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Haran Burri discusses the remote monitoring of cardiac resynchronisation therapy, the ACUITY X4 multipolar leads and the outcomes of the RALLY-X4 study. FILMED AT THE CARDIOSTIM ANNUAL MEETING, JUNE 2016 WHAT ARE THE ADVANTAGES OF THE ACUITY X4 MULTIPOLAR LEADS? 00:10 – So these are quadripolar leads that allow us to more easily position them in the coronary sinus veins. They also give us more options to reduce the pacing thresholds, the captured thresholds. And finally, to avoid pacing the phrenic nerve. WHAT HAVE BEEN THE OUTCOMES OF THE RALLY-X4 STUDY? 00:33 – So, this was actually the first phase which we’re presenting here at CardioStim, the post-marketing clinical follow-up in the first 201 patients. And what we found was that the success for delivery of CRT at three months was present in all but one of the 201 patients, that’s to say, in over 99% of patients who received CRT delivery at three months. And in fact the electrical measurements were very good, with on average about 1 volt captured thresholds and very good stability. We had no cases that needed to be re-operated for early dislodgement. There was one case that needed repositioning due to persistent phrenic nerve capture. WHY IS REMOTE MONITORING OF CRT NEEDED? 01:28 – It’s becoming the standard of care now for these patients. These patients have high incidences of clinical issues, arrhythmias, be it atrial arrhythmias or ventricular arrhythmias that could benefit from being monitored and diagnosed early on. They also have more heart failure events. So, we can monitor various parameters for heart failure. And finally, these patients are also at a somewhat higher risk for technical issues, that’s to say, for instance, high left ventricular threshold. And these are things that we can actually monitor using remote monitoring and act upon them more quickly. WHAT ARE THE LIMITATIONS OF THE REMOTE MONITORING OF CRT DEVICES? 02:14 – So, the limitations are data overload because these devices can upload quite a lot of data off the patients to the hospitals, and the hospital staff are faced with a lot of data overload. So, what could work around this are integrated diagnostics where you have automatic algorithms that look at different parameters and risk stratify patients into higher risk, medium risk and lower risk, meaning that the hospital staff can focus on those patients who are at higher risk—that’s about 10% of the patients—and then deal specifically with those 10% of patients.
Pier Lambiase discusses patient selection for cardiac resynchronisation therapy and the current research into personalised computer models of the heart. Disclosures: Pier Lambiase has received research grants and speaker fees from Boston Scientific and educational grants from Medtronic and St Jude. FILMED AT THE CARDIOSTIM ANNUAL MEETING, JUNE 2016 HOW CAN WE IMPROVE THE SELECTION OF PATIENTS FOR CRT? 00:10 – Well there’s a diverse range of patients that we implant for CRT. The best group are obviously those who have a broad QRS, more than 150 milliseconds. But there’s this intermediate range between about 130 and 150 milliseconds where there’s a bit of variability in response, and that’s mainly due to areas of scar where the leads have been placed, so we can improve it by avoiding placing the leads in scar regions but also identifying sites of late activation and late contraction. And ideally we want to be confident that when we pace that area the tissue is actually going to be synchronised with the rest of the ventricle, and that’s quite a challenge because of the imaging technologies that we’re using; there are some difficulties with identifying those sites optimally. WHAT ARE THE OBSTACLES TO PERSONALISED CRT? 00:55 – Well, the main obstacles are the technology that we have available and also the variability in the patients. So physically, if there’s scar tissue, we’re trying to pace around it. We may be able to get there, for example, in multipoint pacing: where the leads are actually being positioned may mean that you’re pacing an area where the tissue still can’t contract very well, even if you actually pace it. So we’re starting to look at other technologies, for example endocardial pacing where we can get very good haemodynamic responses for the patients. And there are some newer technologies with leadless pacing which are evolving and we can apply. But we have to be very careful about their safety and efficacy in going forward. And selecting which patients are suitable for cardio CRT is going to still be quite a challenge because we have a very good reliable epicardial approach at the moment. So it’s identifying the optimal group that is going to benefit for that. CAN YOU TELL US SOMETHING ABOUT CURRENT RESEARCH ON PERSONALISED COMPUTER MODELS OF THE HEART? 01:54 – So there are two main types of computer models that we use. One is predicting electrical activity, in the electrical response in CRT, and the other is the mechanical response. Now there’s models that come in together to gives us the electro-mechanical response. So essentially we can predict what the haemodynamic response is going to be by pacing different regions of the heart. And this is very, very powerful, particularly in patients who have got a scar in the myocardium. So we can say: If there’s a scar in this region, and we paced just outside, can I predict a better haemodynamic response in that patient putting a lead here versus there? That then goes back to this issue of endocardial versus multipoint pacing or putting more than one lead in the epicardium because essentially we can say, well this patient particularly needs two leads in two areas while this patient would be better off with endocardial pacing. So we can actually prescribe the right pacing technology for the patient, individualised and personalised based on the modelling. And I think we’re very close to that with the technology that we have.

Heart Failure: Latest Videos

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Haran Burri discusses how to assess the longevity of cardiac resynchronisation therapy based on real-life experience, and how his recent data be extrapolated to estimate the impact on the number of replacement procedure. He also discusses the impact of the results on patient morbidity and what may...
Pier Lambiase discusses patient selection for cardiac resynchronisation therapy and the current research into personalised computer models of the heart. Disclosures: Pier Lambiase has received research grants and speaker fees from Boston Scientific and educational grants from Medtronic and St...
Luca Bontempi discusses the challenges of resynchronisation therapy in the elderly along with some of the hot topics in cardiac rhythm management from this year’s meeting. FILMED AT THE CARDIOSTIM ANNUAL MEETING, JUNE 2016 WHAT ARE THE CHALLENGES OF RESYNCHRONISATION THERAPY IN THE...
Haran Burri discusses the remote monitoring of cardiac resynchronisation therapy, the ACUITY X4 multipolar leads and the outcomes of the RALLY-X4 study. FILMED AT THE CARDIOSTIM ANNUAL MEETING, JUNE 2016 WHAT ARE THE ADVANTAGES OF THE ACUITY X4 MULTIPOLAR LEADS? 00:10 – So these are...
A meta-analysis of randomised controlled trials Recently published clinical guidelines recommend cardiac resynchronisation therapy for patients with heart failure with reduced LVEF and non-left bundle branch block QRS morphology. This paper sought to define the potential benefit of CRT in...
Brian Reemsten, MD presents Surgical Options in Pediatric Congenital Heart Failure at the UCLA Heart Failure Symposium, 2013.

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