SHOULD WE CONSIDER RESCUE CRT?

SHOULD WE CONSIDER RESCUE CRT? Isabelle Nault Cardiac Electrophysiologist IUCPQ Learning Objectives • At the end of the session, participants will be able to: • Understand the role of CRT in "end-stage HF" • Identify in-patients in whom CRT should be avoided • Describe the need for any special preparations that should be made for in-hospital CRT Case presentation • 67Y male • Admitted for progressive dyspnea (functionnal class 4), peripheral oedema, orthopnea,and weakness. • Known with: • Ischemic cardiopathy: coronary bypass in 2011, PCI in February • LVEF 40-45% in October 2018 • Atrial fibrillation • RBBB • Creatinine 100 Investigation • Creatinine 178 • Coronary angiogram: Bypass to LAD and RC patent, Bypass to marginal occluded but stents on circumflex patent. No need for revascularisation • Echo: Moderate to severe mitral regurgitation. LVEF 23-30% • Transoesophageal echo confirms moderate to severe mitral regurgitation Case presentation • Despite IV furosemide and milrinone, clinical deterioration with acute renal failure, and respiratory distress. • Dialysis started. What would you offer this patient? • MitraClip • LVAD • CRT-D • CRT-P • CRT-D and AV junction ablation • CRT –P and AV junction ablation Case • Patient was offered CRT-P and AVJ ablation • 48h after CRT, he was weaned off milrinone • Dialysis was no longer necessary and creatinine improved • 10 days later he was discharged home, creatinine 108, functionnal class 2-3, gradually recovering Case presentation • 76Y male • Mixted ischemic and dilated cardiomyopathy • LVEF 15-20% • Dual chamber ICD – pace dependant 3rd degree AV block: paced QRS 200 ms. Previous failure to implant CRT lead in the coronary sinus. • Complex device history with prior extraction (infection) and high DFT • Cardiogenic shock, inotrope dependant (milrinone and levophed) • Renal failure creatinine 212 What would you offer this patient? • LVAD • Another attempt at endovenous CRT • Epicardial CRT (mini thoracotomy) • Palliative care Case- Follow up • Another attempt at endovenous CRT was made and was successful. • Improvement was immediate, with diuresis, improvement in BP and weaning of inotropes. • Renal function improved (creatinine 160-170) • EF remained low (18%) • Patient survived > 4 years, functionnal class 3 with occasional episodes of deterioration most often treated on an outpatient basis with increase in diuretics Rescue CRT in end-stage heart failure patients • No guidance • In current guidelines, recommendation is to implant CRT in « ambulatory class 4 patients » • Studies have generally excluded this population given their poor life expectancy CCS CRT Guidelines • CRT is recommended for patients in sinus rhythm withNYHA class II, NYHA class III, or ambulatory NYHAclass IV heart failure symptoms, a LVEF ≤35%, and QRS duration≥ 130 ms because of LBBB (Strong Recommendation, High-Quality Evidence). • Practical tip: Patients with LBBB and QRS duration≥ 150 ms are more likely to benefit from CRT. • CRT may be considered for patients in sinus rhythm withNYHA class II, NYHA class III, or ambulatory NYHAclass IV heart failure, a LVEF≤35%, and QRS duration ≥150 msec not because of LBBB conduction (WeakRecommendation, Low-Quality Evidence). • Practical tip: there is no clear evidence of benefit with CRT among patients with QRS durations <150ms because of non-LBBB conduction. Exner et al, CJC 29 (2013) CCS CRT Guidelines • CRT may be considered for patients with chronic RVpacing or who are likely to be chronically paced, havesigns and/or symptoms of heart failure, and a LVEF value ≤35% (Weak Recommendation, Low-QualityEvidence) • Practical tip: The risk of CRT upgrade needs to be considered and balanced with the potential benefit of CRT upgrade. • Patients who undergo pacemaker implantation who are likely to have a high pacing burden (similar to BLOCK HF) might benefit from CRT. • CRT may be considered for patients in permanent AF who are otherwise suitable for this therapy (Weak Recommendation, Low-Quality Evidence). • Benefits of CRT appear greatest in patients with ≥95% biventricular pacing. AV node ablation may be necessary to achieve this. Exner et al, CJC 29 (2013) Meta-Analysis • 8 studies • 151 patients • 93% of patients were weaned off inotropes after CRT • 12 months survival 69% Follow-up 877 ± 620 days Age 64±12 years Male 80% Ischemic