Điều trị suy tim bằng dụng cụ vai trò của máy phá rung tự động và tái đồng bộ thất

Điều trị suy tim, bằng dụng cụ ,vai trò của máy, phá rung tự động, và tái đồng bộ thất

Anil Saxena Director Cardiac Pacing & Electrophysiology Fortis Escorts Heart Institute, New Delhi

Management Of Heart Failure Beyond Drugs:

Role of ICD and CRT

How to manage heart failure?

 Remove precipitating factor

 Correct the underlying etiology

 Drug therapy

Additionally…

 Salt and fluid management

 Life style change

 Optimize weight

 Exercise, Reduction of Stress

 Yoga, Meditation

CRT

ICD (Implantable Defibrillator)

What Is CRT?

PR interval 280 msec QRS width 160 msec

15-30% Patients with heart failure have conduction system disease

Heart Failure with Wide QRS

Wide QRS– Increased Mortality

(VEST study analysis)

Gottipaty et al JACC Feb 1999 supplement 145A

Ventricular Dysynchrony

Paradoxical movement of the septum

Benefits Of CRT In Heart Failure

• Improvement in Heart Failure

❖ Increased cardiac output CO (20-25%)

❖ Improved NYHA Class (approx 1)

❖ Reduced number of hospital admissions

❖ Improved quality of life

❖ Reduced mitral regurgitation

• Reduction in progression of heart failure

• Reduced mortality

CRT in Mild Heart Failure?

REVERSE Trial:

Moving towards preventive role of CRT

J Am Coll Cardiol 2008; 52:1834–43

REVERSE Trial:

Moving towards preventive role of CRT

J Am Coll Cardiol 2008; 52:1834–43

REVERSE Trial:

Moving towards preventive role of CRT

J Am Coll Cardiol 2008; 52:1834–43

MADIT-CRT Trial:

Moving towards preventive role of CRT

N Engl J Med 2009;361:1329-38

MADIT-CRT Trial:

Moving towards preventive role of CRT

N Engl J Med 2009;361:1329-38

MADIT-CRT Trial:

Moving towards preventive role of CRT

N Engl J Med 2009;361:1329-38

RAFT Trial:

Moving towards preventive role of CRT

N Engl J Med 2010;363:2385-95

Consensus Guidelines For CRT

Guidelines for CRT in Heart Failure

Arrhythmia & Electrophysiology Review 2016:5(2):80-81

ESC 2016 Guidelines for CRT in Heart Failure

Ponikowski et al European Heart Journal (2016) 37, 2129–2200

Underlying Arrhythmia of Sudden Death

Died one morning after a cardiac arrest

Sudden Cardiac Death

Sudden Cardiac Death

The Chain Of Survival

ICD: Placement

Implantable Cardioverter Defibrillator

CRT-P versus CRT-D

• CRT-D is often chosen on premise, that all patients fulfilling criteria

for CRT also have approved indication for ICD

• In western countries, fraction of CRT-D is 60-80% among patients receiving cardiac resynchronisation therapy

CRT-P versus CRT-D

• Does CRT alone improve survival by reducing mortality?

• Will addition of ICD backup to CRT further improve survival significantly?

Cardiac Resynchronization: Trials

All cause mortality reduction

Characteristic CONTAK CD InSync ICD MIRACLE MUSTIC

Baseline Clinical Characteristics of 4 Randomized CRT (± ICD) Trials

Pooled data from 4 trials involving a total of 1634 patients CRT was associated with a 51% reduction in death from progressive CHF relative to controls Trend toward improvement in all-cause mortality (23% improvement), which did not reach statistical significance because of the short follow-up and

small sample size CRT reduced hospitalization for CHF by 29% (n = 1497)

Investigators concluded that CRT reduces mortality from progressive HF and HF-related hospitalizations in patients with symptomatic left ventricular

dysfunction and ventricular dyssynchrony and also shows a trend toward reducing all-cause mortality

Bradley et al JAMA 2003;289:730-740

Care HF Trial:

All cause mortality reduction

Death or hospitalization All cause mortality

❖ 814 patients

❖ Randomised to (Medical therapy) or (Medical therapy + CRT)

❖ Significant reduction in all cause mortality observed with CRT

Care HF Trial: Extension Phase All cause mortality reduction

Follow-up 37.4 months (range 26.1–52.6 months)

40% Reduction in mortality

Companion Trial:

CRT vs CRT-D: Mortality Reduction

Bristow M et al N Engl J Med 2004;350:21, 2140-50

All Cause Mortality

ESC 2013 Guidelines for CRT-P versus CRT-D

Thank You

anil.saxena@hotmail.com