Hettleman Slides for heart failure Cardiology

CHF

1. Congestive Heart Failure: Update 2002Congestive Heart Failure: Update 2002
Bruce D. Hettleman, MDBruce D. Hettleman, MD
DHMCDHMC
December 2, 2002December 2, 2002

2. CASE PRESENTATIONCASE PRESENTATION
•71 yo retired submarine captain is admitted with 71 yo retired submarine captain is admitted with
pulmonary edema and an elevated troponin. His pulmonary edema and an elevated troponin. His
PMH is notable for advanced CAD and previous MI. PMH is notable for advanced CAD and previous MI.
He had CABGX3 in 1990. He had CABGX3 in 1990.
•Echo demonstrated a severely dilated LV with an EF Echo demonstrated a severely dilated LV with an EF
of 20% and 3+/4 mitral regurgitation.of 20% and 3+/4 mitral regurgitation.
•EKG showed sinus rhythm at 52 with first degree AV EKG showed sinus rhythm at 52 with first degree AV
block and LBBB.block and LBBB.
•Cardiac Cath revealed a patent IMA to the LAD, Cardiac Cath revealed a patent IMA to the LAD,
patent SVG to the RCA and a severely diseased patent SVG to the RCA and a severely diseased
SVG to the circumflex.SVG to the circumflex.

3. What should be done once the patient is What should be done once the patient is
initially stabilized?initially stabilized?
•1. Perform urgent repeat bypass surgery and mitral 1. Perform urgent repeat bypass surgery and mitral
valve replacement.valve replacement.
•2.Perform percutaneous intervention (stent) on the 2.Perform percutaneous intervention (stent) on the
SVG to the circumflex.SVG to the circumflex.
•3. Put in a dual chamber pacemaker3. Put in a dual chamber pacemaker
•4.Maximize medical therapy because he is too high 4.Maximize medical therapy because he is too high
a risk for revascularization.a risk for revascularization.

4. Case Presentation--ContinuedCase Presentation--Continued
•After stenting the SVG to the circumflex his After stenting the SVG to the circumflex his
pulmonary edema subsequently responded to pulmonary edema subsequently responded to
medical therapy and he was able to ambulate but medical therapy and he was able to ambulate but
remained Class III CHF.remained Class III CHF.
•Discharge medications consisted of a Discharge medications consisted of a
diuretic,digoxin, beta blocker, ace inhibitor, aspirin, diuretic,digoxin, beta blocker, ace inhibitor, aspirin,
plavix and spironolactone.plavix and spironolactone.
•He was given dietary and weight-based diuretic He was given dietary and weight-based diuretic
adjustment guidelines.adjustment guidelines.
•Follow-up in CHF Clinic was scheduled for 1 month.Follow-up in CHF Clinic was scheduled for 1 month.

5. What is the most likely adverse event after What is the most likely adverse event after
adding aldactone in the treatment of CHF? adding aldactone in the treatment of CHF?
•1. Hypotension1. Hypotension
•2. Breast enlargement2. Breast enlargement
•3. Yellow vision3. Yellow vision
•4. Hyperkalemia4. Hyperkalemia
•5. Worsening CHF5. Worsening CHF

6. After starting aldactone in Class IV CHF, After starting aldactone in Class IV CHF,
when should electrolytes be rechecked?when should electrolytes be rechecked?
•1. No worries, mate1. No worries, mate
•2. One week ( big worries, mate)2. One week ( big worries, mate)
•3. Four weeks3. Four weeks
•4. Three months4. Three months

7. Potassium LevelPotassium Level
0
1
2
3
4
5
6
7
8
JNRY 15 JNRY 25 20-Feb 1-Apr
Potassium

8. Drugs that have shown to prolong life in CHF Drugs that have shown to prolong life in CHF
are:are:
•1. ACE inhibitors1. ACE inhibitors
•2. Beta Blockers2. Beta Blockers
•3. Digoxin3. Digoxin
•4. Aldactone4. Aldactone
•5. 1,2 and 45. 1,2 and 4

