Cardiac Resynchronization Therapy Selection therapy Echocardiography
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1 Cardiac Resynchronization Therapy Selection therapy Echocardiography Prof. Patrizio LANCELLOTTI CHU Sart Tilman, Liège April, 2010
2 Candidates for CRT : class IA NYHA Functional Class III or IV (Subjective) QRS duration > 120 ms (> 150 ms usually considered) LVEF < 35% (overestimated in case of MR) Stable HF medical treatment for 1-month All Guidelines are unanimous in defining who should receive CRT BUT > 30% of patients are nonresponders
3 EVALUATION OF LV FUNCTION AND SIZE Modified Simpson s Method of discs 4 CV 2 CV Endocardial Border? Load dependent Geometric assumptions Foreshortening in 90% PROSPECT STUDY 20% had LVEF > 35%
4 Causes of 30% CRT nonresponse Inappropriate patient selection Inappropriate lead position Lead in front of necrotic tissue in ischemic pts Non optimal AV and/or VV delays
5
6 Inter-Ventricular dyssynchrony Normal European Society of Cardiology physiologic copyright -All right reserved delay
7 Interventricular Asynchrony inter-ventricular mechanical delay (IVMD) Pulm valve Aorta 86ms 132ms IVMD = LV PEI - RV PEI = 48ms Significant when > 40 ms Rouleau et al., PACE 2001
8 Patient selection : Currently based on electrical, but not mechanical dyssynchrony assessment r = Ghio. Eur H J 2004;25:571
9 Interventricular delay and response to CRT cm * *,** CRT off CRT on CRT off CRT on Miracle study N = 279 pts FU = 6 months delta LVEDV delta LVESV *:p<0.05 CRT off vs on **:p<0.05 IVMD<40ms vs IVMD>40ms IVMD < 40 ms (49%) IVMD > 40 ms (51%) Adamson PB et al, AHA 2002
10 Primary events IVD > 49 ms IVD < 49 ms Days 1500 EHJ 2007
11 AV Dyssynchrony Long AV Diastolic MR 262/768 = 34% AV asynchrony < 40 % Short AV Correction of AV delay LV remodeling (short > long AV?) C. Parsai, ESC 2007
12 INTRA-VENTRICULAR ASYNCHRONY Fauchier. JACC 2002; 40:2022
13 Mechanical dispersion = 40 ms
14
15 Patient selection : Currently based on electrical, but not mechanical dyssynchrony assessment ms Intra-LV Electromechanical Delay % n=104 r 2 = 0.13 p =ns % ms QRS Width Bader. J Am Coll Cardiol 2004;43:248-56
16 INTRA-VENTRICULAR ASYNCHRONY Protosystolic Mesosystolic Endsystolic Spatial Electro mechanical Electro systolic TM, Tracking 2D-Strain 3D Temporel AV closure MV opening 1 Wall: TM lateral 6 Walls: TM/Tracking
17 VISUAL INTERPRETATION : Asynchrony? Delays < 70 ms cannot be detected with the human eye Voigt, Szulik et al., 2007
18 Apical Transverse Motion Pre-CRT Post-CRT Rocking Pre-CRT Post-CRT No Rocking Voigt et al., EHJ 2009
19 Septal to posterior wall motion delay M-mode or color M-mode Radial Spatial 110 ms 112 ms Feasible in only 76% of normals and 45% of patients Predicts reverse remodeling when > 130 ms (specificity?) Poor spatial resolution : 1 point in each wall Pitzalis JACC 2005 (n=20), Diaz-Infante AJC 2007 (n=67), Contak CD (n=79)
20 Septal Flash M-mode or color M-mode short, early systolic septal motion 161 patients, multicenter, septal flash rest: Sens 64%, Spec 55% Septum Septal Flash R Wave MVC Septal Flash AVO Inferolateral Eliminating the septal flash by CRT predicts LV remodeling (100%) C. Parsai, EHJ 2009
21 DLC (IDCM) : Longitudinal Temporal Left lateral wall post-systolic displacement Contraction into early diastole Normal 450 ms Patient LFT 490 Not assessable in 33% Delay in MV opening Cazeau Heart 2000, Sassone Am J Cardiol 2007 (n=31)
22 Color-coded Tissue Doppler Imaging (Longitudinal Spatial) IDCM : QRS 118 ms IntraVA = = 110 ms (> 60 ms Bax AJC 2003) Septal-lateral delay (n=25) : Sens : 76% Spec : 88% LV EF
23 Agreement between SPWMD and SL delay Response Septo-to-Lateral SPWD > 130 ms delay > 65 ms Sens 90% 66% Spec 82% 50% European Society of Cardiology copyright -All right Bleeker reserved Am J Cardiol 2007
24 Color TDI: LV dispersion (Longest Shortest TPS) IntraVA = = 170 ms (> 65 ms Bax JACC 2004) LV disp (n=85): Sens : 92% Spec : 92% reverse remodeling+outcome
25 Time to Peak Systolic Velocity: SD of 12 segments SD-12 = 87 ms SD>32.6 ms (n=54): predictor of LV reverse remodeling Sens : 96%, Spec : 78% Yu et al, Am J Cardiol 2002;91:
26 Other modalities : Strain (n=37) SD ms Reverse remodeling Mele Eur Heart J 2006 (n=59) Exct-12 = 760 ms Sens : 94%, Spec : 83% For reverse remodeling Porciani Eur Heart J 2006
27 Other modalities : Strain Advantages Regional function Passive vs acitve motion Limitations Angle dependency Low signal to noise ratio Moderate reproducibility High operator variability
