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QUAND PROPOSER UN TRAITEMENT ELECTRIQUE ?

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  1. QUAND PROPOSER UN TRAITEMENT ELECTRIQUE ? Prof L DE ROY Université de Louvain CLINIQUES UNIVERSITAIRES UCL DE MONT-GODINNE Belgique

  2. J Am Coll Cardiol 2002;40:1703–19

  3. Recommendations for ICD Therapy LVEF≤35% Class I (A) MADIT I P=0.009 Moss AJ, N Engl J Med 1996;335:1933-40 Buxton AE,, N Engl J Med1999 MUSTT Class II a (B) LVEF≤30% MADIT II P=0.007 Moss AJ, N Engl J Med 2002;346:877-83 J Am Coll Cardiol 2002;40:1703–19

  4. Pacing Recommendations for Dilated Cardiomiopathy P<0.001 MUSTIC P<0.001 J Am Coll Cardiol 2002;40:1703–19 MUSTIC MIRACLE N Engl J Med 2001;344:873-80 P=0.03 N Engl J Med 2002;346:1845-53

  5. Swedberg et al., EHJ 2005;26:1115-1140

  6. CRT Pacemakers Swedberg et al., EHJ 2005;26:1115-1140

  7. CRTP -CRTD N Engl J Med 2004;350:2140-50

  8. CRTP Class I B Cleland JG, N Engl J Med 2005;352:1539-1549

  9. CARE-HF trial : extension phase Worsening heart failure All cause mortality Sudden cardiac death Cleland et al Eur Heart J 2006;27:1928-32

  10. ICD – ICD +CRT ICD +CRT Class II a (B) (COMPANION) Class I (A) (AVID) ICD Class I (A) (MADIT II/SCD HeFT) Swedberg et al., EHJ 2005;26:1115-1140

  11. Class II a (B)

  12. Hunt SA,Circulation 2005;20: e154-e685

  13. Stage C Therapy:Reduced LVEF with Symptoms Cardiac Resynchronization (CRTP / CRTD) Hunt SA,Circulation 2005;20: e154-e685 CARE-HF The use of an ICD in combination with CRT should be based on the indications for ICD therapy.

  14. Stage D Therapy Inform on option to inactivate defibrillation Patients with refractory end-stage HF and implantable defibrillators should receive information about the option to inactivate defibrillation.

  15. Characteristics of patients enrolled and QRS eligibility criteria of the major RCTs on CRT Boriani G., J Interv Card Electrophysiol 2007

  16. Results of cardiac resynchronization in CHF from CRT* *with estimated extent of effect Boriani G., J Interv Card Electrophysiol 2007, feb 24

  17. Indication to CRT according to recent ACC/AHA guidelines CL I (A) Boriani G., J Interv Card Electrophysiol 2007

  18. Qu’en est-il de l’asynchronisme et QRS fins

  19. Magnitude of Improvement in Clinical and Echocardiographic Parameters After CRT* n =33 n =33 Bleeker GB, J Am Coll Cardiol 2006;48:2243–50

  20. Changes in LVESV, LVEDV, and EF in HF pts with narrow QRS complexes with/without significant systolic asynchrony according to asynchrony index Left ventricular end-systolic vol. Left ventricular end-diastolic vol. N=102 Left ventricular ejection fraction Yu CM.,J Am Coll Cardiol 2006;48:2251–7

  21. Qu’en est-il de la classe IV

  22. Time to mode of death by treatment arm for NYHA class IV in COMPANION trial N=217 CRTD CRT A. Time to sudden death B. Time to HF death Lindenfeld JA, Circulation. 2007;115:204-212

  23. FAUT-IL ADJOINDRE SYSTEMATIQUEMENT UN DAI A LA CRT ?

  24. Residual risk of sudden cardiac death in heart failure beta-blocker trials Field M, J Interv Card Electrophysiol, 2007

  25. Survival for biventricular ICD and biventricular PM Ermis C, J Cardiovasc Electrophysiol 2004(15):862-866

  26. CRTD VS CRT META-ANALYSIS OF COMPANION + ERMIS: ALL CAUSE MORTALITY: OR = 0.69 (0.53,0.91) P= 0.008 ABDULLA 2006

  27. Estimated annualized sudden cardiac death rates in patients with nonischemic dilated cardiomyopathy receiving medical therapy Field M, J Interv Card Electrophysiol, 2007

  28. NNT Resynchronisation 1 an 3 ans 1 an 3.5 ans 1 an CRT-D CRT-P Carvedilol Captopril Succinate de metoprolol Aurrichio et al, Circulation 2004, 109; 300 - 307

  29. Number of patients with NYHA class IV heart failure enrolled in primary prevention ICD trials Field M, J Interv Card Electrophysiol, 2007

  30. Percentage of patients after 2 years survival with sustained LV remodeling or an increase in absolute LVEF of 5% after CRT N=89 sustained LV remodeling means LV end systolic volume (LVESV) reduction of 10% Delnoy PP., J Cardiovasc Electrophysiol, 2007(18):298-302

  31. NYHA class IV endpoints by treatment arm in COMPANION trial Primary time to all-cause death or hospitalization Secondary time to all-cause death N=217 Lindenfeld JA, Circulation. 2007;115:204-212 Time to all-cause death or HF hospitalization

  32. Death among patients with AF randomized to CRT vs RV pacing CRT: 49% reduction in the relative risk of all-cause mortality p=0.547 MUSTIC–AF: Multisite Stimulation in Cardiomyopathy Study–Atrial Fibrillation PAVE: Post AV Nodal Ablation Evaluation OPSITE: Optimal Pacing SITE Study Bradley DJ.,Heart Rhythm 2007;4:224 –232

