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Smiseth OA, Russell K, Skulstad H. The role of echocardiography in quantification of left ventricular dyssynchrony: state of the art and future directions. Eur Heart J Cardiovasc Imaging 2011; 13:61-8. [DOI: 10.1093/ejechocard/jer243] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Edner M, Ring M, Henriksson P. Pre-implant right ventricular function might be an important predictor of the response to cardiac resynchronization therapy. Cardiovasc Ultrasound 2011; 9:28. [PMID: 22029550 PMCID: PMC3215970 DOI: 10.1186/1476-7120-9-28] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 10/26/2011] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Cardiac resynchronization therapy is proven efficacious in patients with heart failure (HF). Presence of biventricular HF is associated with a worse prognosis than having only left ventricular (LV) HF and pacing might deteriorate heart function. The aim of the study was to assess a possible significance of right ventricular (RV) pre-implant systolic function to predict response to CRT. DESIGN We studied 22 HF-patients aged 72 ± 11 years, QRS-duration 155 ± 20 ms and with an LV ejection fraction (EF) of 26 ± 6% before and four weeks after receiving a CRT-device. RESULTS There were no changes in LV diameters or end systolic volume (ESV) during the study. However, end diastolic volume (EDV) decreased from 226 ± 71 to 211 ± 64 ml (p = 0.02) and systolic maximal velocities (SMV) increased from 2.2 ± 0.4 to 2.6 ± 0.9 cm/s (p = 0.04). Pre-implant RV-SMV (6.2 ± 2.6 cm/s) predicted postoperative increase in LV contractility, p = 0.032. CONCLUSIONS Pre-implant decreased RV systolic function might be an important way to predict a poor response to CRT implicating that other treatments should be considered. Furthermore we found that 3D- echocardiography and Tissue Doppler Imaging were feasible to detect short-term changes in LV function.
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Affiliation(s)
- Magnus Edner
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
| | - Margareta Ring
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Peter Henriksson
- Karolinska Institutet, Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd Hospital, Stockholm, Sweden
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Johnson L, Lamia B, Kim HK, Tanabe M, Gorcsan J, Schwartzman D, Shroff SG, Pinsky MR. Physiological relevance of quantifying segmental contraction synchrony. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2011; 35:174-87. [PMID: 22017611 DOI: 10.1111/j.1540-8159.2011.03246.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Most current indices of synchrony quantify left ventricular (LV) contraction pattern in terms of a single, global (integrated) measure. We report the development and physiological relevance of a novel method to quantify LV segmental contraction synchrony. METHODS LV pressure-volume and echocardiographic data were collected in seven anesthetized, opened-chest dogs under several pacing modes: right atrial (RA) (control), right ventricular (RV) (dyssynchrony), and additional LV pacing at either apex (CRTa) or free wall (CRTf). Cross-correlation-based integrated (CCSI(int) ) and segmental (CCSI(seg) ) measures of synchrony were calculated from speckle-tracking derived radial strain, along with a commonly used index (maximum time delay). LV contractility was quantified using either E(es) (ESPVR slope) or ESPVR(area) (defined in the manuscript). RESULTS RV pacing decreased CCSI(int) at LV base (0.95 ± 0.02 [RA] vs 0.64 ± 0.14 [RV]; P < 0.05) and only CRTa improved it (0.93 ± 0.03; P < 0.05 vs RV). The CCSI(seg) analysis identified anteroseptal and septal segments as being responsible for the low CCSI(int) during RV pacing and inferior segment for poor resynchronization with CRTf. Changes in ESPVR(area) , and not in E(es) , indicated depressed LV contractility with RV pacing, an observation consistent with significantly decreased global LV performance (stroke work [SW]: 252 ± 23 [RA] vs 151 ± 24 [RV] mJ; P < 0.05). Only CRTa improved SW and contractility (SW: 240 ± 19 mJ; ESPVR(area) : 545 ± 175 mmHg•mL; both P < 0.01 vs RV). Only changes in CCSI(seg) and global LV contractility were strongly correlated (R(2) = 0.698, P = 0.005). CONCLUSION CCSI(seg) provided insights into the changes in LV integrated contraction pattern and a better link to global LV contractility changes.
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Affiliation(s)
- Lauren Johnson
- Cardiovascular Systems Laboratory, Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Faber L, Vlachojannis M, Oldenburg O, Hering D, Bogunovic N, Horstkotte D, Lamp B. Long-term follow-up of cardiac resynchronization therapy: mechanical resynchronization and reverse left ventricular remodeling are predictive for long-term transplant-free survival. Int J Cardiovasc Imaging 2011; 28:1341-50. [PMID: 21964638 DOI: 10.1007/s10554-011-9946-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 08/27/2011] [Indexed: 10/17/2022]
Abstract
We sought to determine whether correction of mechanical left ventricular (LV) dyssynchrony as defined by tissue Doppler imaging (TDI) is predictive for transplant-free long-term survival in patients (pts.) undergoing cardiac resynchronization therapy (CRT). In 76 CRT recipients TDI curves from the septal, lateral, anterior, and inferior basal LV were obtained at baseline and after 6 ± 4 months. A time difference between regional electromechanical delays (EMD) of ≥40 ms was considered dyssynchronous. At follow-up, pts. were classified as TDI-responders (TDI-R: dyssynchrony at baseline, corrected by CRT) versus non-responders (TDI-NR: either not dyssynchronous at baseline, or persisting dyssynchrony). Pts. were then followed by standard echocardiography over 21 ± 6 months and were re-classified as LV remodelers (LV-R: LV volume reduction of >10%) versus non-remodelers (LV-NR). The end-point during clinical long-term follow-up of 65 ± 38 months was all-cause mortality or heart transplantation. 44 out of the 76 pts. (58%) were classified as TDI-R, 32 (42%) as TDI-NR. Significant reverse LV remodeling was observed in 41 (54%) pts., while 35 (46%) did not improve LV size and function. TDI-R was associated with LV-R in 35 pts. (85%; P < 0.001). During long-term follow-up, 38 pts. (50%) reached the end point, 11 (30%) in the TDI-R group, and 27 (70%) in the TDI-NR group (P < 0.0003). Mechanical resynchronization as defined by TDI translates into a significant survival benefit in CRT recipients.
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Affiliation(s)
- Lothar Faber
- Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University Bochum, Georgstr. 11, 32545 Bad Oeynhausen, Germany.
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55
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Celikyurt U, Vural A, Sahin T, Kilic T, Agacdiken A, Ural D. Relationship between left ventricular dyssynchrony and reverse remodeling after cardiac resynchronization therapy. Clin Cardiol 2011; 34:645-8. [PMID: 21913208 DOI: 10.1002/clc.20941] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2011] [Accepted: 06/15/2011] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) is recommended for patients with advanced chronic heart failure. The presence of left ventricular (LV) dyssynchrony before CRT is an important predictor of response to the therapy. We aimed to investigate time course of LV dyssynchrony after CRT and the relationship between LV dyssynchrony improvement and reverse remodeling (RR). HYPOTHESIS The relationship between the improvement of LV dyssynchrony and RR may differ according to criteria used to determine RR. METHODS Thirty patients with advanced heart failure, wide QRS complex, and LVEF ≤35% were included. Echocardiography coupled with tissue Doppler imaging was performed at baseline, and repeated at 1 and 6 months in follow-up. Patients were divided into RR and no-remodeling groups according to 10% decrease in left ventricular end-systolic volume (LVESV) and/or 25% increase in LVEF. RESULTS Left ventricular dyssynchrony improvement was significant at the first month in both the RR and no-remodeling groups according to LVESV decrease. Left ventricular dyssynchrony improvement was continued in the RR group; however, it did not improve significantly in the no-remodeling group. Left ventricular dyssynchrony improvement was significant at the first and sixth month in the RR and no-remodeling groups according to LVEF increase. CONCLUSIONS Our study suggests that LV dyssynchrony improvement plays an important role in the development of RR according to decrease in LVESV. Reverse remodeling according to the increase in LVEF was developed independently from LV dyssynchrony improvement. The improvement in LV dyssynchrony is a necessary but not sufficient explanation for improvement in LVEF and LVESV.
