Home > CARDIOSTIM-EHRA EUROPACE 2016 Pier Lambiase
Electrophysiology, Heart failure, Imaging

CARDIOSTIM-EHRA EUROPACE 2016 Pier Lambiase

Published Online: April 28th 2017

Pier Lambiase discusses patient selection for cardiac resynchronisation therapy and the current research into personalised computer models of the heart.

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.

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