Activation électromécanique dans la tétralogie de Fallot opérée. Dr Xavier Iriart Unité de cardiologie congénitale CHU de Bordeaux
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1 Activation électromécanique dans la tétralogie de Fallot opérée Dr Xavier Iriart Unité de cardiologie congénitale CHU de Bordeaux
2 Geva T et al. JCMR 2011
3 Geva T et al. JCMR 2011
4 1.Surgical lesions and RBBB R =delayed RV electrical activation
5 Dyssynchrony and RBBB in rtof RBBB is common after TOF repair Impact of RBBB on RV electrical activation? Variations among the patients? Consequences on mechanical activation and RV function Potential effect of CRT?
6 What can we learn from the LV? LBBB and LV dyssynchrony Characteristic pattern of LV dyssynchrony Chung et al. Circ 2008 Parsai et al. EHJ 2009 Forsha et al. JASE 2014
7 Uniform pattern of activation in true LBBB Single RV epicardial breakthrough passive LV activation ending with basolateral LV Early activation Late activation Ploux et al. JACC 2013
8 Non specific intraventricular conduction disturbance Various forms of activation NSIVD Non-responder pattern True LBBB NSIVD responder pattern Ploux et al. JACC 2013
9 Different levels of RBBB Proximal: VSD patch (activation delay in all sites) Distal: moderator band level (activation delay in most sites except apex) Terminal: fascicular network (activation delay only in basilar areas) Pig heart The level of block may interfere with the extent of electrical and mechanical dyssynchrony and with the impact of RV/ biventricular pacing Horowitz LN et al. Circulation 1980
10 Typical RV dyssynchrony Delayed RV activation Presence of septal line of block Latest activation delay : RV basis (close to RVOT) Red/orange zones:early activation Bleu zones : late activation Thambo J et al. IJC 2011
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13 RV mechanical activation pattern in rtof Impact of dyssynchrony on RV function Abnormal mechanical activation pattern Right sided septal flash/ early septal activation Prestretch of laterobasal wall Late contraction of laterobasal wall and PSS Hui, Friedberg. Circ Cardiovasc Imaging. 2014
14 RV electromechanical activation
15 Geva T et al. JCMR 2011
16 2. Chronic volume overload and mechanico-electrical changes Helbing et al. Heart 2002 Mueller M. Eur J Echocardiography 2010
17 Impact of chronic volume overload on QRS duration in an animal model Piglet RVOT patch 2 cusps Excised PA banding «rtof» Pig No VSD Surgery 4 months after surgery Thambo JB et al. IJC 2013
18 3. Cellular activation Animal model of rtof 3. rtof and cellular activation rtof pigs return Sedated and Anesthetized MRI or EP/HD study rtof pigs euthanasied Heart In vivo 4 months after surgery 30min 1H30 15min Ex vivo -histology -optical mapping
19 Optical mapping of cardiac electrical activity Face endocardiial surface Epicardial surface camera Dubes et al. Heart 2016, in press
20 Isochrones espacés de 5 ms Temps d activation total du VD allongé dans l épicarde et endocarde des Fallot vs Sham * P < 0.05, ** P < 0.01 Corrélation linéaire entre le temps total d activation endocardique VD et le VTDVD Dubes et al. Heart 2016, in press
21 What s the origin of RBBB after rtof Surgical lesions Proximal RBB lesion (VSD patch) Distal lesions related with infundibulotomy Hemodynamics Chronic ventricular volume overload and progressive RV dilatation Histology: chronic fibrosis E.A. Udink ten Cate et al. Journal of Electrocardiology 2014
22 Mechanical activation L. Jing et al. EHJCI 2014
23 Impact of dyssynchrony on LV function L. Jing et al. EHJCI 2014
24 RV/LV interaction and LV remodeling Sham rtof Base Sham rtof * * 100 µm Apex Base Apex Fibrosis : conduction abnormalities, LV dyssynchrony and pro-arrhythmic mechanism
25 Hemodynamic effects of RV/ BiV stimulation in animal model No benefit of RV stimulation No difference between RV sites Positive effect of biv stimulation Better RV/LV function Shortening of EM activation Epicardial echo Epicardial mapping (Carto ) Thambo JB et al. Heart Rhythm 2010
26 Acute hemodynamic results in patients with rtof Thambo JB et al. Heart Rhythm 2010
27 Clinical evidence are missing for the RV Positive effect of BiV pacing on RV/LV hemodynamics No randomized controlled trial No current recommandations in rtof How to define responder/non responder?
28 What s the best stimulation strategy? RV lead: lat wall RV lead: lat wall LV lead: postero-lat wall Decreased RV dyssynchrony Persistance delayed areas (RVOT, mid RV) Major LV activation delay Pseudo LBBB Limitation: no targeted RV stimulation in our study Major improvement of global electrical activation Thambo et al. Int J cardiol 2013
29 Near normal RV activation Significant delay limited to RVOT Mild to moderate delayed RV activation Importance of the level of block? Red/orange zones:early activation Bleu zones : late activation Thambo J et al. IJC 2011
30 Conclusion Similarities between LBBB-LV dyssynchrony and RBBB-RV dyssynchrony RV LV RV mechanical pattern LV mechanical pattern Hui, Friedberg et al. Circ Cardiovasc Imaging Forsha, Friedberg et al. JASE 2014
31 Conclusion CRT indication for RV failure: complementary to PVR Potential effects on RV failure Reduce RV activation delays Correct inefficient PSS Potential effect on LV dyssynchrony
32
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