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Affiliation(s)
- Umut Celikyurt
- Department of Cardiology, Kocaeli University Medical Faculty, Kocaeli, Turkey.
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Echocardiographic prediction of outcome after cardiac resynchronization therapy: conventional methods and recent developments. Heart Fail Rev 2011; 16:235-50. [PMID: 21104122 PMCID: PMC3074077 DOI: 10.1007/s10741-010-9200-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Echocardiography plays an important role in patient assessment before cardiac resynchronization therapy (CRT) and can monitor many of its mechanical effects in heart failure patients. Encouraged by the highly variable individual response observed in the major CRT trials, echocardiography-based measurements of mechanical dyssynchrony have been extensively investigated with the aim of improving response prediction and CRT delivery. Despite recent setbacks, these techniques have continued to develop in order to overcome some of their initial flaws and limitations. This review discusses the concepts and rationale of the available echocardiographic techniques, highlighting newer quantification methods and discussing some of the unsolved issues that need to be addressed.
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Kindermann M, Mahfoud F, Ukena C, Fröhlig G. [Cardiac resynchronization therapy: preoperative screening. How can we reliably predict response to CRT?]. Herzschrittmacherther Elektrophysiol 2011; 20:131-42. [PMID: 19672672 DOI: 10.1007/s00399-009-0053-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established therapy for patients with advanced heart failure, depressed left ventricular function, and wide QRS complex. However, about 30 to 45% of patients do not respond to CRT. Assuming that the main therapeutic action of CRT is the correction of dyssynchronous myocardial contraction, a plethora of echocardiographic dyssynchrony parameters have been proposed to improve the prediction of response to CRT. However, one multicenter study has recently questioned the utility of any of these indexes. This review delineates the various causes of non-response to CRT, explains the different levels and mechanisms of dyssynchrony and gives a critical overview of currently available echocardiographic techniques for assessment of dyssynchrony. Based upon a discussion of the evidence coming from randomized multicenter studies and against the background of national and international cardiac societies' guideline recommendations on CRT, a rational basis for the evaluation of patients for CRT is proposed.
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Affiliation(s)
- M Kindermann
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 100, 66421, Homburg/Saar, Deutschland.
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Gorcsan J, Yu CM, Sanderson JE. Ventricular resynchronization is the principle mechanism of benefit with cardiac resynchronization therapy. Heart Fail Rev 2011; 17:737-46. [DOI: 10.1007/s10741-011-9274-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Serdoz LV, Daleffe E, Merlo M, Zecchin M, Barbati G, Pecora D, Pinamonti B, Fantoni C, Lupo P, Di Lenarda A, Sinagra G, Cappato R. Predictors for restoration of normal left ventricular function in response to cardiac resynchronization therapy measured at time of implantation. Am J Cardiol 2011; 108:75-80. [PMID: 21529746 DOI: 10.1016/j.amjcard.2011.02.347] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 02/16/2011] [Accepted: 02/16/2011] [Indexed: 11/25/2022]
Abstract
There are no parameters predicting the individual probability of "full response" to cardiac resynchronization therapy (CRT). The aim of this work was to find prognostic factors of full clinical and echocardiographic responses (i.e., ≥50% left ventricular ejection fraction [LVEF] and New York Heart Association class I) after 1 year of CRT. This was a prospective follow-up study that involved 2 hospitals. Patients (n = 75) with advanced heart failure (64 ± 9 years of age, 87% men, LVEF 24 ± 7%) who received CRT were followed for 17 ± 9 months. Univariate and multivariate regression analyses were used to identify predictors of full CRT response. A nomogram predicting the individual probability of full CRT response during follow-up was calculated. There were 13 patients with restoration of normal LVEF versus 62 without (mean LVEF 56% ± 5% vs 31% ± 8%, respectively, p <0.001). Predictors of full response included cause of heart disease, baseline QRS width, and degree of QRS shortening in response to CRT. Patients with nonischemic heart disease, baseline QRS width ≤150 ms, and QRS shortening ≥40 ms in response to CRT had a >75% probability of restoration of normal LVEF. In conclusion, our nomogram using a combination of cause, baseline QRS width, and degree of QRS shortening in response to CRT allows assessment of individual probability of full response. This observation awaits further confirmation from larger series.
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Vitarelli A, Franciosa P, Nguyen BL, Capotosto L, Ciccaglioni A, Conde Y, Iorio G, De Curtis G, Caranci F, Vitarelli M, Lucchetti P, Dettori O, De Cicco V. Additive Value of Right Ventricular Dyssynchrony Indexes in Predicting the Success of Cardiac Resynchronization Therapy: A Speckle-Tracking Imaging Study. J Card Fail 2011; 17:392-402. [DOI: 10.1016/j.cardfail.2010.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Revised: 11/24/2010] [Accepted: 12/22/2010] [Indexed: 10/18/2022]
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Vichova Z, Hénaine R, Basto Duarte M, Lehot JJ, Cannesson M. Impact of biventricular and left ventricular pacing on hemodynamics and left ventricular dyssynchrony compared with right ventricular pacing in the early postoperative period following cardiac surgery. ACTA ACUST UNITED AC 2011; 30:403-9. [DOI: 10.1016/j.annfar.2011.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Accepted: 02/09/2011] [Indexed: 11/27/2022]
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Dependency of Cardiac Resynchronization Therapy on Myocardial Viability at the LV Lead Position. JACC Cardiovasc Imaging 2011; 4:366-74. [DOI: 10.1016/j.jcmg.2011.01.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2010] [Revised: 01/03/2011] [Accepted: 01/07/2011] [Indexed: 11/24/2022]
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Heinke M, Ismer B, Kühnert H, Figulla HR. Transesophageal left ventricular electrogram-recording and temporary pacing to improve patient selection for cardiac resynchronization. Med Biol Eng Comput 2011; 49:851-8. [PMID: 21448690 DOI: 10.1007/s11517-011-0767-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 03/14/2011] [Indexed: 10/18/2022]
Abstract
Cardiac resynchronization therapy (CRT) with biventricular pacing (BV) is an established therapy for heart failure (HF) patients with inter- and intraventricular conduction delay. The aim of this pilot study was to test the feasibility of both transesophageal measurement of left ventricular (LV) electrical delay and transesophageal LV pacing prior to implantation, to better select patients for CRT. Esophageal TO8 Osypka catheter was perorally applied in 30 HF patients in position of maximum LV deflection to measure LV electrical delay and to study arterial pulse pressure (PP) during transesophageal bipolar LV pacing. There were 15 responders with a PP increase of a mean 65 ± 24 mmHg to 79 ± 27 mmHg (P < 0.001) and a mean LV electrical delay of 86.8 ± 33 ms. The 15 non-responders with poor PP increase of a mean 63.5 ± 23.5 mmHg to 64.1 ± 23.9 mmHg (P = 0.065) had a significantly smaller LV electrical delay of 36 ± 21 ms (P < 0.001). During a 34 ± 26 month CRT follow-up, the responders New York Heart Association (NYHA) class improved from 3.1 ± 0.35 to 2.1 ± 0.35 (P < 0.001). Determination of left ventricular electrical delay by transesophageal electrogram recording and transesophageal left ventricular pacing may be additional useful techniques to improve patient selection for CRT.
