1
Optimization of AV and VV Delays
CRT Program
CRM Training and Education
12-09
3
Optimization of BiV Pacing
A-V Delay
V-V Delay
4
AV Delay Optimization
Ensure BiV pacing
Improve diastolic filling
Reduce mitral regurgitation
Cardiac Output
Goals
5
AV Delay Optimization
AV too long
Close to intrinsic PR (fusion)
Loss of CRT
AV too short
Premature mitral valve closure
Hemodynamic compromise
6
AV Delay Optimization
Pulse pressure
Empirical Calculation
Echocardiography
Methods
7
AV Delay Optimization
Pulse pressure
Empirical Calculation
Echocardiography
Methods
9
Pulse Pressure Method
Intrinsic BiV Paced
Auricchio et al., PACE 1998
P R
Aorta
LV
PEP
Time
Pressure
P Vp Time
Pressure
10
Pulse Pressure Method
BiV Pacing
AorticPressure(mmHg)
LV IEGM
Time (s) 0 1 2 3 4 5 6 7 8 9
60
85
110
11
AV Delay Optimization
Pulse pressure
Empirical Calculation
Echocardiography
Methods
15
AV Delay Optimization
Aortic Pressure
Auricchio et al., Circulation 1999
LV dP/dtmax
A-V Delay A-V Delay
BiV
LV
RV
-8
-4
0
4
8
12
16
0
PR - 30 ms
-12
-6
0
6
12
18
24
0 PR - 30 ms
16
AV Delay Optimization
Example for As-Vs = 220 ms
AVopt = (220-30)/2 = 95 ms
Calculation
Auricchio et al., Circulation 1999
2AVopt =
(PR interval) - 30 ms
18
AV Delay Optimization
Pulse pressure
Empirical Calculation
Echocardiography
Methods
19
AV Delay Optimization
Flow Velocity at Mitral Valve
Aortic Velocity Time Integral
Doppler Echocardiography
21
Apical 4-Chamber View
26
Mitral Valve Doppler Echo
SampleVolume
P
A
R
E
T
LV EjectionFilling
ECG
Doppler
27
Pulsed Wave Doppler Echo
4 Chamber View E/A Ratio
Mitral Valve
28
Pulsed Wave Doppler Echo
EA
FlowVelocity
(cm/s)
50 mm/s
ECG
29
AV Delay Optimization
Transmitral Flow Velocity LV filling pressure
E waveEarly diastolic passive filling
A waveLate diastolic active filling atrial contribution
Doppler Echo
31
Left Bundle Branch Block
Q T
A A
R1 R2 R1 R2
T
AE EE
P P P
A A A
32
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
33
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
34
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
35
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
36
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
37
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
38
AV Optimization
Short AV Delay Long AV Delay
“Ritter Formula”
P
A
QA
A wave truncation
ForcedMVC
E
P
AE
SpontaneousMVC
QA
AV AV
39
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
40
Transmitral Flow
At short AV delay
AVshort = 50 ms
QAshort = 128 ms
128 ms
Begin Q
EA
41
Transmitral Flow
At long A-V delay
AVlong = 160 ms
QAlong = 48 ms
48 ms
Q
E A
42
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
43
AV Delay Optimization
Short AV Long AV Optimal AV
46
AV Delay Optimization
Flow Velocity at Mitral Valve
Aortic Velocity Time Integral
Doppler Echocardiography
47
Doppler Echo
Apical Five Chamber View
48
Doppler Echo
Aortic Flow Velocity
Kruck, Biamino 1988
49
Aortic Flow Velocity
LBBB
A A A
AorticFlow
AorticFlow
Velocity
Time
50
Aortic Flow Velocity
Biventricular Pacing
AE
AVD
AorticFlow
AorticFlow
Velocity
Time
51
Velocity Time Integral
Fehske 1988
Integral = Area under the curve
VTI =
AVO
AVC
V * dt
(cm)
53
AV Delay Optimization
Dr. Uhrig, Vivantes Urban Hospital Berlin
VTI = 12.7 cm VTI = 20.5 cm
Velocity Time Integral
54
VTI Method
Fehske 1988
Derived Parameters
Stroke VolumeSV = VTI * AVTI = Velocity Time
IntegralA = Aortic Valve Area
Cardiac OutputCO = SV * HRHR = Heart Rate
56
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
57
LV dP/dt max
LVPressure(mmHg)
dP/dt(mmHg/s)
Jansen et al., Am J Cardiol 2006
58
Agreement with LV dP/dt max
Good Good to reasonable
%
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
59
AV Delay Optimization
Empirical Calculation
Echocardiography
Pulse pressure
Methods
60
AV Delay Optimization
Pulse pressure: hemodynamic testing
Calculation: initial programming
Doppler Echo: non-responders
Summary
61
Optimization of BiV Pacing
A-V Delay
V-V Delay
62
V-V Delay Optimization
LV first
AS
RVP
AV
LVP LVPRVP
VV VV
AV
RV first
AS
VV = 0
AS
RVP
AV
LVP
63
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
64
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
65
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
67
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
68
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
69
V-V Optimization
van Gelder et al., Am J Cardiol 2004
AF SR ischemic SR non-ischemic
70
V-V Optimization
van Gelder et al., JCE 2008
dP/dtmax
Baseline VV=0 QuickOpt VVdP/dt
32 HF pts. with CRT, 20 CAD, SR, QRS 170 ms, EF 23%
71
Optimizing BiV Pacing
72
Optimizing BiV Pacing
I
V1
RV only LV only BiV BiV LVfirst
73
Optimizing V-V Delay
Start with standard setting
VV optimization in patients with persistent dyssynchrony
Trouble shooting option in clinical non-responders
Summary
74
Optimization of BiV Pacing
A-V Delay
V-V Delay