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BIVENTRICULAR PACING

BIVENTRICULAR PACING. Zhu Yi ;Bai Lu; Jin Xingxing; Gu Hangyu; Pan Lingxiao ; Li Ran. Agenda. Case Report The Clinical Problem Background Knowledge Pathophysiology of LBBB Operation of CRT Mechanism of CRT Clinical Uses of CRT Adverse Effects Combine with CCM. Case Report.

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BIVENTRICULAR PACING

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  1. BIVENTRICULAR PACING Zhu Yi ;Bai Lu; Jin Xingxing; Gu Hangyu; Pan Lingxiao ; Li Ran

  2. Agenda • Case Report • The Clinical Problem • Background Knowledge • Pathophysiology of LBBB • Operation of CRT • Mechanism of CRT • Clinical Uses of CRT • Adverse Effects • Combine with CCM

  3. Case Report • A 55-year-old man. • An anterior-wall myocardial infarction, 6 m ago. • Persistent shortness of breath with mild exertion, 3 m ago. • An exacerbation of congestive heart failure. • ECG: sinus rhythm, left bundle-branch block. • UCG: left ventricular ejection fraction of 25%. • Current treatment: furosemide, lisinopril, and carvedilol. • Further treatment: implantation of a biventricular pacemaker????

  4. The Clinical Problem • 1/4 ~ 1/3 heart failure have left bundle-branch block. • Left bundle-branch block causes a poorer prognosis.

  5. Background Knowledge • Regular cardiac output needs: • Electrical synchrony • Mechanical contractibility of cardiac muscle cells

  6. How to achieve electrical synchronization? • Conductive pathway: sinus node internodal tract  A-V node  bundle of His  left and right bundle-branches  Purkinje fiber To assure: • Synchronization of left and right ventricles • Coordination of atrium and ventricles II. Intercalated disc

  7. Cardiac Conduction System Velocity of Conduction (m/s) SA node 0.1~0.2 Atrial 0.3~0.5 AV node0.05~0.1 His Bundle 0.8~1.0 Purkinje Fibres*2.0~5.0 Ventrcular*0.3~0.5

  8. Pathophysiology Of LBBB • LBBB altered depolarization: Anterior septum  inferior & lateral left wall • Dyssynchronous contraction: Interventricular septum  left free wall • Inefficient contraction: Decrease of LVEF & CO

  9. Cardiac Conduction System & Biventricular Pacing

  10. Block of Conductive pathway leads to: Ⅰ . Systole period: Synchronization↓ Strength↓ CO/CI↓ LVEF↓ Ⅱ . Diastole period: Coordination↓  A-V Filling Uncooperate  Inadequate Blood Filling  LVEF↓

  11. Left Bundle Branch Block • Organic Cardiopathy • ECG： Sinus rhythm Left deviation axis QRS≥0.12s(Complete) V1、2 Leads：QS type V5、6 Leads：R type ST-T Segment：Secondary Alteration

  12. ECG Of Left Bundle Branch Block

  13. Operation of CRT-----Pacemaker and Leads

  14. Operation of CRT ---- Standard Approach of Leads • Inserted pacing lead into mouth of the coronary sinus • Advanced posteriorly around the atrioventricular-valve ring • Passed into a venous branch running along the free wall of the left ventricle

  15. Biventricular Pacing for CRT

  16. Mechanism Of CRT • Stimulate R & L ventricles; R atrium is also paced. • Eliminate left wall delay. • Shorten QRS complex. • LV pressure rise rate↑ , pulse pressure↑ , stroke work↑ , CO/CI↑ , PCWP(LV function) ↓ • Not restore normal pattern. • Re-built a physiological mechanical pattern through a fixed electrical pattern.

  17. Effect Summary of CRT • Improve ventricular function • Not increase myocardial consumption • Reverse ventricular remodeling

  18. Clinical Use ---- Indications • Dilated cardiomyopathy (ischemic or non-ischemic) • LVEF ≤ 35% • QRS interval ≥ 120 msec • NYHA class III or IV despite optimal medical therapy (Loop diuretics, BB, ACEI, ARB) • Implantation of both CRT & CVD

  19. Clinical Use -- Contraindications • Increased risks of bleeding • Infection • Life-limiting medical condition • Heart failure requires parenteral inotropic therapy

  20. Adverse Effect -- Implantation • Mutation-induced inability to implant LV lead • Uncomfortable diaphragmatic stimulation – Hiccup • Coronary-sinus dissection • Coronary-vein or -sinus perforation – tamponade • Pneumothorax, complete heart block, and asystole

  21. Adverse Effect – Post-Op • Dislodgment of the LV lead • Infection of the device (Pacemaker pocket) • Atrial arrhythmias • External electromagnetic fields interference (MRI, cell phone, power cable, electrical motor, electrocautery, radiation…)

  22. Combine with CCM I. CCM---- cardiac contraction modulating: modulate Calcium current • stimulate CMC in refractory period increase CMC contractibility directly II. CRT---- cardiac resynchronization therapy: assure synchronization

  23. 我们可以用赞叹的手臂拥抱一千条银河，但当那灿烂的光流贴近我们的前胸，最动人的音乐仍是一分钟六十次雄浑坚实如祭鼓的人类的心跳！医生不是生命的创造者－－他是协助生命神迹保持其本然秩序的人！我们可以用赞叹的手臂拥抱一千条银河，但当那灿烂的光流贴近我们的前胸，最动人的音乐仍是一分钟六十次雄浑坚实如祭鼓的人类的心跳！医生不是生命的创造者－－他是协助生命神迹保持其本然秩序的人！

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