CRT Overview This lecture is intended to give a basic overview of HF to include: -General knowledge of the cardiac cycle and how a normal heart should function -The incidence and prevalence of HF -The patient outcomes with respect to mortality and hospitalization -The description of the classic HF patient -NYHA class and Stages, distribution of population, and modes of death -The decompensation of the HF patient and the treatments provided -Where CRT fits into the HF continuum

CRT : Cardiac Resynchronization Therapy Heart Failure 환자에 적용 2005년 8월 1일부터 보험 급여 CRT-P : CRT Pacemaker (Low power) CRT-D : CRT + ICD (High power)

2005 Hear Failure Guidelines Recommendations for Device Therapy CRT Indication 2005 Hear Failure Guidelines Recommendations for Device Therapy LVEF less than or equal to 35% (<35%) Sinus rhythm NYHA Functional Class III or Ambulatory Class IV symptoms Despite recommended, optimal medical therapy And who have cardiac dysynchrony, which is currently defined as a QRS duration greater than 120ms (>120ms)

CRT Indication What is Heart Failure? “Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood.” ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

CRT Indication Large K9 Heart (approximately the size of normal human heart) Heart from MIRACLE study patient

Ventricular Dysynchrony and Cardiac Resynchronization Electrical: Inter- or Intraventricular conduction delays typically manifested as left bundle branch block Structural: disruption of myocardial collagen matrix impairing electrical conduction and mechanical efficiency Mechanical: Regional wall motion abnormalities with increased workload and stress—compromising ventricular mechanics Cardiac Resynchronization Therapeutic intent of atrial synchronized biventricular pacing Modification of interventricular, intraventricular, and atrial-ventricular activation sequences in patients with ventricular dysynchrony Complement to optimal medical therapy 1 Tavazzi L. Eur Heart J 2000;21:1211-1214

The Donkey Analogy Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living…

Digitalis Compounds Like the carrot placed in front of the donkey

Diuretics, ACE Inhibitors Reduce the number of sacks on the wagon

ß-Blockers Limit the donkey’s speed, thus saving energy

Cardiac Resynchronization Therapy Increase the donkey’s (heart) efficiency

Atrial-synchronized bi-ventricular pacing LV Lead Implant Atrial-synchronized bi-ventricular pacing ☞ Transvenous Approach ▶ Standard pacing lead in RA ▶ Standard pacing or defibrillation lead in RV ▶ Specially designed left heart lead placed in a left ventricular cardiac vein via the coronary sinus

Selecting Vein for CRT Lead Placement LV Lead Implant Selecting Vein for CRT Lead Placement Target: Left ventricular free wall (Lateral, Poster-lateral, Antero-lateral) 1,2,3 A. Lateral (marginal) cardiac vein B. Postero-lateral cardiac vein C. Posterior cardiac vein D. Middle cardiac vein E. Great cardiac vein E A A B B C D E C D 1. Ansalone et al. JACC. 2002;39:489-499 2. Butter et al. CIRCULATION. 2001;104:3026-3029 3. Auricchio et al. AJC. 1999;83:136D-142D LAO View

LV Lead Implant

Left heart Delivery System

CS Cannulation Use extreme care when passing the guide catheter through vessels Due to the relative stiffness of the catheter, damage to the walls of the vessels may include dissections or perforations

Attain Balloon Catheter Balloon occludes most coronary sinuses – inflates to 10 mm Balloon can be inflated and deflated several times Contrast solution can be injected through catheter

CS Anatomy AP View LAO View

Coronary Sinus Lead Attain OTW LV Lead 4 Fr. Lead Body Unipolar, Polyurethane 5.8 mm2 tapered annular electrode Steroid eluting Silicone-Sealed Lead Tip Two distal curves Over-The-Wire Lead Body Advancement with Stylet or Guide Wire (<0.018”) Standard IS-1 connector Steroid collar Electrode Tip seal Guide wire

CS Branch Selection Advance lead near the cardiac vein ostium 3. Advance lead over the wire into the cardiac vein Steer guide wire tip deep into cardiac vein

LV Lead Implant LV Lead Placement (with guide wire)