9. DIG Trial: Effect of Digoxin on Survival in CHFDIG Trial: Effect of Digoxin on Survival in CHF
•NHLBI sponsored study of 7,788 patients with NHLBI sponsored study of 7,788 patients with
class II and III CHF and LVEFs class II and III CHF and LVEFs << 45% or > 45% or >
45%45%
•Randomized, controlled, double-blindedRandomized, controlled, double-blinded
•93% of patients on ACEIs93% of patients on ACEIs
•Superimposable survival curvesSuperimposable survival curves
•25% reduction with Dig on first CHF 25% reduction with Dig on first CHF
hospitalizationhospitalization

10. Weight of Evidence: ACE Inhibitors
Approximately 7000 patients evaluated in long-term
placebo-controlled clinical trials
Improvement in cardiac function, symptoms, and
clinical status; equivocal effects on exercise tolerance
Decrease in all-cause mortality by 20%-25% (P<.001) and
decrease in combined risk of death and hospitalization
by 30%-35% (P<.001)
-Effect shown in SOLVD Treatment, CONSENSUS, and
V-HeFT II trials
Garg and Yusuf, 1995.

11. Weight of Evidence: -
Blockade
Traditionally contraindicated in heart failure, due
to impaired inotropy, early lack of tolerability, and
worsening heart failure
Over 10,000 patients have now been evaluated in
long-term placebo-controlled clinical trials;
Improvement in cardiac function and NYHA class;
and decrease in mortality and morbidity shown in
multiple clinical trials
Effects shown in patients already receiving ACE
inhibitors

12. Improved survival with aldactone in advanced Improved survival with aldactone in advanced
CHF--Rales TrialCHF--Rales Trial

13. Will a permanent pacemaker help this man?Will a permanent pacemaker help this man?
•1. No, he has no indication for a pacemaker and if 1. No, he has no indication for a pacemaker and if
you put one in medicare will send you the bill.you put one in medicare will send you the bill.
•2. Yes, he should have a VVI back up pacemaker 2. Yes, he should have a VVI back up pacemaker
prior to discharge because he has LBBB and may prior to discharge because he has LBBB and may
unpredictably develop complete heart block and die.unpredictably develop complete heart block and die.
•3. Yes, the placement of a routine DDD pacemaker 3. Yes, the placement of a routine DDD pacemaker
will reliably improve his hemodynamicswill reliably improve his hemodynamics
•4.Yes, he ought to have a brand-spankin new 4.Yes, he ought to have a brand-spankin new
biventricular resynchronization device because he biventricular resynchronization device because he
has LBBB.has LBBB.

14. Cardiac Resynchronization Cardiac Resynchronization
Therapy for Heart FailureTherapy for Heart Failure
Mechanisms, Clinical Outcomes,Mechanisms, Clinical Outcomes,
Patient Selection, and ImplantPatient Selection, and Implant

15. Ventricular Dysynchrony and Cardiac Ventricular Dysynchrony and Cardiac
ResynchronizationResynchronization
•Ventricular DysynchronyVentricular Dysynchrony
11

–Electrical:Electrical: Inter- or Inter- or
Intraventricular conduction delays typically manifested as left bundle Intraventricular conduction delays typically manifested as left bundle
branch block branch block
–Structural:Structural: disruption of myocardial collagen matrix impairing electrical disruption of myocardial collagen matrix impairing electrical
conduction and mechanical efficiencyconduction and mechanical efficiency
–Mechanical:Mechanical: Regional wall motion abnormalities with increased workload Regional wall motion abnormalities with increased workload
and stress—compromising ventricular mechanicsand stress—compromising ventricular mechanics
•Cardiac ResynchronizationCardiac Resynchronization
–Therapeutic intent of atrial synchronized biventricular pacingTherapeutic intent of atrial synchronized biventricular pacing
•Modification of interventricular, intraventricular, and atrial-ventricular Modification of interventricular, intraventricular, and atrial-ventricular
activation sequences in patients with ventricular dysynchronyactivation sequences in patients with ventricular dysynchrony
•Complement to optimal medical therapyComplement to optimal medical therapy
11
Tavazzi L. Tavazzi L. Eur HeartEur Heart J 2000;21:1211-1214 J 2000;21:1211-1214