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Affiliation(s)
- Matthias Heinke
- Division of Cardiology, Department of Internal Medicine I, Friedrich Schiller University of Jena, Erlanger Allee 101, 07740 Jena, Germany.
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Seo Y, Ito H, Nakatani S, Takami M, Naito S, Shiga T, Ando K, Wakayama Y, Aonuma K. The role of echocardiography in predicting responders to cardiac resynchronization therapy. Circ J 2011; 75:1156-63. [PMID: 21383516 DOI: 10.1253/circj.cj-10-0861] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This multicenter prospective cohort study aimed to identify both ability of echocardiographic parameters to detect cardiac resynchronization therapy (CRT) volume responders and relation of these parameters with clinical outcomes. METHODS AND RESULTS CRT responder was defined as ≥ 15% reduction of left ventricular (LV) end-systolic volume at 6 months. Seven echocardiographic dyssynchrony parameters were evaluated. The clinical endpoint comprised time to death from any cause or unplanned hospitalization for a major cardiovascular event. Of the 217 patients enrolled, 63 percent were classified as volume responders, in whom significantly fewer events occurred than in non-responders (log rank, P < 0.001). No single echocardiographic criterion had significant power to detect volume responders, but a combining measurement of dyssynchrony between septum and LV free wall with M-mode and tissue Doppler imaging was independently associated with volume responders. In addition, this combined parameter was associated with the endpoint (hazard ratio, 0.66, 95% confidence interval 0.30-0.98, P = 0.04). In contrast, left bundle branch block was identified as an independent predictor of volume responders and more strongly associated with the endpoint (hazard ratio, 0.38, 95% confidence interval 0.20-0.72, P = 0.003). CONCLUSIONS Echocardiographic parameters did not show significant power to detect CRT responders independently.
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Affiliation(s)
- Yoshihiro Seo
- Cardiovascular Division, Institute of Clinical Medicine, Graduate School of Comprehensive Human Science, University of Tsukuba, Tsukuba, Japan
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Kalogeropoulos A, Savoye LP, Georgiopoulou V, Raj L, Lloyd MS, Chiladakis J, Lerakis S, Alexopoulos D, Butler J. Long-term response of the left ventricle to cardiac resynchronization therapy: insights from standard and strain echocardiography. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2011; 17:71-79. [PMID: 21449995 DOI: 10.1111/j.1751-7133.2011.00212.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Left ventricular (LV) response to cardiac resynchronization therapy (CRT) has typically been studied over 3- to 12-month periods. Longer-term data are unclear and response of strain parameters has not been reported. The authors evaluated long-term response with standard and strain echocardiography in 57 patients (52±15 years; 40 male; 30 white; 15 with ischemic etiology) who received a CRT-defibrillator between January 2004 and December 2005. Median ejection fraction (EF) at baseline was 22% (17%-25%). Global longitudinal, radial, and circumferential strain were -6.5% (-5.0% to -8.4%), 10.4% (6.9%-15.1%), and -7.6% (-5.5% to -10.8%), respectively. After a median of 42 months, EF increased by 5% (-1% to 15%; P<.001), with improvements in circumferential (-3.2% [-5.2% to 1.5%]; P=.001), longitudinal (-0.5% [-3.4% to 1.2%]; P=.035), and radial (1.4% [-1.1% to 9.2%]; P=.035) strain. Changes in volumes were nonsignificant. EF improvement ≥5% was observed in 29 patients (50.9%). Relative improvement ≥15% in longitudinal, radial, and circumferential strain was observed in 26 (45.6%), 29 (50.9%), and 37 (64.9%) patients, respectively. Improvement in longitudinal strain and EF was strongly associated with lower rates of heart failure-related and all-cause readmissions. A wide range of long-term LV responses to CRT was observed, with approximately 50% of patients showing favorable responses.
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Affiliation(s)
- Andreas Kalogeropoulos
- Emory Clinical Cardiovascular Research Institute, 1462 Clifton Road NE, Atlanta, GA 30322, USA.
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Bae BS, Kim KJ, Park JG, Jung YS, Ryu HJ, Kang HJ, Lee BR, Jung BC. Improvement in left ventricular systolic dyssynchrony in hypertensive patients after treatment of hypertension. Korean Circ J 2011; 41:16-22. [PMID: 21359064 PMCID: PMC3040398 DOI: 10.4070/kcj.2011.41.1.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 05/31/2010] [Accepted: 06/21/2010] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Left ventricular (LV) dyssynchrony has been commonly detected among hypertensive patients with normal LV systolic function and no evidence of congestive heart failure. The purpose of our study was to assess the changes in LV systolic dyssynchrony (SDS(LV)) among hypertensive patients after antihypertensive treatment, and to determine the relationship between SDS(LV) and other conventional echocardiographic parameters. SUBJECTS AND METHODS Forty one hypertensive patients with normal LV ejection fraction were enrolled. By performing a conventional echocardiographic study, the SDS(LV) was measured as the time difference between the shortest and longest time of the peak myocardial systolic velocities among 12 segments of the basal and mid-levels of the 3 apical views, and radial dyssynchrony of the basal (RDS(base)) and mid-levels (RDS(mid)) measured as the time difference between the earliest and latest peak values on the radial strain curves of each level of the parasternal short-axis views. RESULTS Compared to baseline after six months of antihypertensive treatment, the SDS(LV) improved significantly (48.7±37.9 ms vs. 29.5±34.1 ms, p=0.020). Also the RDS(base) and RDS(mid) improved significantly in respect to the baseline values (129.9±136.3 ms vs. 38.8±45.4 ms, p=0.002 and 75.2±63.8 ms vs. 28.2±37.7 ms, respectively, p<0.001). CONCLUSION The severity of SDS(LV) improved with antihypertensive treatment, and was associated with the regression of LV mass. Furthermore, it might precede improvement in the mitral inflow pattern, as assessed by conventional echocardiography, so that early detection of the benefit of antihypertensive treatment may be possible.
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Affiliation(s)
- Byung Seok Bae
- Department of Cardiology, Fatima General Hospital, Daegu, Korea
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Ghosh S, Silva JNA, Canham RM, Bowman TM, Zhang J, Rhee EK, Woodard PK, Rudy Y. Electrophysiologic substrate and intraventricular left ventricular dyssynchrony in nonischemic heart failure patients undergoing cardiac resynchronization therapy. Heart Rhythm 2011; 8:692-9. [PMID: 21232630 DOI: 10.1016/j.hrthm.2011.01.017] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 01/07/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Electrocardiographic imaging (ECGI) is a method for noninvasive epicardial electrophysiologic mapping. ECGI previously has been used to characterize the electrophysiologic substrate and electrical synchrony in a very heterogeneous group of patients with varying degrees of coronary disease and ischemic cardiomyopathy. OBJECTIVE The purpose of this study was to characterize the left ventricular electrophysiologic substrate and electrical dyssynchrony using ECGI in a homogeneous group of nonischemic cardiomyopathy patients who were previously implanted with a cardiac resynchronization therapy (CRT) device. METHODS ECGI was performed during different rhythms in 25 patients by programming their devices to biventricular pacing, single-chamber (left ventricular or right ventricular) pacing, and native rhythm. The electrical dyssynchrony index (ED) was computed as the standard deviation of activation times at 500 sites on the LV epicardium. RESULTS In all patients, native rhythm activation was characterized by lines of conduction block in a region with steep activation-recovery interval (ARI) gradients between the epicardial aspect of the septum and LV lateral wall. A native QRS duration (QRSd) >130 ms was associated with high ED (≥30 ms), whereas QRSd <130 ms was associated with minimal (25 ms) to large (40 ms) ED. CRT responders had very high dyssynchrony (ED = 35.5 ± 3.9 ms) in native rhythm, which was significantly lowered (ED = 23.2 ± 4.4 ms) during CRT. All four nonresponders in the study did not show significant difference in ED between native and CRT rhythms. CONCLUSION The electrophysiologic substrate in nonischemic cardiomyopathy is consistent among all patients, with steep ARI gradients co-localizing with conduction block lines between the epicardial aspect of the septum and the LV lateral wall. QRSd wider than 130 ms is indicative of substantial LV electrical dyssynchrony; however, among patients with QRSd <130 ms, LV dyssynchrony may vary widely.