28 Lim et al Circulation 2009
29 Longitudinal + Radial Anteroseptum Posterior SPWD 130 ms 190 HF pts with CRT TDI SD-12 (n=67) + SL delay (only ejection phase) Radial dyssynchrony Gorscan JACC 2007 EF Responders (%) Long 2 sites 95% 59% 21% Both Either Neither Long 12 sites 93% 57% 10% Both Either Neither Sens: 88% Spec : 80% if both for EF at 6 months
30 3-D ASSESSMENT OF MECHANICAL LV DYSSYNCHRONY (Normal) (Radial, Longitudinal, Circumferential)
31 3-D ASSESSMENT OF MECHANICAL LV DYSSYNCHRONY (Patient) SD-16 segments 8.3 % for reverse remodeling (n=26) Kapetanakis Circ 2005 Poor agreement with TDI SD-12 : 56.5% for LVMD
32 Prospect study Prospective non randomized identify echo measures of asynchrony and predict response 53 centers, 426 patients QRS > 130 ms 12 echo measures 8 were associated with response No single measure of mechanical dyssynchrony may be recommended ESC 2007 Hotline
33 Prospect study : Interpretation High interecholab variability Need for standardization Coefficient of variation 6.5% LPEI 33.7% TS-SD 72.1% SPWMD Machines + settings? Site of implantation Scar tissue? Pacing optimization? The yield for echo measures SPWMD 72% LPEI 95% TS Lat-Se 67% TS-SD 50% Value of combined MD criteria? The role of etiology? The 3D results? ESC 2007 Hotline
34 - 30 ms IDCM : QRS 130 ms NYHA III 30 ms SD-12 = 9 ms Limitations Angle dependency Active vs passive motion? Peak? Low Systolic velocity
35 IDCM : QRS 130 ms NYHA III 2D-Strain 100 ms Advantages Angle independent Passive vs active motion Radial/longitudinal/Circonf
36 Pre : SD 18%
37 FAILURE TO CRT RESPONSE Age Sex NYHA Dilated cardiomyopathy Systolic BP NT-BNP Ejection fraction End systolic volume QRS IVMD Mit Regurg area Low High Male) Female III IV Absent Present Low High Low High Low High Low High Low High Low High <21.8 >21.8 Care HF NEJM 2007 Reuter AJC 2002,89: Care HF : only 11 % QRS < 150 ms 1. ERO 20 mm² 2. LV EDD 75 mm 3. Ischemic disease 4. Narrow QRS 5. Absence of asynchrony Lack of reverse LV remodeling Cabrero-Bueno Europace 2007 Diaz-Infante AJC 2005,95:1436
38 Extent of Myocardial Necrosis Thin myocardium Microvascular damage Delayed enhancement Thin DWT < 5.5 mm Resting echo Contrast echo Cardiac MRI
39 Extent of Myocardial Necrosis PL Scare R NR 81% 14% European Society of Cardiology copyright Bleeker -All right reserved GB et al. Circulation 2006
40 Global Contractile Reserve Independent predictor of event-free survival after CRT (Da Costa et al. Heart Rhythm 2006) (IVD LV EF at 10 µg/kg/min) Predictive value of 7.5 % dobu-induced increase in LVEF (Ypenburg et al. Am Heart J 2007) Global CR: increase in LVEF by 6.7 % (Lancellotti et al Eur J Echo 2009)
41 Number of patients Local Contractile Reserve Responders Non Responders CR+ DYS+ CR+ DYS- CR- DYS+ CR- DYS- Lancellotti et al Eur J Echo 2009
42 Role of Stress Echo : dynamic asynchrony Rest Exer 30 % normalization (asynchrony at rest) 30 % induction (No asynchrony at rest) 30 % No changes Lancellotti Am European J Cardiol Society 2005, of Cardiology Lafitte copyright JACC -All right 2006, reserved D Andrea EHJ 2007
43 Exercise LV asynchrony predicts response to CRT Lancellotti et al AJC 2005, Rocchi et al Eur Heart J 2009
44 Dynamic Septal Flash Predicts CRT Response low dose dobutamine 52 patients septal flash rest sensitivity 82% specificity 88% septal flash LDD sensitivity 97% specificity 88% Parsai / Sutherland et al, Eur Heart J 2009
45 Veinous anatomy and Necrosis CT MRI Veins CT/MRI Necrosis
46 GCV LV CS RV LMV PL wall PIV PV INF wall
47 How do you select a CRT candidate? 1 Application of official guidelines only 2 Guidelines + evidence of dyssynchrony 3 Guidelines + integrated approach by different imaging methods
48 Conclusions Dyssynchrony is normal and is dynamic Many tools and many (too many?) criteria not included in the guidelines (own echo criteria) No one single echo parameter represents a magic number. Used several matched parameters?. A patient should not be denied CRT on the absence of LV Dyssynchrony alone If no correctable mechanism is present the patient will NOT respond!
49 Stepwise approach QRS > 120 ms, NYHA III, EF < 35% IVD > 49 ms Yes CRT AV asynchrony No Inter + Intra V delay > 102 ms ERO 20 mm² LV EDD 75 mm CRT? LV MD TDI, 2D Strain 3D echo +/- Exer echo LV MD Yes No LV MD Stress echo PL necrosis Yes Viability No Viability Others? No CRT
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