Devices Therapy for

Advanced
Heart Failure
Yoga Yuniadi
Department of Cardiology and Vascular
Medicine, FMUI, and National Cardiovascular
Center Harapan Kita, Jakarta

Outline
1. Electrical
Failure

Remodeling

in

Heart

Mechanisms of electrical remodeling

Ventricle dyssynchrony
Clinical Consequence
2. Cardiac Resynchronization Therapy

Mechanisms of cardiac synchronization

Clinical Evidences
3. When to Perform CRT Implantation

Refractory Heart Failure

Guidelines Directed Medical Treatment
4. Who will be Benefited from CRT

Impact of QRS duration

Overt vs. Mild Heart Failure
Sinus Rhythm vs. Atrial Fibrillation

Normal Heart Conduction

Left Bundle Branch (LBB)

Posterior Fascicle of LBB

Anterior Fascicle of LBB

Right Bundle Branch (RBB)

Cardiac Electrical Remodeling

Primary Secondary
Remodeling Remodeling
Causes Ventricular Pac'rrig Myocardial Infarction
Conduction System !Dysfunction Hypertrophy
Heart Failure

Eiectrophysiology

APD Prolongation

Changes

Mechanisms

echani c a I Stretch
AngiotensiOn II
Electroton US

APD Prolongation
Conduction Slowing
E-C Coupling Changes
Complex Signaling Pathways

Ionic Changes Ito, 'ca., and Cx43 4' h. IkT, and Cx43
E-C coupling proteins 4'<-0Bta
IINcvtitcx
RyR and SERCA2a

Cutler et al. Trends Pharmacol Sci. 2011 ; 32(3): 174-180

Cardiac Memory

Rosenbaum et al. Am J Cardiol.1982; 50(2):213 22.

Electrophysiological
Remodeling in
Heart Failure

Tomaselli GF et al. Cardiovascular Research.1999;42:270 283

Electrical Remodeling
7

I1

a V I V2

Vi

III

a V V3

V6

II

11
A

LBBB, QRS duration 180 ms, PR interval 240 ms

Electrical Remodeling Results in

Mechanical Dyssynchrony

Prevalence of Ventricular Dyssynchrony

in
Heart Failure
Left Bundle Branch Block More Prevalent
with Impaired LV Systolic Function
Preserved LVSF
(1)
Impaired LVSF
(1)
Moderate/Severe
HF (2)

8%

24%

38%
1.Masoudi, et al. JACC 2003;41:21723
2.Aaronson, et al. Circ 1997;95:2660-

Clinical Consequences of Ventricular

Dyssynchrony

Prognosis of
Electrical Remodeling
1 Year Mortality Long-term (45 Mo) Mortality
P < 0.001

49 %

P < 0.001

34%

16%
11%

QRS <
120 ms

QRS >
120 ms

QRS <
120 ms

QRS >
120 ms

Baldasseroni S, et al. Eur Heart J 2002;23:1692-98 Iuliano et al. AHJ 2002;143:1085-91

N=5,517 N=669

Outline
1. Electrical Remodeling in Heart Failure

Mechanisms of electrical remodeling

Ventricle dyssinchroni
Clinical Consequence
2. Cardiac Resynchronization Therapy

Mechanisms of cardiac synchronization

Clinical Evidences
3. When to Perform CRT Implantation

Refractory Heart Failure

Guidelines Directed Medical Treatment
4. Who will be Benefited from CRT

Impact of QRS duration

Overt vs. Mild Heart Failure
Sinus Rhythm vs. Atrial Fibrillation

Cardiac Resynchronization Therapy

Cardiac Resynchronization

Mechanisms of Improvement
Cardiac Resynchronization

Intraventricular
Synchrony

1" dP/dt, 1" EF, 1" CO L MR

(1" Pulse Pressure)

Atrioventricular
Synchrony

Interventricular
Synchrony

L LA

1" LV Diastolic

Pressure

Filling

1" RV Stroke
Volume

L LVESV L LVEDV

Reverse Remodeling
Yu CM et al. Circulation 2002;105:438-445

Metaanalysis of the effects of CRT on

morbidity and mortality
All.r.ause

C RT-MRT-D
CDiback-up pacing

Hazard Ratio 0.66(95% CI a 57-11771

12

42

15 24 30
Number of months post-implant

Subjtat. a1 RSA.

