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Indications on cardiac pacing and cardiac resynchronization therapy Michele Brignole

Indications on cardiac pacing and cardiac resynchronization therapy Michele Brignole Centro Aritmologico , Ospedali del Tigullio , Lavagna, Italy. Task Force members. Michele Brignole (Italy) Angelo Auricchio (Switzerland) Gonzalo Baron- Esquivias (Spain)

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Indications on cardiac pacing and cardiac resynchronization therapy Michele Brignole

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  1. Indications on cardiac pacing and cardiac resynchronization therapy Michele Brignole Centro Aritmologico, Ospedali del Tigullio, Lavagna, Italy

  2. Task Forcemembers Michele Brignole (Italy) Angelo Auricchio (Switzerland) Gonzalo Baron-Esquivias (Spain) Pierre Bordachar (France) Giuseppe Boriani (Italy) Ole-A Breithardt (Germany) John Cleland (UK) Jean-Claude Deharo (France) Victoria Delgado (Nertherlands) Perry M. Elliott (UK) BulentGorenek (Turkey) Carsten W. Israel (Germany) Christophe Leclercq (France) Cecilia Linde (Sweden) LluísMont (Spain) Luigi Padeletti (Italy) Richard Sutton (UK) Panos E. Vardas (Greece) Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  3. Timelines Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  4. Contributors 70 Contributors 26 CPG Members 18 Task Force Members 26 Reviewers 690 comments (98 pages) Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  5. General structure of the document • Pacingforbradycardia • Indications • mode ofpacing • Cardiacresynchronizationtherapy • Indications • mode ofpacing • Complicationofpacing and CRT • Management considerations European Heart Journal 2013; 34: 2281–2329 Europace 2013; 15: 1070-1118

  6. Classification of bradyarrhythmias based on the patient’s clinical presentation Patients considered for antibradycardia PM therapy Persistentbradycardia Intermittentbradycardia Sinusnode disease • AV block: • Sinusrhythm • Atrialfibrillation Suspected (ECG-undocumented) ECG-documented Intrinsic Extrinsic (functional) BBB Reflex syncope Unexplainedsyncope • Parox AVB • SSS (brady- tachy) • Vagal • Idiopathic AVB • Carotid sinus • Tilt-induced Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  7. New classification of bradyarrhythmias: ECG instead of etiology Look for bradycardia No ECG documentation (bradycardia suspected) ECG documentation (bradycardia established) Obtainan ECG documentation Consider PM Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  8. Indication for pacing in patients with persistent bradycardia Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  9. Indication for pacing in intermittent documented bradycardia Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  10. Indication for cardiac pacing in patientswith undocumented bradycardia (reflex syncope) Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  11. CSS: Syncoperecurrence rate No therapy Pacemaker % Brignole 92 (a) Blanc 84 Claesson 07 Claesson 07 Menozzi 93 Brignole 92 (b) Sugrue 86 Morley 82 Crilley 97 Brignole 92 (b) Lopes 11 Sugrue 86 Claesson 07 Brignole 92 (a) Walter 78 Claesson 07 Stryjer 86 Blanc 84 Years

  12. Clinicalperspectives New Clinical perspectives • The decision to implant a pacemaker should be made in the context of a relatively benign condition ………. • ……. carotid sinus syndrome does not affect survival,……. • …….. syncopal recurrences are still expected to occur in up to 20% of paced patients within 5 years……

