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Cardiac resynchronisation therapy: what do the ESC Guidelines tell us?

ESC webinar

23/04/2015 00:00 23/04/2015 00:00 Europe/Paris Cardiac resynchronisation therapy: what do the ESC Guidelines tell us?

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European Society of Cardiology DD/MM/YYYY
Cardiac Resynchronization Therapy (CRT)
Antibradycardia Pacing

Watch part one of the webinar recording


Watch part two of the webinar recording




Carsten Israel and Haran Burri
The format includes case based presentations, online assessment and live discussions with the key opinion leaders who will give you some useful tips for your daily clinical practice.

ESC Clinical practice guidelines on Cardiac Pacing and Cardiac Resynchronization Therapy

Harran Burri answers your questions

What's your opinion on the use of the QLV delay in the positioning of the LV lead?    
Several reports have found this to be a useful marker of response to therapy. It is easily checked at implantation, and a parameter I do look at when positioning the LV lead. However, I do not routinely map several sites to find the latest delay, if my initial site which I am satisfied with had an LV EGM that is late (ie. toward the end of the surface QRS).  

Are there situations when you prefer LV only stimulation?    
In the rare circumstances where the RV threshold is very high, LV pacing alone may be preferable. Otherwise, I use this configuration in patients with LBBB if the device has an automatic optimisation algorithm which proposes LV only pacing (Boston Scientific and Medtronic devices), but nevertheless then check the surface ECG for the morphology of the paced QRS complex (ie good fusion with narrowing of the QRS complex).

Would you implant in a patient with lateral MI (OM  with 100% scar in CMR?
Data do indicate that these patients do not respond if the LV lead is placed overlying the lateral scar.
However, we do not know if the response would be better if the LV lead were positioned in an anterior or anterolateral position, or if sequential biventricular pacing (with LV pre-excitation to overcome latency) would result in better outcome. For these reasons, I do implant these patients, but do not raise their hopes too high for chances of response.

What about placing also RA lead in this pt? from Gasparini et al. 10% of permanent AF are in sinus rhythm after 6 months of CRT if they are super-responder...    
Some patients with chronic AF do cardiovert back to sinus (also if they have CRT-D and receive a shock). There is, therefore, a rationale for implanting an atrial lead in these patients.
However, I don't do this routinely, especially if patients have been in long-standing AF since >2 years, if they have severely dilated atria, and if other markers of adverse atrial remodelling (e.g. atrial smoke) are present.
The atrial lead in these situations adds minor cost, but may be unstable in these fibrosed atria, and may also cause complications such as perforation. Therefore, if there is no need, don't do it.

How long these implants usually last and then need replacement?   
CRT-D longevity has been found to depend on factors such as  LV pacing output and device manufacturer, with about 50% of devices needing replacement after 5 years.
More recent devices have longer longevity due to changes in battery technology, capacitors that don't require reforming, automatic threshold management algorithms, quadripolar leads allowing lower thresholds, LV-only pacing algorithms etc. Look out for an editorial I have just written in Europace on this subject, that should be published in the coming months.

Could LVAD bridge temporary assist device allow to delay the decision to apply CRT?    
No, as LVADs are either destination therapy, or bridge to transplant, not a bridge to CRT. It is usually CRT which is tried before implantation of an LVAD, which is much more invasive and expensive.  Once the patient is equipped with LVAD, the indication for an ICD is questionable for primary prevention (although it is currently a IIa indication according to the current guidelines).

Do You use LifeVest in the 'waiting phase' on OMT?    
This could be useful in selected high-risk patients, e.g. after a large MI. My experience is limited, as LifeVests have just recently been accepted for reimbursement in Switzerland

Carsten Israel answers your questions

Did you implant atrial lead when you did AV block in patients with CRTD and permanent AF?
A number of patients with seemingly "permanent" AF convert to sinus rhythm during long-term follow-up of CRT, either spontaneously or after a shock.
In the individual patient, it is difficult to predict who will stay in permanent AF and who will convert to sinus. However, I had experience with patients with CRT-D and sinus rhythm after an appropriate shock (Israel et al.,
Pacing Clin Electrophysiol. 2008 Mar;31(3):263-5) and worsening of heart failure due to pacemaker syndrome with VVI pacing and retrograde VA conduction. Therefore, to me the addition of an atrial lead even in seemingly permanent
AF seems to be the smaller problem.
What is the management strategy of LBBB >150 milliseconds and MI with reduced EF?
If the patient is stable on HF medical therapy and LVEF was > 35% before MI, I would try to wait 4 weeks and do a control echocardiography.
If then LVEF is still < 35%, I would implant a CRT-D, otherwise, I would recommend regular follow-up visits with echocardiographic control every 6 months. If the patient had an LVEF < 35% already before MI,
I would go for a CR

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This programme is supported by Bayer HealthCare Pharmaceuticals, Bristol-Myers Squibb and Pfizer Alliance, Daiichi Sankyo Europe GmbH, Novartis Pharma AG and Servier in the form of unrestricted educational grants.

The scientific programme has not been influenced in any way by its sponsors.