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 ???)