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Affiliation(s)
- Subham Ghosh
- Cardiac Bioelectricity and Arrhythmia Center (CBAC), Washington University, St. Louis, Missouri 63130-4899, USA
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Chaudhry FA, Shah A, Bangalore S, DeRose J, Steinberg JS. Inotropic Contractile Reserve and Response to Cardiac Resynchronization Therapy in Patients with Markedly Remodeled Left Ventricle. J Am Soc Echocardiogr 2011; 24:91-7. [DOI: 10.1016/j.echo.2010.10.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2009] [Indexed: 01/24/2023]
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Artis NJ, Oxborough DL, Birch KM, Williams G, Tan LB, Pepper CB. Short-Axis 2D Strain from Speckle Tracking Predicts Echocardiographic Response to Cardiac Resynchronization Therapy. Echocardiography 2010; 28:76-84. [DOI: 10.1111/j.1540-8175.2010.01276.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Turschner O, Ritscher G, Simon H, Rittger H, Brachmann J, Sinha AM. Criteria for patient selection in cardiac resynchronization therapy. Future Cardiol 2010; 6:871-80. [PMID: 21142642 DOI: 10.2217/fca.10.100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Since the implementation of cardiac resynchronization therapy (CRT) the prognosis of patients with severe heart failure has been improved owing to a reduction in morbidity and mortality rates, as several multicenter trials have shown. However, several patients treated by CRT still lack improvement or even deteriorate during therapy. In some of them, this might be due to the severity and progression of chronic heart failure. In others, the criteria for the indication of CRT and/or optimized device programming might have not been met. Thus, one important option to improve CRT outcome is to improve CRT patient selection. A lot of publications describing various methods identifying a positive or negative prediction of CRT have been released. In summary, decision making based on all these partly contradictory publications indicate a strong need for guidelines for the use of such expensive therapy. The purpose of this article is to give an overview of CRT and summarize the different methods and the limitations of CRT patient selection parameters. With the focus of the different guidelines, this article tries to give an appropriate overview and aid decision making in CRT patients, including a short view of possible new indications.
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Affiliation(s)
- Oliver Turschner
- Department of Cardiology, Klinikum Coburg, Germany, Medizinische Klinik II, Klinikum Coburg, Ketschendorfer Str. 33, 96450 Coburg, Germany
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Okutucu S, Aytemir K, Evranos B, Aksoy H, Sabanov C, Karakulak UN, Kaya EB, Kabakci G, Tokgozoglu L, Ozkutlu H, Oto A. Cardiac resynchronization therapy improves exercise heart rate recovery in patients with heart failure. Europace 2010; 13:526-32. [PMID: 21076146 DOI: 10.1093/europace/euq410] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
AIMS Heart rate (HR) recovery (HRR), defined as the rate of decline in the HR immediately following the cessation of exercise, is influenced by autonomic function. Heart rate recovery in heart failure (HF) has been shown to correlate with severity of HF. Cardiac resynchronization therapy (CRT) improves cardiac autonomic functions in HF. We aimed to evaluate the effects of CRT on cardiac autonomic function assessed by HRR. METHODS AND RESULTS Forty-eight patients [62.3 ± 10.7 years; 37 men; left ventricular (LV) ejection fraction 24.8 ± 4.1%] with HF were enrolled. A treadmill exercise testing was conducted in all patients by using a modified Naughton protocol before and 6 months after CRT. Heart rate recovery indices were calculated by subtracting first, second, and third minute HR from the maximal HR and designated as HRR1, HRR2, and HRR3, respectively. Standard echocardiography was performed before and 6 months after CRT. Left ventricular reverse remodelling (LVRM) was quantified as the percentage of decline in the LV end-systolic volume after CRT. Mean HRR1 (13.0 ± 5.9 vs. 17.9 ± 8.9 b.p.m., P = 0.001), HRR2 (20.5 ± 9.3 vs. 23.8 ± 11.3 b.p.m., P = 0.001), and HRR3 (25.7 ± 11.1 vs. 29.2 ± 12.0 b.p.m., P = 0.001) values improved 6 months after CRT. Pearson's analyses revealed a good positive correlation between LVRM and ΔHRR1 (r = 0.642, P = 0.001) and a moderate correlation between reduction LVRM and ΔHRR2 (r = 0.591, P = 0.033) and ΔHRR3 (r = 0.436, P = 0.001). CONCLUSION Cardiac resynchronization therapy favourably alters the cardiac autonomic functions. Heart rate recovery indices improved after CRT and the degree of improvement in HRR indices correlated with LVRM.
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Affiliation(s)
- Sercan Okutucu
- Department of Cardiology, Hacettepe University Faculty of Medicine, Sihhiye/Ankara, Ankara 06100, Turkey.
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Palmieri V, Russo C, Buonomo A, Cimmino G, Tartaglione D, Pezzullo S, Celentano A. Test–re-test reproducibility of Doppler echocardiography for assessment of electromechanical dyssynchrony: Implications for heart failure clinic. J Cardiol 2010; 56:271-9. [DOI: 10.1016/j.jjcc.2010.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2010] [Revised: 05/03/2010] [Accepted: 06/10/2010] [Indexed: 11/17/2022]
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Lalonde M, Birnie D, Ruddy TD, deKemp RA, Wassenaar RW. SPECT blood pool phase analysis can accurately and reproducibly quantify mechanical dyssynchrony. J Nucl Cardiol 2010; 17:803-10. [PMID: 20428986 DOI: 10.1007/s12350-010-9231-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 04/06/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Phase analysis of SPECT blood pool imaging has the potential to assess mechanical dyssynchrony (MD). However, wall motion of the left ventricle (LV) from SPECT images can be based on either time-activity or time-distance curves. In this paper, these two techniques were compared using receiver-operator characteristics (ROC) analysis at detecting MD patients from a population of normal subjects. METHODS SPECT phase analysis was performed on 48 normal subjects (LVEF > 55%, normal wall motion, QRS < 120 ms), and 55 MD patients (LVEF < 35%, QRS > 120 ms). ROC analysis was individually performed on each of three phase parameters (phase standard deviation, synchrony, and entropy) for each LV wall motion technique. ROC area differences were assessed using the Student t-test. Intra- and inter-observer reproducibilities were investigated using regression analysis. RESULTS Time-activity-based phase analysis produced excellent ROC areas of .93 or better for all three phase parameters. The time-distance techniques produced significantly (P < .05) lower ROC areas in the range of .53-.76. Time-activity-based phase analysis had excellent intra- and inter-observer reproducibility with correlation coefficients >.96, compared to values of ~.85 for the time-distance methods. CONCLUSION SPECT time-activity-based phase analysis had excellent sensitivity and specificity at detecting MD patients with very high intra- and inter-observer reproducibility.
