Weekly case -Device therapy in HF.pptx file

Weekly case -Device therapy in HF.pptx file

1. Weekly case discussion Presented By: Dr Bisrat A(IMR3) Moderator: Dr Gashaw S ( CF1) 9/28/2025 Dr Bisrat A 1

2. History and Physical Examination Name:T.A 64 year,Female DOE-19/02/2024 09:31 HPI T2DM on Sitagliptin / Metformin 50/1000mg po bid,ASA 75mg po /d/6 years Presented with a complaint of 3months of exertional presyncope and syncope she had mild exertional dyspnea, but no orthopnea or PND No cough. 9/28/2025 Dr Bisrat A 2

3. Cont … BP = 110/70, Temp = 36.1, Pulse = 100,Spo2=92% at RA Pink conjunctivae and NIS Has fine basal crackles JVP flat,S1 and S2 heard No HSM No edema She is conscious 9/28/2025 Dr Bisrat A 3

4. Date 19/02/2024 CBC WBC-5.4k HGB-12.8 PLT-266kK HbA1C 6.3 Hbsag and HCV AB Neg VDRL Neg TSH 1.07 AST,ALT,ALP 27,31,143 Urea and Creat 50 , 0.81 Troponin Quant <0.1 Pro BNP ---- CK-MB 1.31 PT/INR 1.2 PTT 28 albumin 4.9 ELE NA-140 K-4,4 CL-103 CRP <5.0 Lipid profile Chole-186 hdl - 46 ldl-126 TAG-71 9/28/2025 Dr Bisrat A 4

5. ECG rS complexes in leads II, III, aVF , with small R waves and deep S waves qR complexes in leads I, aVL , with small Q waves and tall R waves Left Axis Deviation (LAD atypical RBBB(RBBB pattern in lead V1 and absent significant S-wave in the lateral leads I and aVL STD and TWI on anterior leads 9/28/2025 Dr Bisrat A 5

6. ECHO Ischemic DCM with severe LVSD,EF ~25% 9/28/2025 Dr Bisrat A 6

7. Progress note P-IDCMP with severe LVSD +type DM -Initiated on GDMT CAG was done and it was Unremarkable v/s stable -she was kept for 3 days and discharged with GDMT medications and appointment 9/28/2025 Dr Bisrat A 7

8. Cont.. P-Same+on 14th day of post CAG S-she had intermittent dizziness, fainting, presyncope to syncope 3-4 episodes within 2 weeks   Objective -> BP 140/80 PR 26-126 beats per minute seen at monitor in emergency RR = 18 TO 36 SPO2 95% RA clear chest with good air entry s1 and s2 well heared no fluid, no HSMG no peripheral edema COTPPT Assessment -> SAME+ recurrent cardiac syncope 2ry to ? sick sinus syndome 9/28/2025 Dr Bisrat A 8

9. 2 nd ECG on 11/3/24 9/28/2025 Dr Bisrat A 9

10. Cont … P- HFrEF 2ry to ? IDCMP with severe LVSD (25%) + known type2 DM Subjective -> she was having repeated pre-syncope(around 4-5 times) and her rate at that time was in 24-40 and has also one episode over night P/R-29-36 Asst -Symptomatic 3 rd AV Block Rx- and Adrenaline infusion 9/28/2025 Dr Bisrat A 10

11. Cont.. Case was discussed with consulting cardiologist and CRT-D insertion was recommended After 2 days of ICU stay CRT-D was implanted Stayed for additional 2 days post Implantation v/s –stable p/r-78-100 She was discharged with GDMT medications and appointed after one week 9/28/2025 Dr Bisrat A 11

