WHAT DO ELECTROPHYSIOLOGISTS WANT TO KNOW FROM ECHOCARDIOGRAPHERS BEFORE, DURING&AFTER CARDIAC RESYNCHRONIZATION THERAPY?

Transcription

1 WHAT DO ELECTROPHYSIOLOGISTS WANT TO KNOW FROM ECHOCARDIOGRAPHERS BEFORE, DURING&AFTER CARDIAC RESYNCHRONIZATION THERAPY? Mary Ong Go, MD, FPCP, FPCC, FACC

2 OUTLINE What is CRT Who needs CRT What does the guidelines say about CRT What do electrophysiologists want from echocardiographers

3 CARDIAC DYSSYNCHRONY Atrioventricular Interventricular Intraventricular

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5 Gorcsan J et al, Journal of the American Society of Echocardiography 2008 (21).

6 2012 ACCF/AHA/HRS Focused Update Incorporated into the ACCF/AHA/HRS 2008 Guidelines for Device Based Therapy of Cardiac Rhythm Abnormalities

7 INDICATIONS FOR CRT IN PATIENTS IN SINUS RHYTHM [2013 ESC Guidelines on Cardiac Pacing & CRT] RECOMMENDATIONS CLASS LEVEL REF 1) LBBB with QRS duration >150ms. CRT is recommended in chronic HF patients and LVEF <35% who remain in NYHA functional class II, III and ambulatory IV despite adequate medical treatment. d I A ) LBBB with QRS duration ms. CRT is recommended in chronic HF patients and LVEF <35% who remain in NYHA functional class II, III and ambulatory IV despite adequate medical treatment. d I B ) Non LBBB with QRS duration >150ms CRT should be considered in chronic HF patients and LVEF <35% who remain in NYHA functional class II, III and ambulatory IV despite adequate medical treatment. d IIa B 48 64

8 INDICATIONS FOR CRT IN PATIENTS IN SINUS RHYTHM [2013 ESC Guidelines on Cardiac Pacing & CRT] RECOMMENDATIONS CLASS a LEVEL b REF c 4) Non LBBB with QRS duration ms. CRT may be considered in chronic HF patients and LVEF <35% who remain in NYHA functional class II, III and ambulatory IV despite adequate medical treatment. d IIb B ) CRT in patients with chronic HF with QRS duration <120ms is not recommended. III B 65,66 a Class of Recommendation. b Level of evidence c Reference(s) supporting recommendation(s) Patients should generally not be implanted during admission for acute decompensated HF. In such patients, guideline indicated medical treatment should be optimized and the patient reviewed as an out patient after stabilitization. It is recognized that this may not always be possible.

9 Galderisi M et al, Cardiovascular Ultrasound 2007 (5).

10 Galderisi M et al, Cardiovascular Ultrasound 2007 (5).

11 INTERVENTRICULAR DYSSYNCHRONY

12 Calculation of interventricular mechanical delay by standard Doppler method. ThetimefromECGQwaveto onset of LVOT (=211ms) (left panel) is longer than the time occuring from Q to onset of RVOT (=122ms). The resulting IVMD is of 89ms, thus indicating a significant interventricular dyssynchrony. Galderisi M et al, Cardiovascular Ultrasound 2007 (5).

13 INTRAVENTRICULAR DYSSYNCHRONY

14 Septal to posterior wall motion delay (SPWMD). SPWMD in a normal subject (left panel) and in a patient with CHF and LBBB. Modified from Agler DA et al, Journal of the American Society of Echocardiography 2007 (20).

15 Routine M mode (A) at midventricular level and color coded tissue Doppler M mode (B) demonstrating septal to posterior wall delay of 180 milliseconds, consistent with significant dyssynchrony (>130ms). Gorcsan J et al, Journal of the American Society of Echocardiography 2008 (21).

16 Methodology for measuring lateral wall post systolic displacement. It is measured as the difference of the time interval from QRS onset to maximal systolic displacement of the basal LV lateral wall (assessed by M mode in the apical 4 chamber view) (upper panel) and the time interval from QRS onset to the beginning of transmitral E velocity (assessed by pulsed Doppler of mitral inflow) (lower panel). In this example, the positive value of the difference indicates the co existence of segmental post systolic contraction and diastolic relaxation. Modified from Sassone B et al, Americal Journal of Cardiology 2007 (100).