16. Animation – Ventricular DysynchronyAnimation – Ventricular Dysynchrony
Click to Start/StopClick to Start/Stop

17. Cardiac ResynchronizationCardiac Resynchronization
Click to Start/StopClick to Start/Stop

18. Clinical Consequences of Clinical Consequences of
Ventricular DysynchronyVentricular Dysynchrony
•Abnormal Abnormal
interventricular interventricular
septal wall motionseptal wall motion
11
•Reduced dP/dtReduced dP/dt
3,43,4
•Reduced pulse Reduced pulse
pressurepressure
44
•Reduced EF and Reduced EF and
COCO
44
•Reduced diastolic Reduced diastolic
filling timefilling time
1,2,41,2,4
•Prolonged MR Prolonged MR
durationduration
1,2,41,2,4
11
Grines CL, Bashore TM, Boudoulas H, et al. Grines CL, Bashore TM, Boudoulas H, et al. CirculationCirculation 1989;79:845-853. 1989;79:845-853.
2 2
Xiao, HB, Lee CH, Gibson DG. Xiao, HB, Lee CH, Gibson DG. Br Heart J Br Heart J 1991;66:443-447.1991;66:443-447.
33
Xiao HB, Brecker SJD, Gibson DG. Xiao HB, Brecker SJD, Gibson DG. Br Heart J Br Heart J 1992;68:403-407.1992;68:403-407.
44
Yu C-M, Chau E, Sanderson JE, et al. Yu C-M, Chau E, Sanderson JE, et al. CirculationCirculation. 2002;105:438-445.. 2002;105:438-445.

19. Proposed Mechanisms: Improved Proposed Mechanisms: Improved
Intraventricular SynchronyIntraventricular Synchrony
 dP/dt dP/dt
1,3,4 1,3,4
EFEF
1,51,5

 Pulse Pressure Pulse Pressure
3,4 3,4
 SV&COSV&CO
1, 21, 2
Improved IntraventricularImproved Intraventricular
SynchronySynchrony
1,21,2
 MRMR
11

 LVESVLVESV
11
 LA LA
PressurePressure
11
1
Yu C-M, Chau E, Sanderson J, et al. Yu C-M, Chau E, Sanderson J, et al. CirculationCirculation 2002;105:438-445 2002;105:438-445
2 2
SSøgaard P, Kim W, Jensen H, et al. øgaard P, Kim W, Jensen H, et al. CardiologyCardiology 2001;95:173-182 2001;95:173-182
3 3
Kass D Chen-Huan C, Curry C, et al. Kass D Chen-Huan C, Curry C, et al. CirculationCirculation 1999;99:1567-73 1999;99:1567-73
44
Auricchio A, Ding J, Spinelli J, et al. Auricchio A, Ding J, Spinelli J, et al. J Am Coll CardiolJ Am Coll Cardiol 2002;39:1163-1169 2002;39:1163-1169
5 5
Stellbrink C, Breithardt O, Franke A, et al. Stellbrink C, Breithardt O, Franke A, et al. J Am Coll CardiolJ Am Coll Cardiol 2001;38:1957- 65 2001;38:1957- 65