CRT: 2023 167$

/331

1155 SKI 737 586

416

286.

205

CDirtrod: 1549 144

116.

1433 1395 6136 532

369

24T

10E

All-cause martalityti IF hospitalization

-

Hazard Ratio O. 5 (95% CI 0.5B-4.74]

7.90
9

80
La
:If 70

BO
uJ
50 -

CRT-P/CRT-10
0 hi TIC 09ek-up paci r4g

40 '
12

18 24 50

36

42

4.E.

54

4D1
332

306
240

234
184

169.
137

Number of morrrh.9 pc/RI-

Subjects at Risk
CRT: 2023

1592

Control:1549

1320

1234
1027

implant
11344 771 54.3
am 43f.7 409

Cleland et al. Eur Heart J. 2013;34:3547-3556

How Low Can You Go?

Mann Dl et al. Circulation. 2005;111:2837-2849

Number Need To Treat

CRT:

All cause mortality: 25 (Cochrane 2009)

Hospitalization for HF: 11 (Cochrane 2009)
ACEI:

Heart failure mortality: 24 (Am Fam Phys 2004)

HF mortality and hospitalization: 11 (Am Fam Phys
2004)

Non-HF mortality: 720 (Am Fam Phys 2006)

Outline
1. Electrical Remodeling in Heart Failure

Mechanisms of electrical remodeling

Ventricle dyssinchroni
Clinical Consequence
2. Cardiac Resynchronization Therapy

Mechanisms of cardiac synchronization

Clinical Evidences
3. When to Perform CRT Implantation

Refractory Heart Failure

Guidelines Directed Medical Treatment
4. Who will be Benefited from CRT

Impact of QRS duration

Overt vs. Mild Heart Failure
Sinus Rhythm vs. Atrial Fibrillation

Comparison of ACCF/AHA Stages of HF

and
NYHA Functional Classifications

Guidelines Directed Medical Treatment

Yancy et al. ACCF/AHA Guidelines for Management of HF. Circulation. 2013;128:e240-e327.

The effect of CRT in pre-specified subgroups

on death or heart failure hospitalization
Group

Subjects with events/total subjects Hazard ratio (95% confidence intervals)

ovcrBil

.(11:E2/3872)

1CD subject

Vcs (6824'2437)

0.155 (158, 0.74)

Nromon435)

1170 (0126,10_52)
0.58 (147, 0.71)

(3C11dCr

Melo (87113004)
Female (21 li8681

0.159 (16, 0.761)

0.50 (0.37. I/661

Age

<5g (211,4400)
58-66(242.967)
66-725 (311./964)
>72.5 (318)960

0.131 11146, 0,g1)

1110 .131.54, 119)
0.65 (152, 0.52)
0,62 (149., 0,78)

cLea (4-$7., 0,76)

NYI-LA 11(441.1'1877)

Ill (577/1849)

0.157 (151, 0,79)

0,52 W31 o,r)

IV (64/146)
LVEF <15 (1.30196.5)

0.59 (141, 13.8.3)

16-20(248)784)
Co0DT2162)
(571318)
>35 1271174)

0,56 0.43,
171 (115, 0_83)
0,69 (0-4, I . k 7)
0.56(06, 1.23)

Morphology LBIEID (8210036)

R131'01(11 5T346)
Neilher (123,467)

0,61 (0.53, 0.7)

0,94 (045. 1,37)

1.36).

Systolic BP <WS (316/976)

106-116 mmHg (281'961)
117-130 mmHg (297111681
3-130 mmHg (151051)

up (0.57. 0.871
0,68 (034, 0,86)
0.56 (0.44, 0.71)
0.61 0.44, (I,83)

Ischaemic Yea. (72242232)

(3613/1640)

0.69 (0.6, 0.8)

0.54 (144, 0.157)
0.65 (0..56, 0,74)

ElemNuckers Yes (7993006)

No (28318144

-6.8 (0.54 0 57)

0.2 0.5

15 2

Resyrichronization better OMT ICD bulbar

Cleland et al. Eur Heart J. 2013;34:3547-3556

Indications for CRT therapy algorithm

Patient with oarciomyopathy on GDMT for me or on GDMT and X40 d after MI, or
with implantation of pacing or defibrillation device for special indications
V
LVEF
V
Evaluate general health status