12. Post PROCEDURE FOLLOW UP ECG 9/28/2025 Dr Bisrat A 12

13. 2 ND ECHO 1 MONTH POST CRT-D 9/28/2025 Dr Bisrat A 13

14. 3 RD ECHO 7 MONTHS POST CRT-D 9/28/2025 Dr Bisrat A 14

15. 4 TH ECHO 18 MONTHS POST CRT-D 9/28/2025 Dr Bisrat A 15

16. Heart Failure Device Therapy – ICD and CRT 9/28/2025 Dr Bisrat A 16

17. Cardiac Resynchronization Therapy 9/30/2025 Dr Bisrat A 17

18. What is Dyssynchrony? Dyssynchrony refers to impaired mechanical coordination due to impaired electrical activation of heart muscle. Electrical dyssynchrony identified by prolonged QRS duration on ECG. QRS prolongation typically due to conduction system disease, such as bundle branch block. Chronic pacing-induced conduction delays due to high RV(single chamber) pacing burden. 9/30/2025 Dr Bisrat A 18

19. Types of Dyssynchrony AV Dyssynchrony Interventricular Dyssynchrony Intraventricular Dyssynchrony Other Types Mechanical Dyssynchrony Electrical Dyssynchrony 9/30/2025 Dr Bisrat A 19

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21. Cardiac Resynchronization Therapy All patient with heart failure need optimal pharmacological therapy and lifestyle modifications. But in a small subset, there is a definite role for devices. Intraventricular dyssynchrony in the presence of severe left ventricular dysfunction is an important indication for cardiac resynchronization therapy. Delay between the contractions of the septum and the lateral left ventricular wall causes reduced left ventricular stroke volume. 9/30/2025 Dr Bisrat A 21

22. Cardiac Resynchronization Therapy The important surrogate of ventricular dyssnchrony is an increased QRS duration. In CRT, septum and lateral left ventricular wall contracts simultaneously producing improvement in the left ventricular stroke volume. CRT improves the symptomatic status and survival of the heart failure patients with left ventricular dyssynchrony . But still there is a 30% non-responder rate of patients who do not respond to CRT. 9/30/2025 Dr Bisrat A 22

23. CRT System-Three leads 9/30/2025 Dr Bisrat A 23

24. CRT implant Objectives- lead Placement 9/30/2025 Dr Bisrat A 24

25. Procedure 9/30/2025 Dr Bisrat A 25

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27. ECG in CRT Leads I, II & III are most useful in deciding whether it is RV, LV or biventricular pacing. Since the pattern varies from individual to individual, it is good to preserve the tracings of all modes of pacing for future comparison. 9/30/2025 Dr Bisrat A 27

28. CXR in CRT 9/30/2025 Dr Bisrat A 28

29. Major Trials Time line 9/30/2025 Dr Bisrat A 29

30. Trial Evidences For NYHA CIII-IV MUSTIC MIRACLE MIRACLE- ICD COMPANION CARE HF For NYHA CI-CII REVERSE MADIT- CRT RAFT ECHO- CRT BLOCK- HF 9/30/2025 Dr Bisrat A 30

31. MIRACLE 2002 9/30/2025 Dr Bisrat A 31

32. COMPANION 2004 9/30/2025 Dr Bisrat A 32 A total of 1520 patients who had advanced heart failure (New York Heart Association class III or IV) due to ischemic or nonischemic cardiomyopathies and a QRS interval of at least 120 msec were randomly assigned in a 1:2:2 ratio to receive optimal pharmacologic therapy (diuretics, angiotensin-converting-enzyme inhibitors, beta-blockers, and spironolactone) alone or in combination with cardiac-resynchronization therapy with either a pacemaker or a pacemaker-defibrillator. The primary composite end point was the time to death from or hospitalization for any cause. As compared with optimal pharmacologic therapy alone, cardiac-resynchronization therapy with a pacemaker decreased the risk of the primary end point (hazard ratio, 0.81; P = 0.014 ) , as did cardiac-resynchronization therapy with a pacemaker-defibrillator (hazard ratio, 0.80; P = 0.01 ) . The risk of the combined end point of death from or hospitalization for heart failure was reduced by 34 percent in the pacemaker group (P < 0.002) and by 40 percent in the pacemaker-defibrillator group ( P < 0.001 for the comparison with the pharmacologic-therapy group). A pacemaker reduced the risk of the secondary end point of death from any cause by 24 percent (P = 0.059) and a pacemaker-defibrillator reduced the risk by 36 percent (P = 0.003) .

