0 Optimization of AV and VV Delays Lumax 540 CRM Training and Education.
-
Upload
lily-vaughn -
Category
Documents
-
view
217 -
download
3
Transcript of 0 Optimization of AV and VV Delays Lumax 540 CRM Training and Education.
1
Optimization of AV and VV Delays
Lumax 540
CRM Training and Education
2
Optimization of BiV Pacing
A-V Delay
V-V Delay
3
AV Delay Optimization
Ensure BiV pacing
Improve diastolic filling
Reduce mitral regurgitation
Cardiac Output
Goals
4
AV Delay Optimization
AV too long
Close to intrinsic PR (fusion)
Loss of CRT
AV too short
Premature mitral valve closure
Hemodynamic compromise
5
AV Delay Optimization
Empirical Calculation
Echocardiography
Pulse pressure
Methods
6
AV Delay Optimization
Aortic Pressurein percent
Auricchio et al., Circulation 1999
LV dP/dtmax
in percent
A-V Delay A-V Delay
RV
LV
BiV
-8
-4
0
4
8
12
16
0
PR - 30 ms
-12
-6
0
6
12
18
24
0 PR - 30 ms
7
AV Delay Optimization
Example for As-Vs = 220 msAVopt = (220-30)/2 = 95 ms
Calculation
Auricchio et al., Circulation 1999
2AVopt =
(PR interval) - 30 ms
8
AV Delay Optimization
LV lead in anterior vein
RBBB
Intrinsic PR > 300 ms
AV block II°/III°
Limitations of Calculation Methods
9
AV Delay Optimization
Flow Velocity at Mitral Valve
Aortic Velocity Time Integral
Doppler Echocardiography
10
Echocardiography
Apical Position
4 Chamber View
11
Apical 4-Chamber View
12
Doppler-Echocardiography
Fd = Doppler frequency
f0 = Ultrasound frequency(e.g., 2.4 MHz)
V = Blood flow velocity
= Angle between sound beamand direction of blood flow
c = Speed of sound in humantissue (1,530 m/s)
Fd =2 V cos
cf0
13
Doppler-Echocardiography
Spectral analysisBlood flowvelocity
1.5
1.0
0.5
14
Mitral Valve Doppler Echo
SampleVolume
P
A
R
E
T
LV EjectionFilling
ECG
Doppler
15
Pulsed Wave Doppler Echo
4 Chamber View E/A Ratio
Mitral Valve
16
Pulsed Wave Doppler Echo
EA
Velocity(cm/s)
Time (50mm/s)
ECG
17
AV Delay Optimization
Transmitral Flow Velocity LV filling pressure
E waveEarly diastolic passive filling of the left ventricle
A waveLate diastolic active filling of the left ventricle atrial contribution
Doppler Echo
18
Normal Heart Cycle
P P
A A
R
A
P
E EE
LVFT
S Q
T
IVR IVC IVRIVC
AorticFlow
AorticFlow
Left VentricularFilling Time
Isovolumic Contraction
IsovolumicRelaxation
19
Left Bundle Branch Block
Q T
A A
R1 R2 R1 R2
T
AE EE
P P P
A A A
20
LBBB: Late MV Closure
*IVC = Isovolumic Contraction
P Q T P
A A
R1 R2 R1 R2
IVC* A
P
IVC*
Aortic Valve Opening AVO
MVCMitral Valve Closure
21
LBBB: Late End of LV Systole
P Q T P
A A
R1 R2 R1 R2
IVC
AorticFlow
A
MVC
Aortic Valve Closure
P
LV Systole
AorticFlow
MVC
IVC
AVO
Ejection
22
LBBB: Late Start of LV Filling
* MVO = Mitral Valve Opening** IVR = Isovolumic Relaxation
P Q T P
A
R1 R2 R1 R2
Q T
IVC IVR*
AorticFlow
A
MVC MVO*
AVO AVC
P
AorticFlow
A
23
LBBB: Fusion of E and A
P Q T P
A A
R1 R2 R1 R2
Q T
A
P
E E
ShortLV
FillingTime
E
AorticFlow
AorticFlow
250 ms at HR 65/min
24
P Q T P
A A
R1 R2 R1 R2
Q T
IVC IVRA
MVC
P
E EE
AorticFlow
AorticFlow
Pre Ejection Period (PEP)
LBBB: Resynchronization
25
Biventricular Pacing
PT
P
A A
T
A
P
E EE
AVD
AorticFlow
AorticFlow
IVC IVC
BiV
Pro-longed
LV FillingTime
325 ms at HR 65/min
PEP
BiV BiV
MVC MVC
26
AV Optimization
Short AV Delay Long AV Delay
Ritter Formula
P
A
QA
A wave truncation
ForcedMVC
E
P
AE
SpontaneousMVC
QA
AV AV
27
AV Delay Optimization
Programmed AV Delays
AVshort = short AV (25% of PR)
AVlong = long AV (75% of PR)
Ritter Formula
Ritter et al., PACE 1995
AVopt = AVshort + [(AVlong - AVshort) - (QAshort - QAlong)]
"The Difference of the Differences"
Measured QA Intervals
QAshort = QA at short AV
QAlong = QA at long AV
28
Transmitral Flow
At short AV delay
AVshort = 50 ms
QAshort = 128 ms
128 ms
Begin Q
EA
29
Transmitral Flow
At long A-V delay
AVlong = 160 ms
QAlong = 48 ms
48 ms
Q
E A
30
AV Delay Optimization
Result
Programmed AV Delays
AVshort = 50 ms
AVlong = 160 ms
Measured QA Intervals
QAshort = 128 ms
QAlong = 48 ms
AVopt = AVshort + [(AVlong - AVshort) - (QAshort - QAlong)]
"The Difference of the Differences"