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Affiliation(s)
- Michel Lalonde
- Department of Physics, Carleton University, Ottawa, ON, Canada
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AKSOY HAKAN, OKUTUCU SERCAN, AYTEMIR KUDRET, KAYA ERGUNBARIS, TULUMEN EROL, EVRANOS BANU, FATIHOGLU SEFIKGÖRKEM, KABAKCI GIRAY, TOKGOZOGLU LALE, OZKUTLU HILMI, OTO ALI. Improvement in Right Ventricular Systolic Function after Cardiac Resynchronization Therapy Correlates with Left Ventricular Reverse Remodeling. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 34:200-7. [DOI: 10.1111/j.1540-8159.2010.02919.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tamaki S, Sakata Y, Mano T, Ohtani T, Takeda Y, Kamimura D, Omori Y, Yamamoto K. Long-term β-blocker therapy improves diastolic function even without the therapeutic effect on systolic function in patients with reduced ejection fraction. J Cardiol 2010; 56:176-82. [DOI: 10.1016/j.jjcc.2010.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2010] [Revised: 03/08/2010] [Accepted: 04/12/2010] [Indexed: 11/30/2022]
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Aksoy H, Okutucu S, Kaya EB, Deveci OS, Evranos B, Aytemir K, Kabakci G, Tokgozoglu L, Ozkutlu H, Oto A. Clinical and echocardiographic correlates of improvement in left ventricular diastolic function after cardiac resynchronization therapy. Europace 2010; 12:1256-1261. [DOI: 10.1093/europace/euq150] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Shen X, Aronow WS, Anand K, Nair CK, Holmberg MJ, Hee T, Maciejewski S, Esterbrooks DJ. Evaluation of left ventricular dyssynchrony using combined pulsed wave and tissue Doppler imaging. Arch Med Sci 2010; 6:519-25. [PMID: 22371794 PMCID: PMC3284065 DOI: 10.5114/aoms.2010.14462] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Revised: 11/15/2008] [Accepted: 12/28/2008] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION The combination of pulsed wave (PW) and tissue Doppler imaging (TDI) has been proposed as a new method to assess left ventricular (LV) mechanical dyssynchrony (LVMD), but results have not been validated. We investigated the correlation of a combination of PW and TDI with a positive response to cardiac resynchronization therapy (CRT). MATERIAL AND METHODS We studied 108 consecutive patients who received CRT. Patients with atrial fibrillation were excluded. The time difference (T(PW-TDI)) between onset of QRS to the end of LV ejection by PW (T(PW)) and onset of QRS to the end of the systolic wave in LV basal segments with greatest delay by TDI (T(TDI)) was measured before CRT and during short-term and long-term follow-up. RESULTS The T(PW-TDI) interval before CRT was 74 ±48 ms. Intra-observer variabilities for T(PW) and T(TDI) were 1.5 ±0.24% and 1 ±0.17%. Inter-observer variabilities for T(PW) and T(TDI) were 1 ±0.36% and 1 ±0.64%, respectively. T(PW-TDI) > 50 ms was defined as the cutoff value for diagnosis of LVMD by receiver operating curve (ROC) analysis. During follow-up of 15 ±11 months, the sensitivity and specificity of TP(PW-TDI) to predict a positive response to CRT were 98% and 82%, respectively. The area under the ROC curve was 0.92. There was a significant agreement between LVMD determined by T(PW-TDI) and the positive response to CRT (κ=0.80). CONCLUSIONS Left vertricular dyssynchrony detected by the method combining PW and TDI demonstrated a high reproducibility, sensitivity, specificity and agreement with a positive response to CRT.
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Affiliation(s)
- Xuedong Shen
- Cardiac Center of Creighton, University School of Medicine, Omaha, USA
| | | | - Kishlay Anand
- Cardiac Center of Creighton, University School of Medicine, Omaha, USA
| | - Chandra K. Nair
- Cardiac Center of Creighton, University School of Medicine, Omaha, USA
| | - Mark J. Holmberg
- Cardiac Center of Creighton, University School of Medicine, Omaha, USA
| | - Tom Hee
- Cardiac Center of Creighton, University School of Medicine, Omaha, USA
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van Bommel RJ, Borleffs CJW, Ypenburg C, Marsan NA, Delgado V, Bertini M, van der Wall EE, Schalij MJ, Bax JJ. Morbidity and mortality in heart failure patients treated with cardiac resynchronization therapy: influence of pre-implantation characteristics on long-term outcome. Eur Heart J 2010; 31:2783-90. [PMID: 20693544 DOI: 10.1093/eurheartj/ehq252] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Cardiac resynchronization therapy (CRT) improves cardiac function, heart failure symptoms, and prognosis in selected patients. Many baseline characteristics associated with heart failure may influence prognosis after CRT. The objective of this study was to evaluate the effect of several baseline characteristics in relation to long-term prognosis in heart failure patients treated with CRT. METHODS AND RESULTS A total of 716 consecutive heart failure patients treated with CRT were included in an observational registry. All available data, including clinical and echocardiographic measurements, were analysed in relation to two endpoints: all-cause mortality and a combined endpoint of all-cause mortality or major cardiovascular event. Outcome data were collected by chart review, device interrogation, and telephone contact. Mean follow-up was 25 ± 19 months. During follow-up, 141 patients (20%) died (primary endpoint). Most of these patients (61%) died due to worsening heart failure. A total of 214 patients (30%) reached the secondary endpoint. Larger left ventricular end-systolic volume, less distance covered in the 6 min walking test, poor renal function, more severe heart failure, male gender, presence of atrial fibrillation, no posterolateral left ventricular (LV) lead, and no LV dyssynchrony were associated with poor prognosis after CRT. CONCLUSION In this large single-centre registry, several baseline clinical and echocardiographic characteristics were associated with prognosis after CRT. Worsening heart failure was the main cause of death in heart failure patients treated with CRT.
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Affiliation(s)
- Rutger J van Bommel
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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Zucchelli G, Soldati E, Di Cori A, De Lucia R, Segreti L, Solarino G, Borelli G, Di Bello V, Bongiorni MG. Role of intraoperative electrical parameters in predicting reverse remodelling after cardiac resynchronization therapy and correlation with interventricular mechanical dyssynchrony. Europace 2010; 12:1453-9. [DOI: 10.1093/europace/euq267] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Porciani MC, Cappelli F, Perrotta L, Chiostri M, Rao CM, Pieragnoli P, Ricciardi G, Michelucci A, Jelic S, Padeletti L. Has Mechanical Dyssynchrony Still a Role in Predicting Cardiac Resynchronization Therapy Response? Echocardiography 2010; 27:831-8. [DOI: 10.1111/j.1540-8175.2009.01133.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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Rafique AM, Thomas Peter C, Naqvi TZ. A revised approach to patient selection for cardiac resynchronization treatment using multiple asynchrony parameters in Narrow- and Wide-QRS cardiomyopathy causes cardiac reverse remodelling: a single centre non-randomized prospective study. Europace 2010; 12:1127-35. [DOI: 10.1093/europace/euq136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Reant P, Zaroui A, Donal E, Mignot A, Bordachar P, Deplagne A, Solnon A, Ritter P, Daubert JC, Clementy J, Leclercq C, Roudaut R, Habib G, Lafitte S. Identification and characterization of super-responders after cardiac resynchronization therapy. Am J Cardiol 2010; 105:1327-35. [PMID: 20403487 DOI: 10.1016/j.amjcard.2009.12.058] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 12/04/2009] [Accepted: 12/04/2009] [Indexed: 11/25/2022]
Abstract
Cardiac resynchronization therapy (CRT) has been shown to induce a spectacular effect on left ventricular (LV) function in certain patients. Our aim was to analyze and characterize the super-responders (SRs) to CRT using echocardiography in 186 patients with a conventional indication according to the European Society Cardiology guidelines. The investigation took place before and 6 months after implantation. CRT-SRs were defined by an improvement of the New York Heart Association functional class and LV ejection fraction to > or = 50% in absolute values associated with a relative LV end-systolic volume reduction of > or = 15%. Of the 186 patients, 18 (9.7%) were identified as CRT-SRs and had a significantly lower prevalence of ischemic etiology (11%), lower LV dimensions, lower left atrial volume, and greater global longitudinal strain at baseline. Receiver operating characteristics curves identified global longitudinal strain as the strongest parameter for predicting CRT-SRs, with a cutoff value of -12% (area under the curve 0.87, sensitivity 71%, and specificity 85%, p <0.01). In conclusion, in the present retrospective study, only a left atrial volume <55 ml and global longitudinal strain < or = -12% were independent predictors of CRT-SRs.
