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An ICD for every CRT patient ?
JC Deharo, CHU Marseille
Sudden Cardiac Death in Heart Failure patients
MERIT-HF study, Lancet 1999
0
10
20
30
40
50
60
70
Overall (N=362) NYHA II (N=103) NYHA III (N=232) NYHA IV (N=27)
SCD (% of death)
Patients to be treatedfor saving one life
0
5
10
15
20
25
30Treated pts/
1 life saved
MUSTT MADITII SAVE MERIT-HF
ICDICD
ACE Inh
Beta -
Secondary
prevention
by the ICD
Connolly S.J EHJ 2000, 21: 2071-2078
- 28 %
- 50 %
Secondary prevention by the ICD :Patients with the lowest EF benefit the
most
From AVID Trial, Domanski, JACC 1999
Malignant ventricular arrhythmia
certain or suspected
NYHA class IIIQRS 130 msLV EF 35%
LV Diameter 55 mm
CRT ICD
Secondary prevention ICM (and NICM)
+
+
0
10
20
30
40
50
60
MADIT MUSTT MADIT II
Primary prevention
Mortalityreduction
%
Mortality reduction with ICD therapy (Ischemic CM)
Primary prevention with the ICD :The sickest patients benefit the most
From MADIT Trial, Moss
Circulation 2000
N Engl J Med, March 21, 2002
MADIT II
Primary prevention with the ICD :Patients with the larger QRSd benefit the most
LV EF ≤ 35% ; NYHA class IIIQRS 130 ms ; LV Diameter 55 mm
CRTICD + CRT
No
Primary prevention in ICM
LVEF ≤ 30% 30% < LVEF ≤ 35%+ NSVT
EPS inducible
Yes
Non ischemic cardiomyopathy Primary prevention ?
AMIOVIRTJACC 2003
101
Amio vs ICD
NICM
LVEF ≤ 35%
NYHA I – III
Total : ▬
CATCirc. 2003
104
OPT vs ICD
Recent NICM
LVEF ≤ 30%
NYHA II – III
Total : ▬
DEFINITENEJM 2004
458
OPT vs ICD
NICM
LVEF ≤ 35%
NYHA I – III
Total : ▬ (p=0.06)
SCD-HeFTACC 2004
2521
OPT/Amio/ICD
NICM+ICM
LVEF ≤ 35%
NYHA II – III
Total : ICD+
COMPANIONNEJM 2004
1520
OPT/CRT/CRT-ICD
NICM+ICM
LVEF ≤ 35%
NYHA III – IV
Total : CRT-ICD+
CAT
AMIOVIRT
SCD-HeFT
COMPANION
No
Yes
Non ischemic CMLVEF ≤ 35%
NYHA class IIIQRS 130 ms
LV diameter 55 mmICD + CRT+
Primary prevention in NICM
DEFINITE
15H455th shock 31 J
15H46 no more therapyavailable
VFVT
VT
Class II b :
Non ischemic CM EF ≤ 30 %
or
EF ≤ 35 % + NSVT
French recommendationsICD for primary prevention in NICM
Feasibility
• Implant success 96%• Procedure duration : 192±84 minutes• CS lead positioning : 77±64 minutes• Implant related complications : 12% • CS perforation/dissection : 4/84• CS lead dislodgement : 7/84• Infection : 2/84
JACC 2002
Cost concern
BiV PM Dual
chambre
ICD
ICD + CRT
€ x 3.5
€ x 1.25ICD candidates
MADIT II
↑↑
SCD-HeFT
↑↑↑
Conclusion
ICD in patients indicated for CRT :
– Secondary prevention– Primary prevention in ICM
(Very low EF, young age ???)– Primary prevention in NICM
(Very low EF, young age, heart transplant planed ???)
Recommended