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34. CARE- HF: All cause mortality Cleland JGF: N Engl J Med 2005;352:1539- 49 CRT therapy resulted in 36% reduction in total mortality (80 vs.120) Inclusion: NYHA class III or IV LVEF ≤ 35% QRS ≥120 813 patients, follow up 29.4 months 9/30/2025 Dr Bisrat A 34

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36. Long Term Mortality in MADIT- CRT (5year) – Influence of LBBB LBBB No LBBB (IVCD, RBBB) 1 V1 V6 Goldenberg et al.NEJM 2014;370:1694- 1701 Loss of septal Q 9/30/2025 Dr Bisrat A 36

37. Long Term (5yr) Outcome (Survival) in MADIT- CRT – All patient groups benefit Goldenberg et al.NEJM 2014;370:1694- 1701 All with LBBB 9/30/2025 Dr Bisrat A 37

38. BLOCK HF trial (691 patients with AV block) 9/30/2025 Dr Bisrat A 38 Curtis A: N Engl J Med 2013;368:1585- 93 Primary outcome occurred in 64.3 (RV pacing) and 55.3% (BiV pacing ) pts; hazard ratio for BiV 0.74; 0.60 to 0.90. If LBBB is Bad – How about if we need to RV pace- CRT? In less sick patients?

39. Patient selection criteria 9/30/2025 Dr Bisrat A 39

40. CRT guidelines for pt in AF 9/30/2025 Dr Bisrat A 40

41. Recommendation for upgrade from right ventricular pacing to cardiac resynchronization therapy 9/30/2025 Dr Bisrat A 41

42. Patients with ICD indications 9/30/2025 Dr Bisrat A 42

43. CRT response 9/30/2025 Dr Bisrat A 43

44. Who responds to CRT? Overall response rate 70% Significant dys synchrony Minimal Lateral LV scar Adequate CS anatomy Female sex Lack of prior MI Smaller left atrial Volume 9/30/2025 Dr Bisrat A 44

45. Important Questions? Why doesn’t a patient respond to CRT therapy? What can you do about it? 9/30/2025 Dr Bisrat A 45

46. Non responders to CRT About 30% of patients do not respond to CRT. The reasons could be any one of the following; Not every patient with wide QRS has dyssynchrony and vice versa. Leads may be too close to each other to produce synchronous contraction of septum and lateral wall. Scarred region of the ventricular can cause poor capture and synchronization. 9/30/2025 Dr Bisrat A 46

47. Lead placement: part of failure to respond – anatomy and operator dependent Butter C et al Circulation 2001;104:3026- 29 Singh J et al Circulation. 2011;123:1159- 1166. 9/30/2025 Dr Bisrat A 47

48. Atrial Fibrillation and CRT Pts with AT/AF had worse outcomes 1193 pts with CRT- D in SR at implant followed mean 13 months BiV pace% 98% during SR and 71% during AT/AF BiV pace% of >95% associated with better outcome Santini et al JACC 2011;57:167 9/30/2025 Dr Bisrat A 48

49. Ruwald M et al JACC 2014:64:971- 981 Effect of Ectopy on BiV Pacing/Efficacy (Goal >97% pacing) Heart Failure and Mortality Echo Parameters after 1 year MADIT- CRT with Holter (801 patients) 9/30/2025 Dr Bisrat A 49

50. Monitoring Improvement ECG-Electrical dyssynchrony improvement ECHO-Mechanical dyssynchrony improvement NYHA Class 6 mins walk test Quality of life scores 9/30/2025 Dr Bisrat A 50

51. CRT benefits Identifying responders Symptoms -Improved exercise tolerance -Reduced SOB -Improved NYHA status Reversed LV remodeling -Improved LVEF, Reduced size, reduced MR Prognosis -Reduced CHF hospitalization Reduced mortality 9/30/2025 Dr Bisrat A 51