AVopt = 50 + [(160-50)-(128 - 48)]
= 50 + (110 - 80)
AVopt = 80 ms
31
AV Delay Optimization
Short AV Long AV Optimal AV
32
AV Delay Optimization
Doppler Echocardiography
Flow Velocity at Mitral Valve
Aortic Velocity Time Integral
33
Doppler Echo
Apical Five Chamber View
34
Doppler Echo
Aortic Flow Velocity
Kruck, Biamino 1988
35
Aortic Flow Velocity
LBBB
A A A
AorticFlow
AorticFlow
Velocity
Time
36
Aortic Flow Velocity
Biventricular Pacing
AE
AVD
AorticFlow
AorticFlow
Velocity
Time
37
Velocity Time Integral
Fehske 1988
Integral = Area under the curve
VTI =
AVO
AVC
V * dt
(cm)
38
Velocity Time Integral
ECG
Velocity(m/s)
Time
vmax
Ejection time
vmean Vmax = 1.58 m/s
Vmean = 1.09 m/s
ET = 288 ms
VTI = Vmean * ET
VTI = 0.31 m
39
AV Delay Optimization
Dr. Uhrig, Vivantes Urban Hospital Berlin
VTI = 12.7 cm VTI = 20.5 cm
Velocity Time Integral
40
VTI Method
Fehske 1988
Derived Parameters
Stroke VolumeSV = VTI * AVTI = Velocity Time
IntegralA = Aortic Valve Area
Cardiac OutputCO = SV * HRHR = Heart Rate
41
VTI Method
Objective
Identify optimal AV delay at max. VTI
Procedure
CW Doppler of aortic outflow tract
Decrement AV delay by 20 ms down to ≥ 80 ms
Limitations
Doppler signal quality
Breathing modulations
Intrinsic error 10 - 15%
42
AV Delay Optimization
30 Pts. after CRT implantation NYHA III-IV, LVEF < 35%, SR
BiV on atrial sensed beats AV optimization on LV dp/dt max
Comparison to Ritter formula, diastolic filling time (DFT), LV VTI, E/A VTI
Jansen et al., Am J Cardiol 2006
43
LV dP/dt max
LVPressure(mmHg)
dP/dt(mmHg/s)
Jansen et al., Am J Cardiol 2006
44
Compliance with LV dP/dt max. measurements
Good
Good toreasonable
%
Jansen et al., Am J Cardiol 2006
0
67
43
97
57
87
73
100
0
20
40
60
80
100
Ritter DFT LV VTI E/A VTI
45
AV Delay Optimization
Empirical Calculation
Echocardiography
Pulse pressure
Methods
46
Pulse Pressure Method
Objective
Identify AV delay that provides maximal differencebetween systolic and diastolic blood pressure
Procedure
Arterial line to measure central aortic pressure accurately
47
Pulse Pressure Method
Intrinsic Paced
Auricchio et al., PACE 1998
P R
Aorta
LV
PEP
Time
Pressure
P Vp Time
Pressure
48
Pulse Pressure Method
BiV Pacing
AorticPressure(mmHg)
LV IEGM
Time (s) 0 1 2 3 4 5 6 7 8 9
60
85
110
49
AV Delay Optimization
Pulse pressure: hemodynamic testing
Calculation: initial programming
Doppler Echo: non-responders
Summary
50
Optimization of BiV Pacing
A-V Delay
V-V Delay
51
V-V Delay Optimization
LV first
AS
RVP
AV
LVP LVPRVP
VV VV
AV
RV first
AS
VV = 0
AS
RVP
AV
LVP
52
V-V Optimization
41 pts. with CHF after CRT-PM
AV delay optimization
RV-/LV pre-activation: 0, 12, 20, 40, 80 ms
Endpoints: Cardiac output, mitral regurgitation from echo
Bordachar et al., JACC 2004
53
V-V Optimization
Echocardiographic Parameters
M-mode: septal-to-posterior wall motion delay (SPWMD)
Doppler: Interventricular mechenical delay (IVMD)
Tissue Doppler:
Intra LV delay onset (LV onset)
Intra LV delay peak (LV peak)
SD from 12 segments intra LV delay peak (SDLV peak))
Delayed longitudinal contraction (DLC)
Bordachar et al., JACC 2004
54
V-V Optimization
Bordachar et al., JACC 2004
Parameter
Correlation to Hemodynamics
CardiacOutput
Mitral Regurgitation
LV peak
SD LV peak
LV onset
DLC
SPWMD
IVMD
-0.67
-0.67
-0.64
-0.48
-0.41
-0.24
0.68
0.68
0.63
0.51
0.24
0.06
55
41 CHF pts. with CRT-PM
V-V Optimization
No. of pts.
Bordachar et al., JACC 2004
0
2
4
6
8
10
8040200204080 12 12 ms
LV first RV first
56
166 DCM pts. with CRT (Doppler Echo)
V-V Optimization
0
20
40
60
LV first
80
RV first
40200204080
At Implant
3 months
No. of pts.
Delurgio et al., NASPE 2002
ms
57
V-V Optimization
V-V Optimization
van Gelder et al., Am J Cardiol 2004
AF
SR ischemic
SR non-ischemic
58
Optimizing BiV Pacing
59
Optimizing BiV Pacing
I
V1
RV only LV only BiV BiV LVfirst
60
Optimizing V-V Delay
Start with standard setting
VV optimization in patients with persistent dyssynchrony
Trouble shooting option in clinical non-responders
Summary
61
Optimization of BiV Pacing
A-V Delay
V-V Delay