Comorlaidities and/or frailty

limit survival with good
functional capacity to <1 y

Continue GDMT ..vi

implanted device

V
Acceptable noncardiac health
V
Evaluate NYHA clinical status
V
NYHA class I
LVEF -30%
ORS X150 ins
LBBB pattern
lschemic
cardiameathy

Ems .150ms NonLBBB pattern

NYHA class II
LVEF 35%
ORS X150 ms
LBBB pattern
Sinus rhythm
LVEF .35%
ORS 120-149 ms
LBBB pattern
Sinus rhythm
LVEF .35%
ORS 1-2150 ms
Non-LBBB pattern
Sinus rhythm
ORS .c[50 ms
Non-LBBB
pattern

NYHA class Ill &

Ambulatory class IV
LVEF s35%
OHS -2150 ms
LBBB pattern
Sinus thythim
LVEF 35%
ORS 120-149 ms
LBBB pattern
Sinus rhythm
LVEF 35%
ORS 2150 ms
Non-LBBB pattern
Sinus rhythm
LVEF s35%
ORS 120-149 ms
Non-LBBB pattern
Sinus rhythm

Special CRT
Indications
Anticipated to
require frequent
ventricular pacing
(.40%)
Atrial fibrillation,
if ventricular pacing
is required and rate
control will result in
near 100%
ventricular pacing
with CRT

GOR

Ila

III: Na Benefit

Yancy et al. ACCF/AHA Guidelines for Management of HF. Circulation. 2013;128:e240-e327.

Outline
1. Electrical Remodeling in Heart Failure

Mechanisms of electrical remodeling

Ventricle dyssinchroni
Clinical Consequence
2. Cardiac Resynchronization Therapy

Mechanisms of cardiac synchronization

Clinical Evidences
3. When to Perform CRT Implantation

Refractory Heart Failure

Guidelines Directed Medical Treatment
4. Who will be Benefited from CRT

Impact of QRS duration

Overt vs. Mild Heart Failure
Sinus Rhythm vs. Atrial Fibrillation

Impact of QRS Duration on Clinical Event Reduction

With Cardiac Resynchronization Therapy
Statistics for each study
RR (95% CI) zValue
P Value
COMPANION (ORS, 148-168 rns, n=314)

0/8 (0.59-1.04)

1.70

.09

COMPANION (ORS, >168 ms, n=287)

0.66 (0.47-0.93)

2.35

.02

CARE-HF QRS, >159 ms, n=505)

0.60 (0.46-0.79)

REVERSE (ORS, >151 ms: n=307)

0.42 (0.22-0.81)

2.61

.009

MADIT-ORT (ORS, >149 ms, n=1175)

0.48 (0.37-0.63)

5.41

x.001

RAH (QRS, >149 ms, n=1036)

0,59 (0.48-0.73)

Me1aanal'siS

0.60 (0,53167)

3/0

493
8.67

<.001

c.001
<.001
0.2 0.5 2 5
CRT Better Control Better

Figure 2. Effect of cardiac resynchronization therapy (CRT) on composite clinical events in patients with severely prolonged ORS interval (n=3624: 12=32.1%,
fixed-effect model). CARE-HF indicates Cardiac Resynchronization-Heart Failure''; Cl. confidence interval; COMPANION, Comparison of Medical Therapy,
Pacing. and Defibrillation in Heart Failureth: CRT, cardiac resynchronization therapy: MADIT-CRT, Multicenter Automatic Defibrillator Implantation TrialCardiac
Resynchronization Therapy2'; RAFT, Resynchronization-Defibrillation for Ambulatory Heart Failure Trial22; REVERSE, Resynchronization Reverses Remodeling in
Systolic Left Ventricular Dysfunction': RR, risk ratio.

Sipahi et al. Arch Intern Med. 2011;171(16):1454-1462.

Impact of QRS Duration on Clinical Event Reduction

With Cardiac Resynchronization Therapy

Sipahi et al. Arch Intern Med. 2011;171(16):1454-1462.

CRT in Narrow QRS complex

(EchoCRT)

A Pri r nari Composi te Outcome

B Death from Any Cause.