52. Complications Lead related reintervention-dislodgement, malposition, subclavian crush syndrome CIED-related infections, <12 months-Superficial infection, pocket infections, systemic infections CIED-related infections, >12 months-Pocket infections, systemic infections Pneumothorax Hemothorax Brachial plexus injury Cardiac perforation Coronary sinus dissection/perforation Diaphragmatic stimulation Hematoma, Seroma Tricuspid regurgitation Pacemaker syndrome 9/30/2025 Dr Bisrat A 52

53. Implantable cardioverter defibrillator 9/28/2025 Dr Bisrat A 53

54. OVERVIEW Introduction Elements of the icd Implantation Icd functions Indications Complications Subcutaneous icd Summary 9/28/2025 Dr Bisrat A 54

55. Introduction Sudden cardiac death (SCD) resulting from cardiac arrhythmia is the world's leading cause of cardiovascular mortality, Accounting for over 50 percent of cardiovascular deaths worldwide. Most persons who have an out-of-hospital cardiac arrest do not survive. may have severe, long-term cognitive impairment and motor impairment 9/28/2025 Dr Bisrat A 55

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57. Martin Mower Michel Mirowski 9/28/2025 Dr Bisrat A 57

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59. Evolution With time the devices have grown smaller, more efficient . 9/28/2025 Dr Bisrat A 59

60. Components of ICD 1.Pulse Generator-Battery, Capacitors & Voltage -Circuitry -Connector Blocks 2.Lead System 3.ICD Programmer 9/28/2025 Dr Bisrat A 60

61. Implantable Cardioverter Defibrillator 9/28/2025 Dr Bisrat A 61

62. Types of ICD 9/28/2025 Dr Bisrat A 62

63. Implantation Most current ICD systems utilize one or two transvenous leads placed via the axillary, subclavian, or cephalic vein, with attachment to a pulse generator in the subcutaneous tissue in the infraclavicular anterior chest wall under local anaesthesia . A trend toward single coils rather than dual coils   Choosing the optimal pulse generator location Choosing the optimal lead placement Defibrillation threshold testing Periprocedural monitoring   9/28/2025 Dr Bisrat A 63

64. Choosing the optimal pulse generator location Modern devices are small enough to be implanted in the pectoral region of the anterior chest wall, either subcutaneously or submuscularly, similar to a pacemaker implantation F ewer perioperative complications, shorter procedure time, shorter hospital stays, lower hospitalization costs, and lower total costs Although implantation on the left side is preferred, a right-sided implant can be performed Left side The pulse generator for the S-ICD system is implanted in a subcutaneous pocket in the left lateral, mid-axillary thoracic position. defibrillation energy requirement is usually lower  small risk of arm swelling due to venous occlusion 9/28/2025 Dr Bisrat A 64

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66. Periprocedural monitoring A posteroanterior (PA) and lateral chest radiograph - - to confirm the position of the pulse generator and the associated lead(s) - to exclude any apparent complications, including pneumothorax and lead dislodgment . A 12-lead electrocardiogram (ECG) recorded during pacing to document the ECG appearance of the QRS complex . If patients undergo DFT testing following device implantation, a "deeper" level of sedation may be required, but in most cases DFT testing can be performed without requiring general anesthesia. 9/28/2025 Dr Bisrat A 66

67. Principles of Operation Bradycardia Pacing- Antitachycardia pacing Detection -Relies on rate sensing. When the rate of the sensed R waves falls into the rate defined tachycardia zone, the detection algorithm is initiated and the counter is augmented. Therapy - Antitachycardia Pacing, Cardioversion, Defibrillation. Electrogram Storage- All episodes are stored. Advanced features include rate-adaptive dual-chamber pacing, atrial therapies and cardiac resynchronization therapy. 9/28/2025 Dr Bisrat A 67