17 Methodology for measuring pulsed Tissue Doppler derived time to peak 5m and time to onset 5m (left panel). In the right panel measurements of time to peak Sm (upper panel) and of time to onset Sm (lower panel) are depicted. Am=Myocardial atrial velocity, CTm=Contraction time, Em=Myocardial early diastolic velocity, RTm=Myocardial relaxation time, Sm=Myocardial systolic velocity. Modified from Agler DA et al, Journal of the American Society of Echocardiography 2007 (20).

18 Methodology of calculation of Dyssynchrony Index and Is ability in predicting LV Inverse remodelling. In the upper panel methodology of calculation of Dyssynchrony Index, i.e., the standard deviation of Ts (Ts SD) measured in the basal and mid segments visualizable in the apical views. In the lower panel, Ts SD shows the ability to predict an effective LV inverse remodeling after CRT (lower panel). Values of TS SD>32.6 (black triangles) predict an effective LV reverse remodeling (DLVVs=delta left ventricular end systolic volumes) after CRT. Patients with pre CRT values of Ts SD<32.6 (empty circles) do not present significant LV inverse remodeling at follow up). Modified from Yu CM et al, American Journal of Cardiology 2003 (91).

19 Strain (%) of basal posterior septum and lateral wall in apical 4 chamber view. Lateral wall shows an abnormal relaxation (positive sign of its curve) during systole, with a motion that is opposite to that of the basal posterior septum. Galderisi M et al, Cardiovascular Ultrasound 2007 (5).

20 Speckle tracking imaging demonstrating synchrony of peak segmental radial strain in healthy individual (A) and severe dyssynchrony in patient with heart failure and left bundle branch block referred for resynchronization therapy (B). Gorcsan J et al, Journal of the American Society of Echocardiography 2008 (21).

21 Three dimensional echocardiographic assessment of segmental volume displacement in patient with normal synchrony (A) and with significant dyssynchrony (B). Gorcsan J et al, Journal of the American Society of Echocardiography 2008 (21).

22 STRAIN DELAY INDEX Moss AJ, Hall WJ, Cannom DS, et al. New England Journal of Medicine 2009 (361).

23 SEPTAL REBOUND STRETCH Ruschitzka F, Abraham WT, Singh JP, et al. New England Journal of Medicine 2013 (369).

24 DISCOORDINATION INDICES Tang AS, Wells GA, Talajic M, et al. New England Journal fo Medicine 2010 (363).

25 WHAT ELECTROPHYSIOLOGISTS WANT: DURING CRT

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27 SPECKLE TRACKING & ANTEROSEPTAL POSTERIOR WALL DELAY (ASPWD) Linde C, Abraham WT, Gold MR, et al. Journal of the American College of Cardiology 2008 (52).

28 AV DYSSYNCHRONY

29 RITTER S FORMULA Optimal AV Interval = AV long (QA short QA long) Melzer C, Borges AC, Knebel F, Rchter WS, Combs W, Gaumann G, Theres H. Cardiovascular Ultrasound 2004 (2).

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32 SUMMARY Cardiac resynchronization therapy is an established option for treatment of patients with congestive heart failure class II IV with dyssynchrony Echocardiography plays a pivotal in cardiac dyssynchrony therapy as in other field of cardiography

33 Before CRT: SUMMARY identify dyssynchrony and responders using the different echo indices During CRT: aid in lead placement After CRT: AV VV Optimization to improve LV filling and CO

34 SUMMARY With all the progress, better patient selection and improvement of response rate would not just remain a goal but will become a reality for us to better manage heart failure patients with dyssynchrony

35 THANK YOU JESUS LOVES YOU.

36 Echo

37 What OUTLINE

38 SPECKLE TRACKING Sipahi I, Carrigan TP, Rowland DY et al. Archives of Internal Medicine, 2011 (171).

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