Patie
nt
with
Even
t (%)

0.5

1.0 1.5 2.0

2.5

Years since Random

ation

3.0

3.5

No. at Risk

P
at
ie
nt
w
it
h
[v
e
nt
(
%
)

7
6C
5C
4C
3C

P =0 . 0 2

CRT

iC
:C

Control
0.5

1.0 1.5 2.0

2.5

Years since Random

ation

3.0

3.5

No. at Risk

CRT

404

297

223 155 103

65

42

19

CRT

404

334

267 199 132

84

56

25

Control

405

302

236 166 119

71

44

15

Control

405

335

269 195 141

87

62

27

R u s ch zk it a e t a l . N E n g l J M e d 2 0 1 3 ; 3 6 9 : 1 3 9 5 - 4 0 5 .

Models showing the effects of CRT vs.

control with QRS duration
Mortality endpoint
S m oo t hed e s t im at e
95% tootatrap confidence bounds
Haz
ard
ratio
for
CRT

1 0 0 11 0 1 2 0 1 3 0 1 4 0 1 5 0 1 6 4 1 7 0 1 0 0 1 9 0 2 0 0 2 1 0 2 2 0 2 3 0 2 4 0 2 5 0
ORS duration
Mortarty1HFII endpoint
Smoothed estimate
BM bootstrap confidence bounds
Haza
rd
ratio
for
CRT

_--

1 0 0 11 0 1 2 0 1 3 0 1 4 0 1 5 0 1 6 o - 1 7 0 1 8 0 1 9 4 2 0 0 2 1 0 2 2 0 2 3 0 2 4 0 2 5 0
ORS duration

Cleland et al. Eur Heart J. 2013;34:3547-3556

Role of CRT in Overt vs. Mild HF

Mortality; study group,* rain
study

camcD

ICD

RR (95% CII

MIRACLE OM II, 200423

2/85

21101

1.19 (0.17-8.26)

REVERSE, 2008,*

9/419

3/191

137 (037-4.99)

MA.DIT-CRT, 2.00929

74/10.59

531731

0.94 (0-67-1.32)

154130

0.74 (0-59-0.94

212)1753

0,80 (0 67-0.96)

idVOLEr5

CRT

Favc;I..15

car Pp!

NYHA class I and It

RAFT (claw FP), 20101A

110,1703

Subtotal

195/2301

11, = 0
111Y11Adais111and IV
Lozano at al.,. 200013

51109

10/113

0.52 (0A 8-1.47)

MIRACLE ICI), 200322

14/187

15/182

0.91 (0_45-1.83)

RHYTHM 1CD. 200435

6/119

2/60

1.51 (0_31-7.27)

761186

82/174

0.87 (0,69-1.10)

101/601

109/5.29

0.86 18.168-1.0))

295/2902

321/2282

RAFT {{lass I 201014

Subtotal
P=0
Overall

0,B3 032-0.96)

0.1 0.2 0.5 1 2 r, 10

RR (95% CI)

-'

Meta-analysis: CRT for Less Symptomatic HF

or 171:mloci G amp, a-

11f4:10--

Study. Via, Sc restanci5 E iambs 14:441 Primbs ittal

Pradom I narAT FNMA [lass L.1
al MFALC LE 1 CID II.. 2064 434Z1 2 HS 2

Iiis F. Rally 1J5 9c lF

i.

101

113

1.1-9 CO.1 T-15_2 al-

FLEW EF:Sa 20011111} S 419 3

1-91

117

1.37 CO. 3 7-4_99 I-

AA A.G. EE--CFET. ] 009 11 2 F 3.1 18:69 53

73 1

S_7

0.94 C0.62-1321

RAFT. ...91 II C 13 5 1 SE 394 23.6

904
SO
G Fatlia-E.T.A Mi. zari a c-L-7 1 51 2
van Calclarp at al 2 MEI 4265 6 19 I)
13
54arIcKal 1 95 % C:1) 2557
2 (PDS
Torii Ever= 233 29.6
Fiata,newic!y: Tug' = CI. IX:t cla- squaw = 1.46 : P = 0!23: .1 k = O's
Tsat 10r twill 1 aiTerlz 2 = 2 .43 : P = a01
1.-narlorni naney WM.& [Las s M.. IV
ill ILFSEIC S R. 2.501 C313 5 1 a

