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1、再同步治疗的挑战和思考,王东琦 西安交通大学医学院第一附属医院,Evidence For Heart Failure,在美国，每年因心衰就诊3.4百万，死亡30万。 一年再住院率50%，中重度心衰年死亡率近30%。 65岁者患病率610%。 QRS120ms患者全因死亡率增加约33%。 ,Evidence For CRT,EF35%， QRS120ms ， 经理想药物治疗, NYHA IIIIV :提高心功能分级，改善生活质量，增加活动耐量。 降低死亡率和住院率。 提高生存率。,如何让更多患者受益？,IMPROVE HF,To examine patient and cardiology pr
2、actice characteristics predictive of CRT use in eligible patients in an outpatient registry of systolic heart failure patients,Fonarow GC, et al. Circ Heart Fail. 2008;1:98106.,Percent of Indicated Patients (%),Percent of Indicated Patients Receiving CRT (CRT-D/CRT-P) at Baseline,IMPROVE HF Baseline
3、 Performance on CRT,All Practices (Baseline Review),39.39%,Fonarow GC, et al. Circ Heart Fail. 2008;1:98106.,IMPROVE HF Registry,Less than 40% of CRT-eligible patients received a device at baseline assessment In 1/3 of IMPROVE HF outpatient practices, not a single eligible patient received a CRT dev
4、ice at baseline,手术成功率,在RCTS纳入的4000多例中，CRT（经CS植入LV电极技术）的成功率8892： 鞘管难以插入CS 冠状静脉狭窄或闭锁 难以进入靶血管分支或脱位 膈肌刺激,115,135,Amp CS,60,Straight,115,60,135,Amp CS,Attain StarFix,First active fixation left-heart lead More placement options Vein sizes Vein locations Soft, polyurethane deployable lobes 5 Fr lead body,
5、5.3 Fr electrode with tip seal,For CRT-D devices, the available LV pace polarities are: LV tip to LV ring LV tip to RV coil LV ring to RV coilFor CRT-P devices, the available LV pace polarities are: LV tip/RV ring Unipolar (LV tip/Can) Bipolar (LV tip/LV ring),Pacing Vector Programmability,LV环至RV线圈,
6、LV头端至RV线圈,LV头端至LV环,Non-responder, true or false ?,40 consecutive CRT-D patients admitted to Cleveland Clinic HF ICU Met CRT indications at implant Implanted for at least 3 months (mean 19 months) Increased LVEDV from pre-implant baseline Averaged 1.2 HF hospitalizations 87.5% with LV lead in lateral
7、 or postero-lateral position Biventricular paced 96% of time Acute, serial echo and invasive hemodynamic measurements in CRT ON and CRT OFF modes,Hidden benefit: when CRT turned off, hemodynamic, ECG & echo parameters worsened,PCWP,P 0.001,Cardiac Output,P 0.001,P 0.001,QRS Width,P 40ms 左心室后外侧璧激动延迟,
8、Beshai J et al. N Engl J Med 2007;357:2461-2471,RethinQ 研究 Subgroup Analysis According to the QRS Interval at 6 Months,RethinQ 研究,对于QRS0.12S的患者，CRT能增加高峰氧耗量,改善NYHA分级。 对于QRS0.12S的患者，CRT并不能增加高峰氧耗量。 但是，对于QRS0.12S的患者， CRT可以改善NYHA分级（p=0.04）；有增加六分钟步行距离的趋势（p=0.31）。 Echo-CRT研究。,% of Patients Hospitalised for
9、 HF,Number at Risk CRT OFF 191 187 181 176 119 CRT ON 419 415 411 409 251,P=0.03,Hazard Ratio=0.47,CRT OFF,CRT ON,Months Since Randomisation,REVERSE: CRT delays time to first HF hospitalisation,53% reduction with CRT,Linde C, Abraham WT, Gold WR et al for REVERSE Study Group. J Am Coll Cardiol 2008
10、Dec 2;52(23):1834-43.,Ongoing Studies,MADIT CRT Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization TherapyStudy Objective Determine if CRT-D will reduce the risk of mortality and heart failure events in mild-to-moderate heart failure patients (NYHA Class I and II)
11、compared to ICD-only therapy.Key Inclusion Criteria Ischemic or nonischemic heart disease and NYHA Class I or II Ejection fraction 130ms Sample Size: 1,820,MADIT CRT,CRT was dramatically effective in this large study population, with a 34% reduction in the risk of all-cause mortality or heart failur
12、e. The benefit is dominated by a 41% reduction in heart failure events. This results validate a new indication for cardiac resynchronisation therapy in the prevention of heart failure in at-risk asymptomatic or mildly symptomatic cardiac patients.,DAVID Trial Protocol,760 assessed for eligibility,25
13、0 excluded149 Did not meet Rx criteria55 refused46 Other,510 eligible,4 Not randomized2 Required pacing1 Inadequate defibrillation threshold 1 Decided not to implant,VVI-40 (n=256),DDDR-70 (n= 250),1 had pacing mode set to DDD1 LTF10 Discontinued intervention5 Bradycardia1 CHF and AF1 Brady induced
14、Torsade1 Heart Tx workup1 AF w rapid V response1 multiple shocks due to double counting,3 had pacing mode set to VVI2 LTF5 Discontinued intervention1 Angina1 CHF and Lead Failure1 CHF Hospitalization1 Exacerbation of VT1 Lead Migration,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,Death or First Hospitalization for New or Worsened CHF,Hazard ratio (95% CI), 1.61 (1.06-2.44),0,6,12,18,Months,Cumulative Probability,0.4,0.3,0.2,0.1,0,250 256,159 158,76 90,21 25,No. at Risk DDDR VVI,Wilkoff B, et al. JAMA. 2002; 288: 3115-3123.,
