LEFT VENTRICULAR LEAD PLACEMENT IN THE LATEST ACTIVATED REGION GUIDED BY CORONARY VENOUS ELECTROANATOMIC MAPPING
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1 LEFT VENTRICULAR LEAD PLACEMENT IN THE LATEST ACTIVATED REGION GUIDED BY CORONARY VENOUS ELECTROANATOMIC MAPPING Dott. Massimiliano Maines C. Angheben, D.Catanzariti, I.DiMatteo, A.Cima, M. Del Greco Venice, October
2 Main limitations of the angiographic CRT device implantation 1. The need of prolonged radiation exposure (dangerous both for patients and physicians). 2. The need of CS angiography (with contrast liquid infusion), dangerous for patients (one-third of patients with HF have concomitant stage 3 or greater chronic kidney disease). 3. The lack of clear indications (only anatomical!) for LV lead placement >> decreasing number of CRT responder.
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4 NavX 3.0 vs Angio Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
5 Endoscopic view Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
6 CRT$DEVICES$IMPLANT$USING$$ NON2FLUOROSCOPIC$NAVIGATION$SYSTEM.!! Del!Greco!M!,!Maines!M,!Colella!A,!Marini!M,!Zecchin!M,!Mureddu!R,!Allocca!G,! Marenna!B,!Rossi!P,!Vaccari!D,!Angheben!C,!Di!Ma;eo!I,!Indiani!S.! % PROCEDURAL$$ SUCCESS$$ pts 0 PROCEDURAL$DATA$ 24% P< % -73% 76% NO YES CS ANGIOGRAPHY LANDOLINA!ET!AL.!Circula(on.,2011;123: $ BUTTER!ET!AL.$PACE,2010;,33: , Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
7 CS elettroanatomic map during SR$ $
8 >30%!non!responder!!! Part of this for a suboptimal LV lead position! Daubert JC, Saxon L, Adamson PB, Auricchio A, Berger RD, Beshai JF et al EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Europace 2012;14:
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11 AIM Evaluated the latest activated region in coronary sinus in patients underwent CRT devices implant
12 Methods Consecutive CRT patients underwent intra-procedural coronary venous EAM using EnSite NavX. A guidewire (Vision Wire Biotronik) was used to map the coronary veins during intrinsic activation and during RVA pacing
13 80% The Window of interest Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
14 POPULATION PATIENTS 46 AGE years 72.9±7.3! Male sex (%) 80 Ejection fraction (mean±standard deviation) 29.45±6.43 ETIOLOGY ischaemic non ischaemic CONDUCTION DELAY LBBB RBBB RBBB+AFB PM NO DELAY 55% 45% 69% 7% 6% 9% 9% RYHTM RS FA 77% 23% QRS (ms) 122.6±26.7 IRC (%) 46% Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
15 More$delayed$ac>va>on LAO$ L a t e s t a c t i v a t i o n during sinus r h y t h m - patients$ Latest activation during RV pacing* - patients! Anterior$ 6$ 11! Antero-lateral$ 15$ 15! Postero-Lateral$ 25$ 19! Posterior$ 0$ 1! RAO$ A P AL PL Basal$ 20$ 30! Medium$ 23$ 13! Apical$ 3$ 3! * Position of the catheter in right ventricle was septal in 74% and apical in 26 % of the patients B M A
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17 LBBB!!SR! Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
18 LBBB!!PACE! Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
19 SR True LBB Pacing
20 PSEUDO!LBBB!!SR! Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
21 SR Pseudo LBB Pacing
22 SR No LBB Pacing
23 RBBB!!RS!!FINESTRA!80%! Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
24 SR RBB Pacing
25 Durata!media!del!QRSD:!122.6!ms! Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
26 Average!LVLED:!80.2$%$ Number of mapped branches: 2.6 +/- 0,7
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28 MORE!LATE!IT!IS!BETTER! Division of Cardiology, S. Maria del Carmine Hospital Rovereto (Italy)
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32 Conclusions 1. The electroanatomical CRT device implantation dramatically reduce radiation exposure (> 70 %). 2. The electroanatomical CRT device implantation allows to overcome the problem of the contrast liquid infusion for CS visualization. 3. The electroanatomical CRT device implantation provide the possibility to guide (with very high precision) the left ventricular lead toward the position with the most delayed ventricular activation. On the basis of previous studies this approach could increase the number of CRT responders.
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34 MAPS!OF!POTENTIAL!
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