34

99_6.
63
5115

O. 311 CO. 57-11941

O. 9-3 03. 14-.6_7-ifF
51c4 750 [nib la
O. El 3 (.:t 77-11 9b-1.

-E-

3.06 90.17- 707A)

-0_1
0.7A {0. 35 1931

il Mr.A.CLE 2002 431} 12 273 1S

2_1

PATH -C HE 2 E. 13 1) 2 14 I::

1 7

-0_1

Jil ILPSTIC AF_ 2 002 C3) 1 75 6

VI 11144 C LE I CO 2E03 CI S.5 SA 197 1 5

1L

EL1

152
2AS
{3
363

23
211
0_4
1 KS

.
H liahres at al 2E03 43143 11 2.15 1.6
P.4151-1- E H F R. 711413 [9111 2 43 3
C CAI Pa[ill c 2-004 .13 7) 121 217 77
R H ITH.1.11 I CEI C29) .6 113 2

3.00 CO.10-70541
7 lli. MOS-95_9 3) .
0.91 CO. 45- 1_1E1 F
0. SS CO. 3 7- 1_4 5 1
Q67 C0.12-379F
O.95 CO. 93- 1_094
1.51 CO. 3 1
-7271.
O. 156 CO. cps- 1 a _4433
0.57 CO. 5 5-6. Sal-

95

65

WaL-1-7-L 7315 a 51 1 53 1
C ARE- 11F. 2 609 4-313 32 1E9 126
H CIS M.1.:CF. 2046 1 1.5 1

47
494

0_1
137

1.5

112

1.136 CO. 0 7-14516

El ELJ PWE . 2006 C2 3 5 E 37 3

37

0.7

].O6 CO. 54- 7_40 1

Rate. 3 007 12 11 5 57 2

HS

6_4

2.44 [0. 41.-12 -1

PD-CI-FF. 2 007 14 DI 2 32 A
ID E :IR EA 5EF_ 2 957 : 2 5 i -a 26S 5

32

04

O. 50 CO. 115-2_ 451

0.55 .53.1 3- 1_191:

. .bXIS

1387

169

1113

Plapti ol al. 2001. 17 4 1 7 44 5

AS.

13

13-LEFT FF. 7131E1 (171- E. 9. 41

HS

0.1

C CM 1141-. 21] 0 QM: 2 27 A

27

-H

54451443.1 4 95 X C 2 51 3

1997

Total s4.0rr9 291 251

FirtorDamalily: 7au = O.0t Era squaw- = 11 _fi 1 : P = 0 . 117; J3 =
1-0101 ErFs-n fs 5fi5 577
Tait 1or oriial 1 41144th .5 =3.1: P = 11001
H lalarneanarry_ Tana] = O.OR :=111 --pauari = 13.4 Cc P = 0
Tel {SS 3 CI) S 0110
94 J T = O 'X To.= Its -ow:rail an 1:-=r_ = 4.OU .P K a .
[c-!
2

Tani as cuts-row 3 Hiarances : J44:11.

0.39 CO. 3 5-a2 GI

.5.11 CO. 01 - 1_{.11 1
O.5{' CO. 1 0- 2_41:11

II
.4
495

0711 90. 57-43_94 F

4111P

0%
4002

'

1989O.
3 E9:
1 CO.
72-6-9.0
Famers.
F 3A:ors
CorrlF r=4
1:1

FAO. Pato 057. CR

Al Majed et al. Ann Intern Med. 2011;154(6):401-412.