  13. Indication for cardiac pacing in patients with undocumented bradycardia (BBB) Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  14. Algorithm for patientswith unexplained syncope and BBB BBB and unexplainedsyncope Reduced EF (<35%) Preserved EF (>35%) ConsiderICD/CRT-D ConsiderCSM/EPS Appropriate therapy (if negative) Consider ILR Appropriate therapy (if negative) Clinical follow-up Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  15. Dual-chamber versus ventricular pacing Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  16. Choiceofpacing mode Sinus node disease AV block Persistent Intermittent Persistent Intermittent Chronotropicincompetence No chronotropicincompetence SND No SND AF 1° choice DDDR + AVM 2° choice AAIR 1° choice DDD + AVM 2° choice AAI 1° choice DDDR + AVM 2° choice DDDR, no AVM 3° choice AAIR 1° choiceDDDR 2° choiceDDD 3° choiceVVIR 1° choiceDDD 2° choiceVDD 3° choiceVVIR VVIR DDD + AVM(VVI if AF) ConsiderCRT if low EF/HF Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  17. Challenging indications for CRT: the “Entry criterium” Favors CRT-D Favors ICD LBBB Non LBBB 0.1 0.2 0.5 1 2 5 10 Hazard ratio Font: MADIT CRT Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  18. Indications for CRTin patients in sinus rhythm Magnitudeof benefit from CRT Wider QRS, LBBB, females, non-ischemiccardiomyopathy Highest (responders) Males, ischemiccardiomyopathy Lowest (non-responders) Narrower QRS, non-LBBB Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  19. Indications for CRTin patients in sinus rhythm Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  20. Indication for CRT in patients with permanent AF Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  21. Indications for AVJ ablation (±CRT)in permanent AF Heartfailure, NYHA class III-IV and EF <35% Reduced EF and uncontrollable HR, any QRS QRS ≥120 ms QRS <120 ms Adequate ratecontrol Inadequate rate control CRT * Incomplete BiVpacing Complete BiVpacing No AVJ abl No CRT* AVJ abl& CRT AVJ abl& CRT * Consider ICD accordingguidelines AVJ ablation No AVJ ablation Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  22. Upgraded or de novo CRT in patients withconventional pacemaker indications and HF • Clinical perspectives • A strategy of initially conventional antibrady pacing with late upgrade in case of worsening symptoms seems reasonable • In the decision process physicians should take into account the excess complication rate related to the more complex biventricular system, the shorter longevity of CRT devices and the excess of costs. Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  23. Time to death of any causein the European CRT Survey 1,00 0,98 p=0.85 0,96 0,94 0,92 0,90 Proportion of patients surviving 0,88 0,86 De-novo implantations 0,84 Upgrades 0,82 0,80 0 50 100 150 200 250 300 350 400 450 500 Days after implantation Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  24. Backup ICD in patients indicated for CRT New Comparative results of CRT-D versus CRT-P in primary prevention Clinical guidance to the choice of CRT-P or CRT-D in primary prevention Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  25. New Choice of pacing mode(and CRT optimization) • Clinical perspectives • The usual (standard) modality of CRT pacing consists of simultaneous biventricular pacing (RV and LV) with a fixed 100-120 ms AV delay with LV lead located in a posterolateral vein, if possible. Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  26. New Indication for prevention and terminationof atrial tachyarrhythmias Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  27. New Optimal pacing mode in children Bradycardia Dyssynchrony associated HF Sinus node dysfunction (Complete) AV block Intrinsic LBBB RV pacing induced dyssynchrony Treatdyssynchrony Single-site LV (or BIV) pacing Treatdyssynchrony Single-site LV (or BIV) pacing Preventdyssynchrony Atrial pacing only Preventdyssynchrony (Left) ventricularpacingonly • Clinical perspectives • LV pacing alone… seems to be non-inferior to biventricular pacing for improving soft end-points (quality of life, exercise capacity and LV reverse remodelling) …. LV pacing alone seems particularly appealing in children and young adults. Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  28. New MRI in patients with implantedcardiac devices Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  29. Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  30. New Remote managementofarrhythmias and device Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

  31. Style innovation • Clinicallyoriented, simple, readyforuse • Short and simplearticulationofrecommendations • Descriptionof benefit and harm • Rating ofqualityofevidence • Acknowledgmentofdifferencesof opinion Europace 2013; 15: 1070-1118 European Heart Journal 2013; 34: 2281–2329

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