Download What is Heart Failure?

CRT Overview
 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)
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
 Ventricular Dysynchrony1
 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
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
LV Lead Implant
Selecting Vein for CRT Lead Placement
Target: Left ventricular free wall
(Lateral, Poster-lateral, Antero-lateral)
E
A
A
D
BB
C
D
LAO View
C
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
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
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

Tip seal
Steroid collar
Electrode
Guide wire

Over-The-Wire Lead Body Advancement
with Stylet or Guide Wire (<0.018”)
Standard IS-1 connector
CS Branch Selection
1. Advance lead near the
cardiac vein ostium
3. Advance lead over the
wire into the cardiac
vein
2. Steer guide wire tip
deep into cardiac vein
LV Lead Implant
LV Lead Placement (with guide wire)