recommendation for CRT Therapy

► “Patients with LVEF less than or equal to 35%,

sinus rhythm, and NYHA functional class III or

ambulatory class IV symptoms despite

recommended, optimal medical therapy and who

have cardiac dyssynchrony, which is currently

defined as a QRS duration greater than 120 ms,

should receive cardiac resynchronization therapy

unless contraindicated.” (Level of Evidence: A)

Cardiac Resynchronization Therapy*

in Patients With Severe Systolic

Heart Failure

For patients with LVEF less than or equal to 35% with

NYHA functional Class I or II symptoms who are receiving

optimal recommended medical therapy and who are

undergoing implantation of a permanent pacemaker

and/or ICD with anticipated frequent ventricular pacing,

CRT may be considered.

CRT is not indicated for asymptomatic patients with

reduced LVEF in the absence of other indications for

pacing.

CRT is not indicated for patients whose functional status

and life expectancy are limited predominantly by chronic

noncardiac conditions.

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*All primary SCD prevention ICD recommendations apply only to patients who are receiving optimal medical therapy and have reasonable expectation

of survival with good functional capacity for more than 1 year.