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83
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Edner M, Ring M, Särev T. Sequential biventricular pacing improves regional contractility, longitudinal function and dyssynchrony in patients with heart failure and prolonged QRS. Cardiovasc Ultrasound 2010; 8:12. [PMID: 20384995 PMCID: PMC2868788 DOI: 10.1186/1476-7120-8-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Accepted: 04/12/2010] [Indexed: 11/10/2022] Open
Abstract
AIMS Biventricular pacing (BiP) is an effective treatment in systolic heart failure (HF) patients with prolonged QRS. However, approximately 35% of the patients receiving BiP are classified as non-responders. The aim of this study is to evaluate the acute effects of VV-optimization on systolic heart function. METHODS Twenty-one HF patients aged 72 (46-88) years, QRS 154 (120-190) ms, were studied with echocardiography, Tissue Doppler Imaging (TDI) and 3D-echo the first day after receiving a BiP device. TDI was performed; during simultaneous pacing (LV-lead pacing 4 ms before the RV-lead) and during sequential pacing (LV 20 and 40 ms before RV and RV 20 and 40 ms before LV-lead pacing). Systolic heart function was studied by tissue tracking (TT) for longitudinal function and systolic maximal velocity (SMV) for regional contractility and signs of dyssynchrony assessed by time-delays standard deviation of aortic valve opening to SMV, AVO-SMV/SD and tissue synchronization imaging (TSI). RESULTS The TT mean value preoperatively was 4.2 +/- 1.5 and increased at simultaneous pacing to 5.0 +/- 1.2 mm (p < 0.05), and at best VV-interval to 5.4 +/- 1.2 (p < 0.001). Simultaneous pacing achieved better TT distance compared with preoperative in 16 patients (76%). However, it was still higher after VV-optimization in 12 patients 57%. Corresponding figures for SMV were 3.0 +/- 0.7, 3.5 +/- 0.8 (p < 0,01), and 3.6 +/- 0.8 (p < 0.001). Also dyssynchrony improved. CONCLUSIONS VV-optimization in the acute phase improves systolic heart function more than simultaneous BiP pacing. Long-term effects should be evaluated in prospective randomized trials.
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Affiliation(s)
- Magnus Edner
- Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Stockholm, Sweden.
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Quantifying the role of regional dyssynchrony on global left ventricular performance. JACC Cardiovasc Imaging 2010; 2:1350-6. [PMID: 20083067 DOI: 10.1016/j.jcmg.2009.07.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2009] [Revised: 07/23/2009] [Accepted: 07/28/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVES We hypothesize that left ventricular (LV) segmental dyssynchrony, quantified by paradoxical systolic wall thinning, determines changes in global LV performance in a model of canine right ventricular (RV) pacing-induced dyssynchrony and the response to cardiac resynchronization therapy (CRT). BACKGROUND Quantification of LV dyssynchrony is important to assess the impact of CRT. METHODS Seven pentobarbital-anesthetized open-chest dogs had LV pressure-volume relations and mid-LV short-axis echocardiographic speckle tracking radial strain imaging during right atrial (RA) pacing, RV pacing to simulate left bundle branch block, and CRT using RV pacing plus either LV free-wall (CRTfw) and apical (CRTa) pacing. The area under the segmental LV time-radial strain positive and negative curves defined global thickening and thinning, respectively. Dyssynchrony was defined as the maximum time difference between earliest and latest peak segmental positive strain among 6 radial sites. RESULTS RA pacing had minimal dyssynchrony (58 + or - 40 ms). RV pacing induced both dyssynchrony (213 + or - 67 ms, p < 0.05) and reduced LV stroke work (SW) (67 + or - 51 mJ, p < 0.05). CRTfw and CRTa decreased dyssynchrony (116 + or - 47 ms and 50 + or - 34 ms, respectively, p < 0.05 vs. RV pacing), but only CRTa restored LV SW to RA pacing levels. RV pacing decreased global thickening (129 + or - 87%.ms) compared with RA pacing (258 + or - 133%.ms, p < 0.05), whereas CRTfw and CRTa restored regional thickening to RA pacing levels (194 + or - 83%.ms and 230 + or - 76%.ms, respectively). The sum of thickening and thinning during RV (230 + or - 88%.ms vs. 258 + or - 133%.ms, p < 0.05) correlated (r = 0.98) with RA thickening, suggesting that all the loss of LV function was due to thinning. CONCLUSIONS Dyssynchrony causes proportional changes in regional LV wall thinning and global LV SW that were reversed by CRT, suggesting that dyssynchrony impairs LV systolic function by causing paradoxical regional wall thinning and that CRT effectiveness can be monitored by its reversal. Thus, monitoring paradoxical regional thinning reversal may be used to define CRT effectiveness.
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Carerj S, Raffa S, Martiniello AR, Leto A, Scandura S, Capasso F, La Carrubba S, Citro R, Izzo A, Mangano S, Zito C, Penco M, Caso P. Ventricular Mechanical Asynchrony in Patients with Different Degrees of Systolic Dysfunction: Results from AVE Registry by the Italian Society of Cardiovascular Echography (SIEC). Echocardiography 2010; 27:110-6. [DOI: 10.1111/j.1540-8175.2009.00995.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Han Y, Chan J, Haber I, Peters DC, Zimetbaum PJ, Manning WJ, Yeon SB. Circumferential myocardial strain in cardiomyopathy with and without left bundle branch block. J Cardiovasc Magn Reson 2010; 12:2. [PMID: 20047696 PMCID: PMC2806866 DOI: 10.1186/1532-429x-12-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 01/05/2010] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has been shown to decrease mortality in 60-70% of advanced heart failure patients with left bundle branch block (LBBB) and QRS duration > 120 ms. There have been intense efforts to find reproducible non-invasive parameters to predict CRT response. We hypothesized that different left ventricular contraction patterns may exist in LBBB patients with depressed systolic function and applied tagged cardiovascular magnetic resonance (CMR) to assess circumferential strain in this population. METHODS We determined myocardial circumferential strain at the basal, mid, and apical ventricular level in 35 subjects (10 with ischemic cardiomyopathy, 15 with non-ischemic cardiomyopathy, and 10 healthy controls). Patterns of circumferential strain were analyzed. Time to peak systolic circumferential strain in each of the 6 segments in all three ventricular slices and the standard deviation of time to peak strain in the basal and mid ventricular slices were determined. RESULTS Dyskinesis of the anterior septum and the inferior septum in at least two ventricular levels was seen in 50% (5 out of 10) of LBBB patients while 30% had isolated dyskinesis of the anteroseptum, and 20% had no dyskinesis in any segments, similar to all of the non-LBBB patients and healthy controls. Peak circumferential strain shortening was significantly reduced in all cardiomyopathy patients at the mid-ventricular level (LBBB 9 +/- 6%, non-LBBB 10 +/- 4% vs. healthy 19 +/- 4%; both p < 0.0001 compared to healthy), but was similar among the LBBB and non-LBBB groups (p = 0.20). The LBBB group had significantly greater dyssynchrony compared to the non-LBBB group and healthy controls assessed by opposing wall delays and 12-segment standard deviation (LBBB 164 +/- 30 ms vs. non-LBBB 70 +/- 17 ms (p < 0.0001), non-LBBB vs. healthy 65 +/- 17 ms (p = 0.47)). CONCLUSIONS Septal dyskinesis exists in some patients with LBBB. Myocardial circumferential strain analysis enables detailed characterization of contraction patterns, strengths, and timing in cardiomyopathy patients with and without LBBB.