20. Prevalence of Inter- or Intraventricular Prevalence of Inter- or Intraventricular
Conduction DelayConduction Delay
11
Havranek E, Masoudi F, Westfall K, et al. Havranek E, Masoudi F, Westfall K, et al. Am Heart JAm Heart J 2002;143:412-417 2002;143:412-417
22
Shenkman H, McKinnon J, Khandelwal A, et al. Shenkman H, McKinnon J, Khandelwal A, et al. CirculationCirculation 2000;102(18 Suppl II): abstract 2293 2000;102(18 Suppl II): abstract 2293
33
Schoeller R, Andresen D, Buttner P, et al. Schoeller R, Andresen D, Buttner P, et al. Am J Cardiol.Am J Cardiol. 1993;71:720-726 1993;71:720-726
44
Aaronson K, Schwartz J, Chen T, et al. Aaronson K, Schwartz J, Chen T, et al. CirculationCirculation 1997;95:2660-2667 1997;95:2660-2667
55
Farwell D, Patel N, Hall A, et al. Farwell D, Patel N, Hall A, et al. Eur Heart JEur Heart J 2000;21:1246-1250 2000;21:1246-1250
IVCD 15%IVCD 15%
IVCD >30%IVCD >30%
General HF General HF
PopulationPopulation
1,21,2
Moderate to SevereModerate to Severe
HF Population HF Population
3,4,53,4,5

21. Increased Mortality Rate with LBBBIncreased Mortality Rate with LBBB
•Increased 1-year Increased 1-year
mortality with presence mortality with presence
of complete LBBB of complete LBBB
(QRS > 140 ms)(QRS > 140 ms)
•Risk remains significant Risk remains significant
even after adjusting for even after adjusting for
age, underlying cardiac age, underlying cardiac
disease, indicators of disease, indicators of
HF severity, and HF HF severity, and HF
medicationsmedications
Baldasseroni S, Opasich C, Gorini M, et al. Baldasseroni S, Opasich C, Gorini M, et al. Am Heart JAm Heart J 2002;143:398-405 2002;143:398-405
11.911.9
5.55.5
16.116.1
7.37.3
00
55
1010
1515
2020
All CauseAll Cause Sudden CardiacSudden Cardiac
All patients N=5517All patients N=5517
LBBB N=1391LBBB N=1391
HRHR
**
1.70 1.70
(1.41-2.05)(1.41-2.05)
HR HR
**
1.58 1.58
(1.21-2.06)(1.21-2.06)
Cause of DeathCause of Death
1
-
Y
e
a
r

M
o
r
t
a
l
i
t
y

(
%
)
1
-
Y
e
a
r

M
o
r
t
a
l
i
t
y

(
%
)
* HR = Hazard Ratio* HR = Hazard Ratio

22. Proposed Mechanisms of Proposed Mechanisms of
Cardiac ResynchronizationCardiac Resynchronization
Cardiac ResynchronizationCardiac Resynchronization
Improved Intraventricular Improved Intraventricular
SynchronySynchrony
Improved Atrioventricular Improved Atrioventricular
SynchronySynchrony
Improved Interventricular Improved Interventricular
SynchronySynchrony
Yu C-M, Chau E, Sanderson J, et al. Yu C-M, Chau E, Sanderson J, et al. CirculationCirculation 2002;105:438-445 2002;105:438-445

23. Summary of Proposed MechanismsSummary of Proposed Mechanisms

Yu C-M, Chau E, Sanderson J, et al. Yu C-M, Chau E, Sanderson J, et al. CirculationCirculation 2002;105:438-445 2002;105:438-445
IntraventricularIntraventricular
SynchronySynchrony
AtrioventricularAtrioventricular
SynchronySynchrony
InterventricularInterventricular
SynchronySynchrony
 LALA
PressurePressure
 LV DiastolicLV Diastolic
FillingFilling
 RV StrokeRV Stroke
VolumeVolume
 LVESVLVESV  LVEDVLVEDV
Reverse RemodelingReverse Remodeling
Cardiac ResynchronizationCardiac Resynchronization
 MRMR dP/dt, dP/dt,  EF, EF,  COCO
(( Pulse Pressure)Pulse Pressure)

