Oct 8, 2016 - Spironolactone 50mg/day. - Torasemid 5mg/day. - Panangin 2 tab x 3 times/day. - Trimetazidine 35mg x 2 times/day. - Rosuvastatin 10mg/day ...
Cardiac resynchronization an underutilized therapy. Clinical case. 6th edition of Moldavian National Society of Cardiology Congress 7, 8 October 2016 Darciuc Radu cardiologist
1
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
1
2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure
1
Obstacles?
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Belgium
1
Romania
1
Republica Moldova
1st implant – 01.04.2016
1
Designed by Dooder - Freepik.com
Clinical case
1
65 years old male (1950) CAD from 2005 (retrosternal chest pain) EcoCG – Aortic aneurysm Coronaroangiography 2006 (Chisinau) - LMCA – 75% - ostial LAD – 65% mid LAD – 40%, distal LAD – 75% - ostial DIA I – 60% - ostial CX – 60%, mid CX – 40% - mid RCA – 40%, distal RCA – 60% - left subclavian artery – 65%
1
Ecocardiography 2006 - Aortic root (sinus of Valsalva) – 56-58mmm, acending Ao - 44mm - LV TDD – 68mm, EF – 53% - Aortic insuficiency II-III - Mitral insuficiency I-II
Bakulev Institute (Moskow 12.02.2007) - 2 DES (crush) - LMCA - 1 DES - mid LAD - 1 DES – PDA - 1 DES – mid PL
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Bakulev Institute (Moskow) Coronarography (10.2007) - LMCA - patent stent - proximal LAD – 30% restenosis - mid LAD – patent stent, distal LAD – 65% stenosis - DIA I – 80% ostial stenosis (small vessel) - DIA II – 70% ostial stenosis (small vessel) - CX – ocluded - mid RCA – 65% stenosis, distal RCA – 50% stenosis - PDA – patent stent - PL – ostial stenosis 65%, mid – patent stent
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Bakulev Institute (Moskow) Cardiac surgery (09.10.2007) - David's operation - by-pass on 2 arteries: vein ->OM II, vein ->PL - postoperative period – hemorrhagic complications (Novoseven administration needed) 21.10.2007 – Acute miocardial infarction Coronarography + PCI - mid-distal LAD oclusion - oclusion of PL venous graft - PCI LAD and PL (1 DES on LAD + 1 DES PL)
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LBBB – QRS 140-150 ms 2011 - PVC – 291/24h, multifocal, couplets, triplets
Coronarography (28.05.2015) - LMCA – intrastent stenosis 25% - LAD I – intrastent stenosis 25-50%, LAD II – 25% - DIA I – 25-50% stenosis, DIA II 25-50% stenosis - CX I – ocluded, CX II charging from OM II patent graft - OM II – 25% - RCA I – 25-50%, PD – 50-75% - PL - 25%
February 2016 - Carvedilol (6,25mg/day) - Aspirin 75mg/day - Losartan 25mg/day - Torasemid 5mg/day - Rosuvastatine 10mg/day - Rivaroxaban 15mg/day - Trimetazidine 35mg bid
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23.02.2016 – syncope K+ - 3,4 mmol/l ECG – PVC – trigeminy VT was suspected. Amiodarone i/v started. Holter ECG – 5269 PVC/24 h, 12 couplets, 1 triplet
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Medical treatment: - Bisoprolol 2,5mg/day - Amiodarone -> loading -> 200mg/day - Losatan 25mg/day - Rivaroxaban 20mg/day - Spironolactone 50mg/day - Torasemid 5mg/day - Panangin 2 tab x 3 times/day - Trimetazidine 35mg x 2 times/day - Rosuvastatin 10mg/day
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QRS - 160ms
Echocardiography dynamics 30/09/2009
09/09/14
09/04/15
21/03/16
LA
48
49
52
60
LV TDD
72
74
82
80
IVS
12
11
9
9
PWLV
12
11
8
8
EF
33
37
28
28
RV
28
29
31
31
RA
48
46
48
53
MV insuf.
II
III
II
III
AoV insuf.
II
II
II
II
TV insuf.
II
II
II
II
PSAP
37
35
38
43 1
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Cardiac MRI CRT-D implantation
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MRI – fibrotic lesions
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MRI – regional contractility
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MRI – Aneurysm
1
1
QRS - 160ms
QRS - 160ms
QRS - 140ms
QRS - 160ms
QRS - 140ms
CRT optimisation
1
AV delay VV delay LV only pacing?
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1
Echocardiograpy - LA size (antero-posterior diameter in mm) 62
60
58
56
54
52
50
48 09/04/2015
21/03/16
03/05/2016
09/09/2016
1
Echocardiograpy - LV size 83
(LV TDD mm)
82 81 80 79 78 77 76 75 74 73 09/04/15
21/03/16
03/05/16
09/09/16
1
Echocardiograpy - RV size (PLAX mm) 31,5
31
30,5
30
29,5
29
28,5
28 09/04/2015
21/03/16
03/05/2016
09/09/2016
1
Echocardiograpy - RA size (medio-lateral mm)
60
50
40
30
20
10
0 09/04/2015
21/03/16
03/05/2016
09/09/2016
1
Echocardiograpy pulmonary artery systolic pressure (mmHg) 50 45 40
43 38
37 35
35 30 25 20 15 10 5 0 09/04/2015
21/03/16
03/05/2016
09/09/2016
1
5 months after CRT-D implant
5 months after CRT-D implant
5 months after CRT-D implant
Obstacles?
1 Designed by Dooder - Freepik.com
Designed by Dooder - Freepik.com
Designed by Dooder - Freepik.com
1
Thank you!