21:11

JACO Heats Patine VoL I, No. 6,

2013 by rho Annelimn. CAI-go of Cardiology Foundation ISSN 2213-] 779336.00
FubLshti by Elsevic r http JO I Eiljje hi-2013.06.003

Cardiac Resynchronization Therapy in Patients

With Atrial Fibrillation
The CERTIFY Study (Cardiac Resynchronization Therapy in
Atrial Fibrillation Patients Multinational Registry)
Maurizio Gasparini, MD,* Christophe Leclercq, MD, PHD,f Maurizio Lunati, MD,t
Maurizio Landolina, MD, Angelo Auricchio, MD,I Massimo Santini, D, Giuseppe Boriani, MD,# Barbara
Lamp, MD,' Alessandro Proclemer, MD,tt Antonio Curnis,
Catherine Klersy, MD, MSM Francisco Leyva, MDR

Results

Median follow-up was 37 months. Toll mortality (6.B vs. 6.1 per 100 personyearsi and cardiac mortality 14.2 vs. 4.0)
were similar for patients with AF AVJIA and patients in SR (both p NS). In contrast. the AF drugs group had a higher
total and cardiac mortality than the SR group and the AF AVIA group {11.3 and al. respectively; p 0.001). On
multivariable analysis. AF AVM had total mortality (hazard ratio [HR]: 0.93, 95% confidence interval [CI]: 0.74 to 1.67)
and cardiac mortality (HR: 0.9.R, 95% CI: 0..66 to 1.17) similar to that of the SR group, independent of known
confounders. The AF drugs group, however. had a higher total mortality (MR: 152. 95% GI: 1.26 to 1.82) and
cardiac mortality (HR: 1.57, 95% CI: 1.27 to 1.94) than both the SR group and the AF AVJA group (both p 0.001).

ConclusionsLongterm survival after CRT among patients with AF AVM is similar to that observed among patients in SR.

Mortality is higher for AF patients treated with rate-slowing drugs. (1 Am Coll Cardiol MF 2013;1:500-7) .1',1
2013 by the American College of Cardiology Foundation

Survival After CRT

Gasparini et al. J Am Coll Cardiol HF 2013;1:5007

Left Ventricular Reverse

Remodeling
After CRT

Gasparini et al. J Am Coll Cardiol HF 2013;1:5007

Rev Fort Cardiot. 2014;33(11):717-725

Revista Portuguesa de

Cardiologia

Portuguese journal of Cardiology

ELSEVIER
DOYIVIA

www,revportcardiol.org

REVIEW ARTICLE

Cardiac resynchronization therapy in patients

with atrial fibrillation: A meta-analysis
Study or subgrow
Ferreira eta]-1G
Gaspa.rirli et al.lic
Khadjooi et al.113

Linde et al-

37

Moihoek et al.g

Nas8irnento et al.

AF
Events ID Lai

Events Total

Weight

53
243
86

2
135
45

10

64

10

30

30 6.1%

10

12

19

264 16.6%

1.0g [0.4g, 2A-21

16g0 100.0%

1.36 [0.9Z 2.011

604

94

78 5.6%

Odds ratio
M-1-1, random, 95% CI

1'3
:34
24

Total (g5% CI)

Total events

SR

1042 34.1%
209 24.8%
67

11816

11:1!D CrossM ark

Cid& ratio

M-H, random; 95% CI

8.84 [1.8542_211
1.09 [073.1-641

1.41 [039, 2.511

1.06 [0-41.2-741

2. [0.51, 9,991

214

Heterogeneity-. Taut =0.07; ohl-squiare.. 7.46,11=5 (r11-11g); 12= 88%

0.1 1

Test for overall effect: 2=1.55 (p=0,002)In favor of AFIn favor of SR

Cardiovascular mortality for patients with atrial fibrillation versus sinus rhythm.

1CI1CI

Non Responders in AF Patients

Odds ratio
AF SR
Study or sublgroupEvents TotalEvents Total
Weight MA-I, random: 95 CI
30 3.1%
Molhoek et al.911306
2.32 [0.72, 7.411
4
1.5011.04, 2.16i
511 31.3%
Gasparini et al. 65 162 158
0.78 [0.38, 1.581
167 8.3%
Delnov et al.18139628
0.92 10.44, 1.941
58 7.7%
Buck et al.1224 56 26
1.83 [0.82, 4.06J
78 6.6%
Ferreira et al.1175316
1.64 [1.08, 2.511
344 23.4%
Tolosana et al.1552 126 103
1.01 p.36, 2.821
96 4.0%
Kim et al.136 2622
1.60 [0.57; 4.47J
67 4.0%
WiiCon et al.1711 19 31
1.50 [0.47, 4.821
Wo et al.118 13 16
40 3.1%
1.40 [0.70; 2.93]
Tolosana et al." 16 46 43
156 8.5%
141 [1.15,1.731
Total (95% Cl) 630
1547 100,0%
crk