68. Uses of ICDs Primary Prevention Prior Myocardial Infarction(at least 40 days ago) and LVEF ≤ 35% Cardiomyopathy, NYHA II to III with LVEF < 35% Syncope who have structural heart disease and inducible VT/VF Long QT, Torsades on RX, Brugada , ARVD, HCM Secondary Prevention Prior episode of resuscitated VT/VF or sustained hemodynamically unstable VT Episodes of spontaneous sustained VT in the presence of Heart Disease(valvular, ischemic, hypertrophic, dilated or infiltrative cardiomyopathies ) and other settings( eg channelopathies ) 9/28/2025 Dr Bisrat A 68

69. Clinical trials PRIMARY PREVENTION - ICM MADIT-I (Moss et al.1996) CABG-Patch (Bigger et al.1997) MUSTT (Buxton et al. 2000) MADIT-II (Moss et al. 2002 ) DINAMIT ( Hohnloser et al. 2004) SCD- HeFT ( Bardy et al. 2005) IRIS (Steinbeck et al. 2009) PRIMARY PREVENTION – NICM CAT ( Bänsch D et al. 2002 ) AMIOVIRT ( Strickberger et al. 2003 ) DEFINITE ( Kadish A, et al. 2004 ) COMPANION (Bristow et al. 2004) SCD- HeFT ( Bardy et al. 2005) DANISH ( Kober L, et al. 2016 ) 9/28/2025 Dr Bisrat A 69

70. In patients with a prior myocardial infarction who are at high risk for ventricular tachyarrhythmia, prophylactic therapy with an implanted defibrillator leads to improved survival as compared with conventional medical therapy. 9/28/2025 Dr Bisrat A 70

71. They found no evidence of improved survival among patients with coronary heart disease, a depressed left ventricular ejection fraction, and an abnormal signal-averaged electrocardiogram in whom a defibrillator was implanted prophylactically at the time of elective coronary bypass surgery 9/28/2025 Dr Bisrat A 71

72. Electrophysiologically guided antiarrhythmic therapy with implantable defibrillators, but not with antiarrhythmic drugs, reduces the risk of sudden death in high-risk patients with coronary disease 9/28/2025 Dr Bisrat A 72

73. In patients with a prior myocardial infarction and advanced left ventricular dysfunction, prophylactic implantation of a defibrillator improves survival and should be considered as a recommended therapy 9/28/2025 Dr Bisrat A 73

74. Prophylactic ICD therapy does not reduce overall mortality in high-risk patients who have recently had a myocardial infarction. Although ICD therapy was associated with a reduction in the rate of death due to arrhythmia, that was offset by an increase in the rate of death from nonarrhythmic causes. 9/28/2025 Dr Bisrat A 74

75. Prophylactic ICD therapy did not reduce overall mortality among patients with acute myocardial infarction 9/28/2025 Dr Bisrat A 75

76. In patients with NYHA class II or III CHF and LVEF of 35 percent or less, amiodarone has no favorable effect on survival, whereas single-lead, shock-only ICD therapy reduces overall mortality by 23 percent. 9/28/2025 Dr Bisrat A 76

77. In patients with severe, nonischemic dilated cardiomyopathy who were treated with ACE inhibitors and beta-blockers, the implantation of a cardioverter–defibrillator significantly reduced the risk of sudden death from arrhythmia and was associated with a nonsignificant reduction in the risk of death from any cause. 9/28/2025 Dr Bisrat A 77

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79. Recommendations for Primary Prevention of SCD in Patients With Ischemic Heart Disease 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death

80. Recommendations for Primary Prevention of SCD in Patients With NICM 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death

81. Hypertrophic cardiomyopathy

82. Arrhythmogenic right ventricular cardiomyopathy

83. Cardiac amyloidosis

84. Catecholaminergic Polymorphic Ventricular Tachycardia

85. Long QT Syndrome

86. Clinical trials SECONDARY PREVENTION AVID ( The AVID Investigators 1997 ) CASH ( Kuck et al. 2000 ) CIDS ( Conolly et al. 2000 ) 9/28/2025 Dr Bisrat A 86