24. Achieving Cardiac ResynchronizationAchieving Cardiac Resynchronization
Mechanical Goal: Atrial-synchronized bi-ventricular pacingMechanical Goal: Atrial-synchronized bi-ventricular pacing
•Transvenous ApproachTransvenous Approach
–Standard pacing lead in RAStandard pacing lead in RA
–Standard pacing or defibrillation lead in RVStandard pacing or defibrillation lead in RV
–Specially designed left heart lead placed in a left ventricular Specially designed left heart lead placed in a left ventricular
cardiac vein via the coronary sinuscardiac vein via the coronary sinus
Right AtrialRight Atrial
LeadLead
Right VentricularRight Ventricular
LeadLead
Left VentricularLeft Ventricular
LeadLead

25. CRT Improves Quality of Life Score and CRT Improves Quality of Life Score and
NYHA Functional ClassNYHA Functional Class
QoLQoL NYHANYHA
PATH-CHFPATH-CHF
1 1
(n=41)(n=41) ++ ++
InSync (Europe)InSync (Europe)
2 2
(n=103)(n=103) ++ ++
InSync ICD (Europe)InSync ICD (Europe)
3 3
(n=84)(n=84) ++ ++
MUSTICMUSTIC
4 4
(n=67)(n=67) ++
MIRACLEMIRACLE
5 5
(n=453)(n=453) ++ ++
MIRACLE ICDMIRACLE ICD
6 6
(n=364)(n=364) ++ ++
1
Auricchio A. Stellbrink C, Sack S., et al. Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol J Am Coll Cardiol 2002;39:2026-2002;39:2026-
2033 2033
22
Gras D, Leclercq C, Tang A, et al. Gras D, Leclercq C, Tang A, et al. Eur J Heart FailureEur J Heart Failure 2002;4:311-320 2002;4:311-320
33
Kuhlkamp V. Kuhlkamp V. JACCJACC 2002;39:790-797 2002;39:790-797
4 4
Linde C, Leclercq C, Rex S, et al. Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol J Am Coll Cardiol 2002;40:111-118 2002;40:111-118
5
Abraham W, Fisher W, Smith A, et al.Abraham W, Fisher W, Smith A, et al.
N Engl J Med.N Engl J Med. 2002;346:1845-1853 2002;346:1845-1853
66
Leon A. Leon A. NASPE Scientific Sessions – Late BreakingNASPE Scientific Sessions – Late Breaking
Clinical Trials. Clinical Trials. May 2002; Medtronic Inc. data on fileMay 2002; Medtronic Inc. data on file
++ Statistically significant improvement with CRT (p Statistically significant improvement with CRT (p  0.05) 0.05)
 Not statistically significant or No statistical analysis performed on dataNot statistically significant or No statistical analysis performed on data
Blank Blank Indicates test neither performed nor reported Indicates test neither performed nor reported

26. CRT Improves Exercise CapacityCRT Improves Exercise Capacity
1
Auricchio A. Stellbrink C, Sack S., et al. Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol J Am Coll Cardiol 2002;39:2026-2002;39:2026-
2033 2033
22
Gras D, Leclercq C, Tang A, et al. Gras D, Leclercq C, Tang A, et al. Eur J Heart FailureEur J Heart Failure 2002;4:311-320 2002;4:311-320