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Affiliation(s)
- Yuchi Han
- Departments of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Jonathan Chan
- Departments of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- School of Medicine, University of Queensland, Brisbane, Australia
| | - Idith Haber
- Department of Medicine (Cardiology), University of Chicago Medical School, Chicago, IL, USA
| | - Dana C Peters
- Departments of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Peter J Zimetbaum
- Departments of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Warren J Manning
- Departments of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Susan B Yeon
- Departments of Medicine (Cardiovascular Division), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Hudaverdi M, Hamilton-Craig C, Platts D, Chan J, Burstow DJ. Echocardiography for the clinician: a practical update. Intern Med J 2010; 40:476-85. [PMID: 20059600 DOI: 10.1111/j.1445-5994.2010.02167.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Echocardiography is the mainstay of cardiovascular diagnostics, and is the most performed test for the evaluation of cardiac function. Critical and costly management decisions are based on quantification of left ventricular volumes and ejection fraction. Recent advances in echocardiography, such as microsphere contrast echocardiography for left ventricular opacification and perfusion imaging, three-dimensional transthoracic and trans-oesophageal imaging, strain and tissue Doppler imaging, all contribute to improving accuracy and reproducibility of these important measurements. Such techniques are now routinely available on standard echocardiography equipment in Australian centres for daily use. Hand-carried ultrasound devices have been developed, which are portable, are affordable and offer increased availability of echocardiography to the wider community. Clinicians should be actively encouraged to adopt these technologies to improve the diagnostic quality and reproducability of echocardiography for our patients. This article provides an overview of important recent advances in echocardiographic imaging with an emphasis on their role in clinical practice today.
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Affiliation(s)
- M Hudaverdi
- Department of Echocardiography, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
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The importance of ventricular dyssynchrony in predicting the response to cardiac resynchronization therapy. COR ET VASA 2010. [DOI: 10.33678/cor.2010.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Birnie D, deKemp RA, Ruddy TD, Tang AS, Guo A, Williams K, Wassenar R, Lalonde M, Beanlands RS. Effect of lateral wall scar on reverse remodeling with cardiac resynchronization therapy. Heart Rhythm 2009; 6:1721-6. [DOI: 10.1016/j.hrthm.2009.08.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2009] [Accepted: 08/09/2009] [Indexed: 10/20/2022]
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Recent advances in cardiac resynchronization therapy: echocardiographic modalities, patient selection, optimization, non-responders—all you need to know for more efficient CRT. Int J Cardiovasc Imaging 2009; 26:177-91. [DOI: 10.1007/s10554-009-9523-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Accepted: 10/16/2009] [Indexed: 12/24/2022]
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Lo Q, Thomas L. Echocardiographic evaluation of systolic heart failure. Australas J Ultrasound Med 2009; 12:21-29. [PMID: 28191069 PMCID: PMC5024850 DOI: 10.1002/j.2205-0140.2009.tb00067.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Echocardiography is the most commonly used modality for evaluating left ventricular size and function in the context of systolic heart failure. Traditional techniques, though extensively used, have their limitations and more recently several newer technologies have emerged that are more reproducible, provide prognostic information, guide therapies and have an important role in monitoring progress. This review will evaluate the traditional and more novel techniques used and briefly provide an overview of the role of echocardiography in guiding and monitoring therapies in patients with systolic heart failure.
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Affiliation(s)
- Queenie Lo
- Liverpool Hospital; Department of Cardiology; Sydney New South Wales 2170 Australia
| | - Liza Thomas
- Liverpool Hospital; Department of Cardiology; Sydney New South Wales 2170 Australia
- The University of New South Wales; Sydney New South Wales 2052 Australia
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92
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Friedberg MK, Roche SL, Mohammed AF, Balasingam M, Atenafu EG, Kantor PF. Left ventricular diastolic mechanical dyssynchrony and associated clinical outcomes in children with dilated cardiomyopathy. Circ Cardiovasc Imaging 2009; 1:50-7. [PMID: 19808514 DOI: 10.1161/circimaging.108.782086] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND We investigated diastolic mechanical dyssynchrony and its relation to clinical status in pediatric dilated cardiomyopathy (DCM). METHODS AND RESULTS We calculated a diastolic and systolic dyssynchrony index (standard deviation of time to peak tissue early diastolic/systolic velocity in 12 left ventricular segments) in 33 children with DCM and 46 control subjects. A threshold to diagnose diastolic dyssynchrony was determined, and cardiac function and clinical outcomes were compared between DCM patients with and without diastolic dyssynchrony. Left ventricular wall motion was more synchronized in diastole than in systole. The diastolic dyssynchrony index was significantly higher in children with DCM than in control subjects (28.1+/-18.1 versus 9.1+/-3.8 ms, P<0.0001). A 17-ms threshold indicated the presence of diastolic dyssynchrony. Patients who died or underwent transplantation had greater diastolic dyssynchrony (diastolic dyssynchrony index 37.9+/-20.5 versus 22.1+/-13.8 ms, P=0.01), and the rate of transplant-free survival appeared to be worse for DCM patients with diastolic dyssynchrony than for patients with synchronous DCM (hazard ratio 2.98, P=0.11; hazard ratio adjusted for disease duration 2.95, P=0.17). CONCLUSIONS Left ventricular diastolic mechanical dyssynchrony is common in pediatric DCM, especially in patients who subsequently experience transplantation or death, and may be associated with a decreased length of transplantation-free survival.
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Affiliation(s)
- Mark K Friedberg
- Divisions of Pediatric Cardiology, The Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada.
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93
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Bjåstad T, Torp H. Single-pulse tissue doppler using synthetic transmit beams. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2009; 56:2134-2144. [PMID: 19942501 DOI: 10.1109/tuffc.2009.1296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Tissue Doppler imaging (TDI) is a common technique for investigating myocardial function. Typically, B-mode data and TDI data are recorded using separate acquisitions and combined into a single, color overlaid image. In this work, we present a novel method for TDI imaging, where both TDI and B-mode are created from the same acquisition. Velocities are calculated from the phase shift between neighboring transmit events in the B-mode scan; hence the name singlepulse tissue Doppler (SPTD). Using a novel transmit beam interleaving pattern, this method provides TDI and B-mode at the same high frame rate with an adjustable Nyquist velocity limit. Through simulations and measurements, this work investigates the bias and variance of the SPTD velocities and compares the estimates to those of the conventional TDI autocorrelation estimation method. The results showed that the method introduces an additional bias and variance in the velocity estimates compared with conventional TDI. However, by applying bias compensation, the SPTD velocity estimates were close to those of regular TDI. Using SPTD, the whole left ventricle was imaged within a 65-degree sector at a frame rate of 110 frames per second (43 transmissions per frame).