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88. The ICD is more effective than an AAD in reducing arrhythmic cardiac death, while nonarrhythmic cardiac death is unchanged. Of note, apparent arrhythmic death still seems to constitute 38% of all cardiac deaths despite treatment with an ICD. However , the ICD remains superior to an AAD in prolonging survival after life-threatening arrhythmias. 9/28/2025 Dr Bisrat A 88

89. In this study, a 23% (nonsignificant) reduction in all-cause mortality rate was found in patients receiving ICD therapy compared with amiodarone/metoprolol over a long-term follow-up. The reduction was much larger, 61%, for sudden cardiac death. (SIGNIFICANT) No differences were found in all-cause mortality and sudden death rates between patients assigned to amiodarone and those assigned to metoprolol. 9/28/2025 Dr Bisrat A 89

90. CIDS observed a relative reduction in all cause mortality of 19.7% with the ICD compared with amiodarone (which is not statistically significant), with a 33% relative reduction in arrhythmic death . In light of the results of the AVID study, CIDS provides further support for the superiority of the ICD over amiodarone in the treatment of patients with symptomatic sustained VT or resuscitated cardiac arrest . 9/28/2025 Dr Bisrat A 90

91. This study is the first to describe the characteristics of a U.S . national cohort of patients receiving a secondary prevention ICD in contemporary practice and their outcomes. Nearly 9 of 10 patients receiving a secondary prevention ICD in clinical practice are alive 1 year after implantation. The risk of death varies by indication and is highest among patients who survive SCD or sustained VT in the fi rst year after device implantation. 9/28/2025 Dr Bisrat A 91

92. Guidelines for Secondary Prevention ICD Implantation Implantable Cardioverter-De fi brillators for Secondary Prevention of Sudden Cardiac Death: A Review

93. The CHD population represents a very small minority of ICD implantations but has been relatively well-defined. 9/28/2025 Dr Bisrat A 93

94. Recommendations for management of ventricular arrhythmias in patients with congenital heart disease 2015 European Society of Cardiology guidelines for the management of patients with ventricular arrhythmias (Priori et al.) 9/28/2025 Dr Bisrat A 94

95. Complications- Peri -procedural / Early (<30 days) Bleeding / hematoma pneumothorax / hemothorax Cardiac perforation & tamponade Lead dislodgement / malposition Pocket infection / superficial wound infection Venous thrombosis Anesthesia / sedation complications 9/30/2025 Dr Bisrat A 95

96. Intermediate (1–12 months) Pocket infection evolving to device infection Lead insulation failure / early mechanical lead Inappropriate shocks Psychological complications Venous obstruction / SVC syndrome 9/30/2025 Dr Bisrat A 96

97. Chronic complications >1yr Lead fracture, insulation failure, or conductor break Device infection (late) Device erosion / skin breakdown Inappropriate shocks Generator failure / battery depletion 9/30/2025 Dr Bisrat A 97

98. SUBCUTANEOUS ICD Despite many well-documented benefits for appropriate patients, TV-ICDs possess a number of drawbacks, which are most notably related to the reliance on endovascular leads. S-ICD is comprised of a pulse generator and a shocking lead The pulse generator is implanted in a subcutaneous pocket in the left lateral, mid-axillary thoracic position. 9/28/2025 Dr Bisrat A 98

99. Ref-https://www.jacc.org/doi/10.1016/j.jacc.2015.11.026

100. Take Home Message CRT has emerged as an effective therapy in patients with LVD refractory to CHF medications and a wide QRS duration. Major clinical trials have proven significant morbidity and mortality benefits from CRT. The issue of nonresponse to CRT continues to be a major problem. While the response to CRT in patients with a native LBBB or ­RV-paced rhythm is well documented, the response in patients with RBBB or a nonspecific IVCD continues to be debated. 9/28/2025 Dr Bisrat A 100

101. THANK YOU 9/28/2025 Dr Bisrat A 101