33
Kuhlkamp V. Kuhlkamp V. JACCJACC 2002;39:790-797 2002;39:790-797
4 4
Linde C, Leclercq C, Rex S, et al. Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol J Am Coll Cardiol 2002;40:111-118 2002;40:111-118
5
Abraham W, Fisher W, Smith A, et al.Abraham W, Fisher W, Smith A, et al.
N Engl J Med.N Engl J Med. 2002;346:1845-1853 2002;346:1845-1853
66
Leon A. Leon A. NASPE Scientific Sessions – Late BreakingNASPE Scientific Sessions – Late Breaking
Clinical Trials. Clinical Trials. May 2002; Medtronic Inc., data on fileMay 2002; Medtronic Inc., data on file
6 Min Walk6 Min WalkPeak VOPeak VO
22
ExerciseExercise
TimeTime
PATH-CHFPATH-CHF
1 1
(n=41)(n=41) ++ ++
InSync (Europe)InSync (Europe)
2 2
(n=103)(n=103) ++
InSync ICD (Europe)InSync ICD (Europe)
3 3
(n=84)(n=84) ++
MUSTICMUSTIC
4 4
(n=67)(n=67) ++ 
MIRACLEMIRACLE
5 5
(n=453)(n=453) ++ ++ ++
MIRACLE ICDMIRACLE ICD
6 6
(n=364)(n=364)  ++ ++
++ Statistically significant improvement with CRT (p Statistically significant improvement with CRT (p  0.05) 0.05)
 Not statistically significant or No statistical analysis performed on dataNot statistically significant or No statistical analysis performed on data
Blank Blank Indicates test neither performed nor reported Indicates test neither performed nor reported

27. CRT Improves Cardiac Function/StructureCRT Improves Cardiac Function/Structure
1
Auricchio A. Stellbrink C, Sack S., et al. Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol J Am Coll Cardiol 2002;39:2026-2002;39:2026-
2033 2033
22
Gras D, Leclercq C, Tang A, et al. Gras D, Leclercq C, Tang A, et al. Eur J Heart FailureEur J Heart Failure 2002;4:311-320 2002;4:311-320
33
Kuhlkamp V. Kuhlkamp V. JACCJACC 2002;39:790-797 2002;39:790-797
4 4
Linde C, Leclercq C, Rex S, et al. Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol J Am Coll Cardiol 2002;40:111-118 2002;40:111-118
5
Abraham W, Fisher W, Smith A, et al.Abraham W, Fisher W, Smith A, et al.
N Engl J Med.N Engl J Med. 2002;346:1845-1853 2002;346:1845-1853
66
Young J. Young J. ACC Scientific Sessions – Late BreakingACC Scientific Sessions – Late Breaking
Clinical Trials III. Clinical Trials III. March 2002; Medtronic Inc., March 2002; Medtronic Inc.,
data on file data on file
++ LVESV, LVESV,
++ LVEDV LVEDV ++ MIRACLE ICDMIRACLE ICD
6 6
(n=362)(n=362)
++ LVEDD, LVEDD,
++ LVEDV, LVESV LVEDV, LVESV ++ ++MIRACLEMIRACLE
5 5
(n=453)(n=453)
 LVEDD,LVESDLVEDD,LVESD
 Filling Time Filling Time  MUSTICMUSTIC
4 4
(n=67)(n=67)
++ Filling Time Filling Time
++InSync ICD (Europe)InSync ICD (Europe)
3 3
(n=84)(n=84)

++ Filling Time Filling Time
++InSync (Europe)InSync (Europe)
2 2
(n=103)(n=103)
++ LVEDP LVEDP
++ LV dP/dt LV dP/dt
maxmax
PATH-CHFPATH-CHF
1 1
(n=41)(n=41)
OtherOther MRMRLVEFLVEF
++ Statistically significant improvement with CRT (p Statistically significant improvement with CRT (p  0.05) 0.05)
 Not statistically significant or No statistical analysis performed on dataNot statistically significant or No statistical analysis performed on data
Blank Blank Indicates test neither performed nor reported Indicates test neither performed nor reported