Total events 223 449

Fletengeneitrau2z 0.00; chi-square .14, d 9 (p41.73);
Test for overall effect:Z=328 (p=0.001)

Year

Odds ratio
M-H. random, 95% CI

2004
2006
2007
2008
MEI
2008
2009
2011
2011
2012

I
0.01 0.1 1 10 100
In favor of AF In favor of SR

Lopes et al. Rev Port Cardiol. 2014;33(11):717-725

Role of AV Junction Ablation in AF

patient with CRT

Lopes et al. Rev Port Cardiol. 2014;33(11):717-725

Role of CRT to AF
New Onset AF
Persistent and
Permanent AF Conversion
to SR after CRT

lower incidence among CRT

than controls matched for
age, sex, and EF (8.3% vs.
30.6%, HR 0.23, 95% CI
0.090.76)
lower among CRT

Fung et al. Am J Cardiol. 2005;96:728731

Dascia et al. It J Cli Pract. 2011;65:1149
1155

responders compared with

non-responders (50.0% vs.
15.0%, odds ratio (OR) 5.67,
95% CI 1.3623.59)

Parachute Implant System

Costa et al. Circ Heart Fail. 2014;7:752758

Percutaneous Ventricular Restoration Using the Parachute

Device in Patients With Ischemic Heart Failure
Three-Year Outcomes of the PARACHUTE First-in-Human Study
Marco A. Costa, MD, PhD; Ernest L. Mazzaferri Jr, MD; Horst Sievert, MD;
William T. Abraham, MD

P Value*

LV n i t

Death

111TransplantiVAD 10) 0.4792

LV ESVit 60%

la IV 3) 0.0299

Cardiac output,

m 1) <0.0001

LV erigth, ecii
EF, %

4) 0.0095

a" 9) 0.0132
of

1 6 1 . M . - 0 1

7.0.0012

Stroke volume, r 2096

9) 0.2893

Head rate, Ppm

8.0.5020

Lki mass, g 0,4

6M 12M 24M 36M

Initial Evidences
PUBLISHED PAPERS AND ABSTRACTS
Bozdag-Turan, I., Berrnaoui, B. and Turan, R.G. et al. Left ventricular partitioning device in a
patient with chronic heart failure: Short-term clinical follow-up. International Journal of
Cardiology. 2013, 163 (1): el-e3.
htitp:livirww.ncbi.nlm.nih_oovipubmedi22824252
Mazzaferri, E.L. Jr., Gradinac, S. and Sagic, D. et al. Percutaneous Left Ventricular
Partitioning in Patients with Chronic Heart Failure and a Prior Anterior Myocardial Infarction:
Results of the PARACHUTE Trial. American Heart Journal. 2012,163 (5): 812-820.
htto://virmv.ncbi.nlm.nih_oovipubmedi22807859
Sagic, D., Otasevic, P. and Sievert, H. et at Percutaneous Implantation of the Left Ventricular
Partitioning Device for Chronic Heart Failure: A Pilot Study with 1-Year Follow-p_ European
Journal of Heart Failure_ 2010; 12 (6): 600-606.
hftp:ilvirmw.ncbi.nlm.nih_oovibubmedi20400453

ONGOING STUDIES
ClinicarTrials_gov. A Multinational Trial To Evaluate The Parachute Implant System
(PARACHUTE) NCT01286116_ http:hrwmv.clinicaJtrials.clovict2ishowINCT01286116?
term=Parachute&rank=1_ Accessed 2B February 2013.
Clinicaffrials.gov. Safety Study of the Ventricular Partitioning Device (VPD) Implant System in
Heart Failure Patients (PARACHUTE) NCT00573560.
http:Iformv.clinicaltilals.00vrict2ishow7term=Parachute&rank=3. Accessed 28 February 2013.
Clinicaffrials.gov. A Multinational Trial to Evaluate the Long-term Safety of the Parachute
Implant System (PARACHUTE Ill) NCT01297296. ica1tlials.00vict2ishow?
term=Parachute&rank=4. Accessed 28 February 2013.
Clinicaffrials_gov. A Pivotal Trial to Establish the Efficacy and Long-term Safety of the
Parachute Implant System (PARACHUTE IV) NCT01614652_
http:Ifwvindv.clinicaltrials.00vict2ishow?terrn=Parachute&rank=5. Accessed 28 February 2013.

