Referat

Non Apical RV
pacing in CRT
dr. Beny Hartono SpJP, FIHA
Dr.dr.Muh.Munawar
SpJP,FIHA,FACC,FESC,FSCAI,FAPSIC,FASCC,FCAPSC

RD Robin H Wibowo

Outline
Background
Rationale
The Evidence
Conclusion

RD Robin H Wibowo

Background

RD Robin H Wibowo

Background
CRT is currently only successful in
about two thirds of heart failure
patients
The optimal location of the RV lead is
still a matter of debate.
RD Robin H Wibowo

Background
RV apex has been the preferred site due

to the ease of placement, stability,

reliability, and lead design.
Conventional lead placement in the apex

of the right ventricle can induce cardiac

dyssynchrony and thus increase morbidity
and mortality.
RD Robin H Wibowo

RATIONALE

Acute and long-term effects of RV

apical
pacingactivation
Changes in electrical activation
and mechanical
Metabolism/perfusion
Changes in regional perfusion
Changes in oxygen demand
Remodeling
Asymmetric hypertrophy
Histopathological changes
Ventricular dilation
Functional mitral regurgitation
Hemodynamics
Decreased cardiac output
Increased LV filling pressures
Mechanical function
Changes in myocardial strain
Interventricular mechanical dyssynchrony
Intraventricular mechanical dyssynchrony
RD Robin H Wibowo

J Am Coll Cardiol. 2009;54:764-776

CRT in HF
Hospitalization

Mortality

Freemantle N et al Eur J Heart Fail 2006;8:433

Normal conduction

RD Robin H Wibowo

The anatomy

RD Robin H Wibowo

Angiographic
differentiation

RD Robin H Wibowo

THE EVIDENCE
RD Robin H Wibowo

REVERSE
Sub-analysis of the active group (CRT-ON), the
precise locations of the LV and RV lead tips based
on postoperative AP and lateral chest Xray
International, multicentre, double- blinded
randomized
12-month clinical fup
Echocardiographic responses
The death
Heart failure (HF) hospitalizations
RD Robin H Wibowo

REVERSE
the apex was preferred in 78% of recipients
of CRT-D.
Ultimately placed at the apex in 68%, and in
the septum or elsewhere in 32% of patients
No significant differences of clinical and echo
No recommendations regarding the
placement of the RV lead
RD Robin H Wibowo

Data comparison
Miranda
et al

a single-blind prospective randomization

of 53 patients to RV septal versus RV
apical lead for MES
Greatest in septal locations and greater
of CRT responders,by EF 6MWT, with no
adverse safety

Kristians
en et al

shown similar reverse remodeling and

reversal of LV dyssynchrony at 6 months
between RV apex and high posterior
septal RV implant as adjudicated by
orthogonal view fluoroscopy
RD Robin H Wibowo

Data comparison

Kuyif
a et
al

MADIT-CRT database to show that an

excess of the endpoint of either
VT/VF or death
No difference in the primary
endpoints of HF or death

Ronn
et al

Randomized design in 33 patients

with classical CRT indications
No difference between apex and
RVOT RV lead in endpoints of EF,
QoL, peak oxygen uptake, BNP, or 6MWT.
RD Robin H Wibowo

SEPTAL CRT
Prospective, multicenter, European, single-blind, randomized
controlled trial
Non inferiority hypothesis
Primary end point:
Changes in the LVESV between baseline and 6 months
Secondary end points:
the % of echo-responders defined by a reduction in the

LVESV > 15% at 6 months

the implant success rate of the RV lead
the proportion of patients experiencing 1 MAE
including deaths from all causes
Serious cardiac Adverse Event

Study Flowchart

1 Year Mortality

RD Robin H Wibowo

SEPTAL CRT
No = in the percentage of echo-responders, i.e.
reduction in LVESV > 15% at 6 months, 50% in
both groups, p = 0.99
No = in the implant success rate:
90.0% in the Septum randomized group
86.8% in the Apex randomized group
Low implant success rate mostly due to the
lack of defibrillation testing (n = 27)
2 patients crossed over due to failure of fulfilling
the RV
implantation criteria in each group

SEPTAL CRT conclusion

First multicenter randomized prospective trial comparing

RV apical and RV septal pacing in CRT-D recipients

Septal CRT demonstrates the non-inferiority of RV septal

pacing when compared to conventional RV apical pacing

in CRT patients
No = in LVESV reduction between baseline and 6 months
Similar percentage of echo-responders (50%)
No difference in implant success rate

No statistical = for the safety and efficacy endpoints:

Total mortality: 3.0% vs.3.8% (p=0.749)
MAE : 34.8% vs. 39.7% (p=0.446)

Conclusions
Non apical RV pacing, may offer a
physiologically beneficial, if not safer
and superior alternative to RV apical
pacing.

RD Robin H Wibowo

Future directions
the ideal choice for pacing with
significant dependency in patients
may be between physiologically
optimised biventricular pacing
versus anatomically optimised
selectivesite RV paving
RD Robin H Wibowo

Gracias
RD Robin H Wibowo

Endpoint, Desain, dan Temuan Utama Studi Acak

Terkontrol yang Mengevaluasi CRT pada Gagal
Jantung

CRT algorithm

RD Robin H Wibowo