Heart disease 64% Functionnal class 4 80% QRS duration 171±33 ms LBBB 50% RBBB 9% IVCD 21% Paced 10% LVEF 20±6% CRT-D 96.8% Hernandez et al, CRT in Inotrope-Dependant HF Patients, JACC HF, vol6 No9: 2018 To Class 1 2% To Class 2 36% To Class3 43% Class 4 10% Rematch: first generation pulsatile LVAD Hernandez et al, CRT in Inotrope-Dependant Heart Failure Patients, JACC HF; vol 6, no9: 2018 Heartware HVAD Hernandez et al, CRT in Inotrope-Dependant Heart Failure Patients, JACC HF; vol 6, no9: 2018 Hernandez et al, CRT in Inotrope-Dependant Heart Failure Patients, JACC HF; vol 6, no9: 2018 Learning from studies where CRT did not work as well • 84 patients • 20% inotrope-dependant • EF<35% • 24% had QRS < 120 ms • Only 25% had LBBB • 1y LVAD-free survival predictors and mortality • BNP>690 pg/ml • Intrope dependance Imamura et al, Journal of Cardiac Failure vol 21 no 6 2015 Learning from studies where CRT did not work as well • 67 patients • Advanced HF class 3 or 4 • Only 16% responders • Positive response to CRT: • é LVEF 10% • Predictors of response: • LA volume index <43ml/m2 • LBBB • LVAD-free survival in responders was 86% vs 52% in non responders Imamura et al, Circulation Journal 2015 Evidence for CRT in AF • MUSTIC trial • 37 patients – cross over study • Improvement in 6min walk test, peakVO2, trend towards better QOL. 84,6% patients prefered BIV pacing RV pacing Leclercq et al, Comparative effect of BIV and RV in HF patients with AF, EHJ 2002 • RAFT AF • 1798 patients, 229 in AF with controlled HR • No benefit in AF subgroup Tang et al, CRT for mild to moderate AF, NEJM 2010 Atrioventricular junction ablation • Improves response to CRT in permanent AF patients • Improved LV remodeling • Gasparini et al, JACC 2016 • Lower mortality in patients with AVJ ablation compared to rate controlled by medication • Gasparini et al, EHJ 2008 • Survival in AF+AVJ ablation similar to SR population, better than AF under medication for rate control • Gasparini et al, JACC HF 2013 Target: ≥ 95% BIV pacing Functional mitral regurgitation Atrial Fibrillation Sinus Rhythm P value Reduction in LVESV 18.6% reduction 18.1% reduction ns Reduction in LA volume 2.3% reduction 10.2% reduction 0.05 Mitral annular diameter (A4C) 3.4% reduction 3.9% reduction ns Mitral annular diameter (PSLAX) 0 4.4% reduction <0.001 Improvement in functional mitral regurgitation (≥1grade) 30.7 % of patients 45.6% of patients 0.011 Ventricular reverse remodeling with CRT is similar in patients with atrial fibrillation and sinus rhythm but atrial reverse remodeling is significantly better in sinus rhythm. The reduction of functional mitral regurgitation with CRT is superior in sinus rhythm. Van Der Bijl et al, Impact of AF on improvement of FMR in CRt, Heart Rhythm 2018 Left epicardial lead during cardiac surgery • 48 patients • EF < 35% and QRS ≥120 ms undergoing cardiac surgery for CABG ± valvular surgery • CRT+ • LVEF improved from 24±5% to 43±13% (compared to 27±8% to 34±12% CRT-) • LVEDD improved from 65±8mm to 56±9mm (vs 61±6 mm to 58±7 CRT-)÷ • 25% had early connection (≤1 month) because of severe heart failure symptoms Freedom from HF and or cardiac death CRT+: hospit 1 before 3 after CRT, 0 death CRT- : hospit 4, death 2 Survival Abstract presented at CCS 2016. Courtesy of Dr Mario Senechal Patient Selection • LBBB • Non LBBB with significant intraventricular delay • In studies where CRT response was poor, mean QRS duration was 127-147 ms whereas in studies with good CRT response the mean QRS duration was 153-205 ms • AF • Aim for very high LV pacing % (>95%) • Liberal approach to AV junction ablation Considerations for CRT in end-stage Heart Failure • Responders to CRT have the same characteristics as responders in « healthier » population: stick to guideline’s recommendations! • QRS duration, LBBB, dyssynchrony • Small amount of contrast needed: renal failure should not be a reason to withold treatment • Decision between CRT-D and CRT-P: according to underlying disease. Shared decision making. • AF: control heart rate Conclusion • Rescue CRT can be considered in Class 4 heart failure patients under inotrope therapy as some may benefit from such therapy • The decision needs to be individualized and the presence of dyssynchrony is key • The choice of CRT-P vs CRT-D must be discussed • Complication rate is low especially when compared to that of LVAD