  33. Results of cardiac resynchronization in CHF from CRT* *with estimated extent of effect Boriani G., J Interv Card Electrophysiol, 2007

  34. Effect of CRT on all-cause mortality Abdulla J.,Cardiology 2006;106:249–255

  35. Identification des patients: les études en resynchronisation Patients CARE-HF • NYHA III-IV (+ de 6 sem) • Ischémique ou non • DTDS > 30 mm/m² • FE <35% • QRS > 120 ms Si 120 <QRS>149 ms 2 des critères suivants sont requis: • Retard pré-éjection Ao > 140 ms • Délai inter-vent mécan.> 40 ms • Retard activation postéro-lat. paroi vent. gauche • Rythme sinusal COMPANION • NYHA III-IV • CHF isch ou non • Hospit dans l’année écoulée • FE<35% • Φ LVED > 60 mm • QRS >120ms • PR >150ms • Rythme sinusal • MIRACLE • NYHA III-IV • FE< 35% • QRS > 130 ms • Φ LVED > 55mm • Rythme sinusal Devices CRT CRT - D CRT - P Bénéfices • Amélioration NYHA, périmètre de marche, QoL. • Réduit les hospitalisations pour IC et toutes causes • Réd. Mortalité tt causes - 36% • Réd. Hospitalisations - 52% • Amélioration des symptômes • Amélioration des capacités d’effort • Réduction de la mortalité -36% • Réduc. Hospitalisations -37%

  36. Etiologie HF 38% ischémique Fraction d’éjection 26% NYHA 1-2-3-4 [%] 0 – 0 – 94 – 6 Durée du suivi 29.4 mois Arythmies auriculaires 21% Historique de diabète 21% Durée du QRS 165 ms QRS > 120 ms 100% Test de marche 6 min - ACE I 80% Bétabloquant 72% Diurétique 99% Spironolactone 56% Statine 39% CARE-HF • Critères d’inclusion : • - NYHA III-IV, • QRS > 120ms, • LVEDD > 30 mm • FE < 35%. • Objectifs primaires : • - mortalité - hospitalisation pour cause cardiovasculaire - 36% 813 patients (82 centres en Europe) p = 0.002 TMO [404 patients] TMO + CRT-P [409 patients] http://www.care-hf.com La réduction du risque absolu (RA) est de 9.4% (p = 0.002) après 29.4 mois. Elle (RA) grimpe à 13.4% (p<0.0001) après 36.4 mois (Care HF extension) Cleland JN Engl J Med. April 14, 2005;352:1539-1549

  37. Etiologie HF 59% ischémique Fraction d’éjection 22% NYHA 1-2-3-4 [%] 0 – 0 – 86 – 14 Durée du suivi 12 mois Arythmies auriculaires - Historique de diabète 41% Durée du QRS 160 ms QRS > 120 ms 100% Test de marche 6 min 258 m ACE I 69% Bétabloquant 68% Diurétique 97% Spironolactone 55% Statine - COMPANION • Critères d’inclusion : • NYHA III-IV, • QRS > 120 ms, • PR interval > 150ms, • LVEDD > 60mm • EF < 35%. • Objectifs primaires : mortalité ou hospitalisation 1.520 patients (128 centres au Etats-Unis) - 36% TMO [308 patients] TMO + CRT-P [617 patients] TMO + CRT-D [595 patients] p = 0.003 Le défibrillateur associé à la resynchronisation diminue la mortalité de 36% (p = 0.003) par rapport au groupe contrôle. Bardy GH. N Engl J Med. January 20, 2005;352:225-237

  38. Remboursements Critères d’inclusion ESC Remboursements Mort subite TV soutenue Patient IC symptomat. FE Basse < 30 – 35% Post MI > 40 j NYHA III-IV QRS Long > 120 ms FE altérée NYHA III IV FE Basse < 35% QRS Long > 120 ms Mort subite TV soutenue Pt survivants de FV FV avec syncope FV avec FE < 40% + sympt DAI AVID Pt NYHA I-III FE <35% Post infar asympt Tachy vent MADIT I Pt CHF FE<35% NYHA II-III DAI SCD- HeFT Pt NYHA I-III FE <30% Post infar asympt LVD MADIT II Symptômes Syncope Périodes de vertige Bradycardie Prophylaxie HF Dysfonction cérébrale Ethiologie Fibrose tissu de conduct. Post MI Congénital Chirurgical /complic. chir. Ablation Syndrome sinus carotid. Cardiomyop – Myocardite Maladie valvulaire ECG AV Block Block Faisceau de Hiss Block de branche Syndrome sinusal Tachy atriale Tachy ventriculaire Pt NYHA III-IV FE <35 DTDS >30 mm/m QRS > 150 CARE HF CRT NYHA III-IV CHF isch ou non Hospit dans l’année écoulée FE<35% Φ LVED > 60 mm QRS >120ms PR >150ms COMPANION CRT-D

  39. Life-Years Gained per Device Implanted Saluke TV,Circulation, 2004;109:1848-1853

  40. Meta-analysis of trials comparing ICD with control on mortality in patients with heart failure and/or left ventricular systolic dysfunction Cleland JGF,The European Journal of Heart Failure 6 (2004) 501–508

  41. All-cause mortality among patients with NICM randomised to ICD vs medical therapy in secondary prevention NICM=nonischemic cardiomyopathy Desai AS, JAMA 2004;292/2874-2879

  42. Total annual costs of New York Heart Association class III–IV heart failure patients Field M, J Interv Card Electrophysiol, 2007

  43. LV ejection fraction after CRT at 2 years survival P<0.001 Delnoy PP., J Cardiovasc Electrophysiol, 2007(18):298-302

  44. Number of patients with NYHA class IV heart failure enrolled in primary prevention ICD trials Field M, J Interv Card Electrophysiol, 2007