Consider

LVAD as
BTT

Decision tree for elective

mechanical
circulatory support
Consider

BIVAD or TAH

Low LVAD

Supportive

High LVAD

Cardiology

as BTT

If
revorsible

risk

(eg, infection

AKI, rnalmutritioril
......
Cons ider
HF Symptoms Limiting Daily
Functioning and Quality of Life

Optim al Pharm acologic an d

Resynchronization Therapy >3mos

Not Eligible

Transplant Candidate

Low RV

for Transplant

Failure Risk

High RV
Failure Risk

after LVAD

after LVAD

Low RV
Failure Risk

High RV
Failure Risk

after LVAD

after LVAD

S t e w a r t e t a l . C i r c u l a t i o n . 2 0 1 2 ; 1 2 5 : 1 3 0 4 -1 3 1 5

Devices in Evolution

I m p l a n t a b l e LVAD s i n E u r o
HeartMate

r' '14 ta5P-r

ik
14:3r6:11
g

VINIIMAIM t flr.
morn vairnarp

PtiO/Fr

Jarvik 2000

Manufacturer Thoratec

Ware HVAD
,ar-tWare Jarvik Heart

Flow profile Pulsatile

lus (centrifugal) Continuous (axial)

Implant site Abdomen

ricardium Pericardium

Driver Electric
Weight 1150 g

Electric Electric

Iritny
o
r ppl

160g 90g

Displacement 400 rnL

50 rnL 25 mL

FDA approval BTT, DT

IDE IDE
ion; HVAD, HeartWare ventricular assist
e.

BTT indicates bridge to transp

device; IDE: investigational devil
*Thoratec PVAD is the same

14birtililm I LIMB
SOW' 4574tillse

Stewart et al. Circulation. 2012;125:1304-1315

Conclusion
Electrical
remodeling
and
ventricle
dyssynchroniy
are nor rare in patient with heart failure and
drive
to worse prognosis
CRT is the only therapeutic modality to correct
electrical remodeling
Patient selection is utmost important to achieve
better reponse of CRT implantation
Mild HF and AF patients are also benefi ted from
CRT implantation
Some new promising devices are under
investigation to be available in the market soon

Take Home Message

CRT is covered by BPJS
Always think for CRT Implantation
when
dialing with HF characterized by:

Low EF 35%
LBBB
QRS duration 5 ms

3rd Minn'

Meeting

Fix The Rhythm

And M.dintain The Pulse
STIMPOSIA I rail Olt upERT
1.111351143.41:11S I PLENARY LECILIFte I DERATE
SESSION

SYMPOSIA
Robotic Ahl tion
Sudden Cardiac Dent
Ablation
Ventric le /IV Tachycardia
Pharrnacothera
.
p
Atrial Fibrillation;
5 roke firevent4o
Devices iar0 blation
r
it4562 19f alsow Tuat t),
t

Syncope
g Evaluation
Arrhythmi Drugs Who, MISRift*
grallaralpHale
a
Interpr
t'ng Unknown

ntk81Keitl
y

WORKSHOP
KG
Advanc
edPediatric
ECG
Anhyth rtoa
Advanced Par ornaltaT (Guru ,
Device The-ropy For He ar E Fal lova
AlTial Fibrillati on r Ablate a
nd Pier Fibr i Ilation r Hoe
rondinarnit and E I actris.a I
CADdig'FVF5i411
Sudden Cardiac Death
taordnvacive Rhythm Monitoring
SyrnWpo
f Prethroionis I ; 13101.1c Concarri of Paring
r' &Mit

IIFONMATION AND FtEGINIVATFON

= WEN Rid
Ai I NEWELL Iml I. 1C WE ill.

CALL FOR
1 0 . . . 3

} 1 . 1 . =

R M. 1 0 =.

ABSTRACT EE %mom,
MastAINUMIIIN
111hiewmalliWflimAPHIC141
r.

Wiwi* i

MCI

Type of Respons to CRT

Responders

Expected Normal Responders

Super Responders
Non Responders

Icl. Negative Responders