Atrial dyssynchrony syndrome: An overlooked cause of heart failure with normal ejection fraction

Transcription

1 Atrial dyssynchrony syndrome: An overlooked cause of heart failure with normal ejection fraction JC Eicher, G Laurent, O Barthez, A Mathé, G Bertaux, JE Wolf Heart Failure Treatment Unit, Rhythmology and Cardiac Stimulation Unit University Hospital of Dijon, France Heart Failure Congress 2011, Gothenburg

2 Disclosures None

3 Background Heart failure with preserved ejection fraction (HFPEF) Highly prevalent (approximately 50%) Same (?) prognosis as HFREF Medical treatment : none Pathophysiology : still poorly understood the arterial hypothesis abnormal ventriculo-arterial coupling the ventricular hypothesis «subtle» LV systolic dysfunction LV diastolic dysfunction the atrial hypothesis increased LA stiffness (Kurt M, et al. Circ Cardiovasc Imaging 2009)

4 Patients HFPEF LVEF > 50% no MR > grade II NYHA III + recurrent hospital admissions for CHF Sinus rhythm, interatrial block (P wave duration > 120 ms) Peculiar Doppler mitral inflow pattern Late, short, abruptly terminated A wave cf pacemaker syndrome or short PR interval

5 Methods Doppler echocardiography Mitral E, A, e velocities Mitral E/A, E/e ratios Mitral and tricuspid A wave durations Mitral and tricuspid A wave deceleration times Interatrial electromechanical delay

6 Methods Doppler echocardiography Mitral E, A, e velocities Mitral E/A, E/e ratios Mitral and tricuspid A wave durations Mitral and tricuspid A wave deceleration times Interatrial electromechanical delay

7 Methods Doppler echocardiography LA volumes (Simpson) Vmax VpreA Vmin LA function reservoir :LA expansion index (Vmax-Vmin/Vmin x 100) conduit : LA passive emptying fraction (Vmax-VpreA/Vmax x 100) booster : LA active emptying fraction (VpreA-Vmin/VpreA x 100)

8 Methods Right heart catheterization Pulmonary arterial pressure Pulmonary capillary wedge pressure Cardiac output Electrophysiological study Right A-V interval Left A-V interval Inter-atrial delay

9 Results 7 patients 6 F, 1 M Mean age 75 ± 7 years Mean number of days in hospital during the last 2 years : 32 ± 31 6 walking distance 190 ± 15 m Mean Nt-proBNP level : 4700 ± 2000 pg/ml

10 Results LV / LA volumes & function LV end diastolic diameter (mm) 52 ± 6 LV ejection fraction (%) 72 ± 10 LV mass (g/m²) ± 23.6 normal values 1 LA volume (ml/m²) 56.8 ± 15.5 < 29 LA expansion index (%) 43 ± ± 150 LA passive emptying fraction (%) 20 ± 6 44 ± 15 LA active emptying fraction (%) 13 ± 9 40 ± 12 1 Sirbu C. Eur J Echocardiogr 2006

11 Results Doppler echocardiographic features Mitral E velocity (ms) 140 ± 19 E L A Mitral E deceleration time (ms) ± 29.5 Mitral E/A ratio 3.7 ± 1.4 Mitral Mitral E/e ratio 22.2 ± 4.2 Mitral A duration (ms) 99.1 ± 14.4 Tricuspid A duration (ms) ± 23.6* Mitral A deceleration time (ms) 33.6 ± 13.8 Tricuspid A deceleration time (ms) 90 ± 15.3** Interatrial delay (ms) ± 40.8 Mitral L wave (%) 100 Tricuspid Systolic pulmonary artery pressure 63.6 ± 13.1

12 Results Catheterization mean PAP (mmhg) 43.7± 6.7 PCWP (mmhg) 26.2 ± 4.7 V wave (mmhg) 49.4 ± 11.6 CI (l/min/m²) 2.2 ± 0.9 Electrophysiological study Right A-V interval (ms) 170 ± 30 Left A-V interval (ms) 30 ± 20 Interatrial delay (ms) 140 ± 20

13 Baseline Sinus Rhythm 100 mm/s RAVD LAVD RA-LA HV LAVD: Left atrio-ventricular delay, RAVD: Right atrio-ventricular delay

14 100 mm/s Coronary sinus pacing RAVD LAVD

15 Patient #2 BSL SR

16 Patient #2 BSL SR

17 Patient #2 CS PACING

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19 Discussion Interatrial block Highly prevalent partial 32.8% in a general population 59% in patients > 60 years old Ariyarajah V, Chest 2005 Advanced 1% of the general population Bayes de Luna, J Electrocardiogr % in candidates to PM, 32% in sick sinus syndrome Daubert JC, Arch Mal Coeur 1994 Poorly perceived clinical consequences LA size correlated with P wave duration Ariyarajah V, Chest 2005 Association of IAB with AF Agarwal YK, Am J Cardiol 2003 IAB as a predictor of stroke Lorbar M, Am J Cardiol 2005 LA electromechanical dysfunction Goyal SB, Am Heart J 2001 DIA

20 Discussion All 7 pts exhibited : 1. Interatrial block with delayed LA systole 2. Severely raised filling pressures 3. Features of decreased LA compliance Hypotheses : atrial dyssynchrony syndrome Severe interatrial conduction delay Short left A-V interval LA emptying interrupted by closing MV Increased LA stiffness Post-capillary pulmonary hypertension

21 Conclusion Some patients with HFPEF present with IAB One major cause of CHF could be decreased LA compliance Pacing inside the coronary sinus is able to normalize the left A-V interval Whether these patients could be improved by atrial resynchronization deserves further investigation.

22 PCWP modulation at BSL SR

23 PCWP modulation during pacing

24 PeR interval < 30ms Wipe speed :67mm/s

25 67mm/s 200mm/s

26 31/12 : 6 WD 170 m 06/01 : 6 WD 262 m

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28 Echo-Doppler results HFPSF IACD, no HF p LVEF (%) 72 ± ± 10 NS LVEDD 52 ± 6 51 ± 8 NS Left ventricular mass (g) 202 ± ± 59 NS Mitral E/A ratio 3.7 ± ± Mitral E/e ratio 22.2 ± ± 2.1 < Mid-diastolic L wave (%) < Mitral A wave duration (ms) 98.2 ± ± 29 < Mitral A wave velocity (cm/s) 41 ± ± 22 NS Tricuspid A wave duration (ms) 178 ± ± 8 NS Interatrial electromechanical delay (ms) ± ±