ECG interpretation postCRT

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  1. 1. BY-Dr Sarita Choudhary
  2. 2. Increasing number of new cases of heart failure being diagnosed Recent studies show despite optimal medical drug treatment mortality remains > 25% at three years Hospital admissions and office visits are frequent following diagnosis 20-40% of patients with heart failure have conduction disease and QRSd > 120 msec
  3. 3. Cardiac resynchronization therapy (CRT) is a recommended treatment for patients with moderate to severe (drug-refractory) heart failure with left ventricular (LV) systolic dysfunction and evidence of ventricular dyssynchrony dened by a QRS duration >120 ms. It improves symptoms, exercise tolerance, quality of life , morbidity and mortality. However, the problem of non-response to CRT remains crucial with prevalence of 30% of non- responders for clinical response and 45% for echocardiographic response.
  4. 4. Notable Recommendation Changes in 2012 ACCF/AHA/HRS Focused Update 2012 DBT Focused Update Recommendations Comments Class I 1. CRT is indicated for patients who have LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration greater than or equal to 150 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. (Level of Evidence: A for NYHA class III/IV; Level of Evidence: B for NYHA class II) Modified recommendation (specifying CRT in patients with LBBB of 150 ms; expanded to include those with NYHA class II symptoms). Class IIa 1. CRT can be useful for patients who have LVEF less than or equal to 35%, sinus rhythm, LBBB with a QRS duration 120 to 149 ms, and NYHA class II, III, or ambulatory IV symptoms on GDMT. (Level of Evidence: B) New recommendation 2. CRT can be useful for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS duration greater than or equal to 150 ms, and NYHA class III/ambulatory class IV symptoms on GDMT. (Level of Evidence: A) New recommendation 3. CRT can be useful in patients with atrial fibrillation and LVEF less than or equal to 35% on GDMT if a) the patient requires ventricular pacing or otherwise meets CRT criteria and b) AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRT. (Level of Evidence: B) Modified recommendation (wording changed to indicate benefit based on ejection fraction rather than NYHA class; level of evidence changed from C to B). 4. CRT can be useful for patients on GDMT who have LVEF less than or equal to 35% and are undergoing new or replacement device placement with anticipated requirement for significant (40%) ventricular pacing. (Level of Evidence: C) Modified recommendation (wording changed to indicate benefit based on ejection fraction and need for pacing rather than NYHA class; class changed from IIb to IIa).
  5. 5. Notable Recommendation Changes in 2012 ACCF/AHA/HRS Focused Update 2012 DBT Focused Update Recommendations Comments Class IIb 1. CRT may be considered for patients who have LVEF less than or equal to 30%, ischemic etiology of heart failure, sinus rhythm, LBBB with a QRS duration of greater than or equal to 150 ms, and NYHA class I symptoms on GDMT. (Level of Evidence: C) New recommendation 2. CRT may be considered for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with QRS duration 120 to 149 ms, and NYHA class III/ambulatory class IV on GDMT. (Level of Evidence: B) New recommendation 3. CRT may be considered for patients who have LVEF less than or equal to 35%, sinus rhythm, a non-LBBB pattern with a QRS duration greater than or equal to 150 ms, and NYHA class II symptoms on GDMT. (Level of Evidence: B) New recommendation Class III: No Benefit 1. CRT is not recommended for patients with NYHA class I or II symptoms and non-LBBB pattern with QRS duration less than 150 ms. (Level of Evidence: B) New recommendation 2. CRT is not indicated for patients whose comorbidities and/or frailty limit survival with good functional capacity to less than 1 year. (Level of Evidence: C) Modified recommendation (wording changed to include cardiac as well as noncardiac comorbidities).
  6. 6. Ventricular Dysynchrony1 Electrical: Inter- or Intraventricular conduction delays typically manifested as left bundle branch block Structural: disruption of myocardial collagen matrix impairing electrical conduction and mechanical efficiency Mechanical: Regional wall motion abnormalities with increased workload and stresscompromising ventricular mechanics Cardiac Resynchronization Therapeutic intent of atrial synchronized biventricular pacing Modification of interventricular, intraventricular, and atrial-ventricular activation sequences in patients with ventricular dysynchrony Complement to optimal medical therapy 1 Tavazzi L. Eur Heart J 2000;21:1211-1214
  7. 7. Abnormal interventricular septal wall motion Reduced dP/dt Reduced pulse pressure Reduced EF and CO Reduced diastolic filling time Prolonged MR duration
  8. 8. Intraventricular Synchrony Atrioventricular Synchrony Interventricular Synchrony LA Pressure LV Diastolic Filling RV Stroke Volume LVESV LVEDV Reverse Remodeling Cardiac Resynchronization MR dP/dt, EF, CO ( Pulse Pressure)
  9. 9. Transvenous Approach Standard pacing lead in RA Standard pacing or defibrillation lead in RV Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus Right Atrial Lead Right Ventricular Lead Left Ventricular Lead
  10. 10. Use extreme care when passing the guide catheter through vessels Due to the relative stiffness of the catheter, damage to the walls of the vessels may include dissections or perforations
  11. 11. Varying Patient Anatomy 1,2,3
  12. 12. CS Os Middle Posterior Postero-lateral Great Lateral Antero- lateral Anterior Step 2: Perform Venograms
  13. 13. Step 2: Perform Venograms
  14. 14. Response more likely Response less likely QRS duration >150ms