28. 11
Gras D, Leclercq C, Tang A, et al. Gras D, Leclercq C, Tang A, et al. Eur J Heart FailEur J Heart Fail 2002;4:311-320 2002;4:311-320
2
Auricchio A. Stellbrink C, Sack S., et al. Auricchio A. Stellbrink C, Sack S., et al. J Am Coll Cardiol J Am Coll Cardiol 2002;39:2026-20332002;39:2026-2033
3 3
Linde C, Leclercq C, Rex S, et al. Linde C, Leclercq C, Rex S, et al. J Am Coll Cardiol J Am Coll Cardiol 2002;40:111-118 2002;40:111-118
NYHANYHA QoLQoL 6 Minute6 Minute
WalkWalk
Peak VOPeak VO
22
InSync European InSync European
and Canadian Studyand Canadian Study
1 1
(n=67, followed to 12 months)(n=67, followed to 12 months) ++ ++ ++
PATH-CHF StudyPATH-CHF Study
22

(n=29, followed to 12 months)(n=29, followed to 12 months)
++ ++ ++
++
MUSTIC StudyMUSTIC Study
33
(n=42 in sinus rhythm group, (n=42 in sinus rhythm group,
n=33 in atrial fibrillation group n=33 in atrial fibrillation group
followed to 12 months)followed to 12 months)
++ ++ ++ 
Cardiac Resynchronization OutcomesCardiac Resynchronization Outcomes
Sustained for at least 12 monthsSustained for at least 12 months
++ Statistically significant improvement with CRT (p Statistically significant improvement with CRT (p  0.05) 0.05)
 No statistically significant improvement with CRT No statistically significant improvement with CRT
Blank Indicates test neither performed nor reportedBlank Indicates test neither performed nor reported

29. Step 1: Cannulate CSStep 1: Cannulate CS
Attain LDS Model 6216AAttain LDS Model 6216A

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

30. Step 2: Perform Venograms Step 2: Perform Venograms
Varying Patient Anatomy Varying Patient Anatomy
1,2,31,2,3
2. Neri et al. 2. Neri et al. Europace Europace 2000;I :D95 Abstract 88/22000;I :D95 Abstract 88/2
1. Potkin et al. 1. Potkin et al. Am J Cardiol Am J Cardiol 1987;60:1418-14211987;60:1418-1421
3. Hill et al.3. Hill et al. EuropaceEuropace 2000;I:D238 Abstract 167/22000;I:D238 Abstract 167/2
Photos Courtesy of Dr. Daniel GrasPhotos Courtesy of Dr. Daniel Gras

31. Cardiac Venous AnatomyCardiac Venous Anatomy
CS Os
Middle
Posterior
Postero-lateral
Great
Lateral
Antero-
lateral
Anterior
Step 2: Perform VenogramsStep 2: Perform Venograms

32. Lead in Lateral Cardiac VeinLead in Lateral Cardiac Vein
Step 2: Perform VenogramsStep 2: Perform Venograms

33. Step 4: Place LeadStep 4: Place Lead
Attain OTW Model 4193Attain OTW Model 4193
Click to Start/StopClick to Start/Stop

34. Step 4: Place LeadStep 4: Place Lead
Attain OTW Model 4193Attain OTW Model 4193
Courtesy ofCourtesy of
Dr. Daniel GrasDr. Daniel Gras
Click to Start/StopClick to Start/Stop

35. LAO View: LAO View:
Tracking Over the WireTracking Over the Wire
Click to Start/StopClick to Start/Stop
Courtesy ofCourtesy of
Dr. Daniel GrasDr. Daniel Gras

36. Step 4: Place Leads Step 4: Place Leads
Attain LV Model 2187 Attain LV Model 2187
Video compliments of Video compliments of
Dr. Vince PaulDr. Vince Paul
Click to Start/StopClick to Start/Stop

37. Biventricular Pacing is indicated for the Biventricular Pacing is indicated for the
reduction of CHF symptoms in patients with:reduction of CHF symptoms in patients with:
•1. Stable Class III-IV CHF1. Stable Class III-IV CHF
•2. QRS> 130 ms2. QRS> 130 ms
•3.EF <35%3.EF <35%
•4. Optimal medical therapy4. Optimal medical therapy