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Affiliation(s)
- Tore Bjåstad
- Dept. of Circulation & Med. Imaging, Norwegian Univ. of Sci. & Technol., Trondheim, Norway.
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94
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Dreger H, Borges AC, Ismer B, Schattke S, Stegemann B, Baumann G, Melzer C. A modified echocardiographic protocol with intrinsic plausibility control to determine intraventricular asynchrony based on TDI and TSI. Cardiovasc Ultrasound 2009; 7:46. [PMID: 19781060 PMCID: PMC2767344 DOI: 10.1186/1476-7120-7-46] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Accepted: 09/25/2009] [Indexed: 11/10/2022] Open
Abstract
Background Established methods to determine asynchrony suffer from high intra- and interobserver variability and failed to improve patient selection for cardiac resynchronization therapy (CRT). Thus, there is a need for easy and robust approaches to reliably assess cardiac asynchrony. Methods and Results We performed echocardiography in 100 healthy subjects and 33 patients with left bundle branch block (LBBB). To detect intraventricular asynchrony, we combined two established methods, i.e., tissue synchronization imaging (TSI) and tissue Doppler imaging (TDI). The time intervals from the onset of aortic valve opening (AVO) to the peak systolic velocity (S') were measured separately in six basal segments in the apical four-, two-, and three-chamber view. Color-coded TSI served as an intrinsic plausibility control and helped to identify the correct S' measuring point in the TDI curves. Next, we identified the segment with the shortest AVO-S' interval. Since this segment most likely represents vital and intact myocardium it served as a reference for other segments. Segments were considered asynchronous when the delay between the segment in question and the reference segment was above the upper limit of normal delays derived from the control population. Intra- and interobserver variability were 7.0% and 7.7%, respectively. Conclusion Our results suggest that combination of TDI and TSI with intrinsic plausibility control improves intra- and interobserver variability and allows easy and reliable assessment of cardiac asynchrony.
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Affiliation(s)
- Henryk Dreger
- Medizinische Klinik für Kardiologie und Angiologie, Campus Mitte, Charité-Universitätsmedizin Berlin, Germany.
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95
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Friedberg MK, Dubin AM, Van Hare GF, McDaniel G, Niksch A, Rosenthal DN. Acute Effects of Single-site Pacing from the Left and Right Ventricle on Ventricular Function and Ventricular-Ventricular Interactions in Children with Normal Hearts. CONGENIT HEART DIS 2009; 4:356-61. [DOI: 10.1111/j.1747-0803.2009.00327.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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96
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Lim P, Mitchell-Heggs L, Buakhamsri A, Thomas JD, Grimm RA. Impact of left ventricular size on tissue Doppler and longitudinal strain by speckle tracking for assessing wall motion and mechanical dyssynchrony in candidates for cardiac resynchronization therapy. J Am Soc Echocardiogr 2009; 22:695-701. [PMID: 19501329 DOI: 10.1016/j.echo.2009.04.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND Myocardial dysfunction and left ventricular (LV) geometry deformation may reduce the accuracy of tissue Doppler imaging (TDI) in assessing myocardial contractility. METHODS In 92 patients with heart failure who underwent cardiac resynchronization therapy (CRT), we assessed the impact of LV end-diastolic volume on the accuracy of peak longitudinal velocity (TDI) and strain (epsilon(L) by speckle tracking) to assess regional wall motion and LV dyssynchrony. RESULTS Peak-epsilon correlated to normal (-13% +/- 6%, n = 259), hypokinetic (-10% +/- 5%, n = 347), and akinetic (-7% +/- 5%, n = 498, P < .0001) wall motion independent of LV size. In contrast, velocity failed to distinguish normal from dysfunctional segments in patients with severe LV dilatation (end-diastolic volume > 250 mL). The 12 standard deviation of time to peak systolic velocity and the opposing septal-lateral wall delay by strain and TDI failed to predict response to CRT, whereas the 12 segment standard deviation of time to peak epsilon correlated to end-systolic volume reduction (r = -0.39, P < .001). CONCLUSION Accuracy of TDI in assessing LV wall regional motion is limited in severely dilated ventricles and probably affects LV dyssynchrony measurement.
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Affiliation(s)
- Pascal Lim
- Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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97
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New aspects on the assessment of left ventricular dyssynchrony by tissue Doppler echocardiography: comparison of myocardial velocity vs. displacement curves. Int J Cardiovasc Imaging 2009; 25:699-704. [PMID: 19655270 DOI: 10.1007/s10554-009-9484-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 07/14/2009] [Indexed: 02/02/2023]
Abstract
The purpose of this study is to assess the incremental value of tissue Doppler (TDI) derived displacement curves (TDint) compared to TDI velocity curves (TDvel) for the evaluation of left ventricular (LV) dyssynchrony (LVD). About 25 patients (pts.) with systolic heart failure were studied by TDvel and TDint. Four TDI sample volumes were placed at the basal and four at the mid ventricular myocardium, utilising two imaging planes. LV dyssynchrony (LVD) was defined as an interregional delay of >40 ms corrected for heart rate. 10 pts. had synchronous contraction, 15 pts. LVD as defined by two experts (EC). To determine diagnostic accuracy and intra-observer variability two identical sets of 100 documents (25 pts. x two imaging planes x two modalities) were produced and presented in random order to one trained (TR) and two untrained (UR) readers. The TR more frequently classified documents as unreadable (7.5 vs. 3.5%, P < 0.05) but more often as correct, i.e., consistent with EC (72.0 vs. 57.8%, P < 0.001). 8.7% of the documents were classified as unreadable using TDvel, 1.0% when applying TDint (P < 0.001). The mean value of correct classification of all 3 readers was 54.3% (TDvel only), 70.7% (TDint only), and 77.7% (combining both modalities), (P < 0.001). The kappa value for TR and TDint was 0.68, for TDvel 0.29. For UR, kappa did not differ (TDint: 0.58; TDvel 0.51). TDint is superior to TDvel in accuracy, reproducibility, and applicability for skilled and unskilled investigators when evaluating LVD by TDI. The combined application of TDint and TDvel is optimal.
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98
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Triantafyllou KA, Karabinos E, Kalkandi H, Kranidis AI, Babalis D. Clinical implications of the echocardiographic assessment of left ventricular long axis function. Clin Res Cardiol 2009; 98:521-32. [DOI: 10.1007/s00392-009-0046-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2008] [Accepted: 06/29/2009] [Indexed: 10/20/2022]
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99
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Maruskova M, Gregor P, Bartunek J, Tintera J, Penicka M. Myocardial viability and cardiac dyssynchrony as strong predictors of perioperative mortality in high-risk patients with ischemic cardiomyopathy having coronary artery bypass surgery. J Thorac Cardiovasc Surg 2009; 138:62-8. [DOI: 10.1016/j.jtcvs.2008.11.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 09/26/2008] [Accepted: 11/20/2008] [Indexed: 10/21/2022]
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100
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Echocardiography and noninvasive imaging in cardiac resynchronization therapy: results of the PROSPECT (Predictors of Response to Cardiac Resynchronization Therapy) study in perspective. J Am Coll Cardiol 2009; 53:1933-43. [PMID: 19460606 DOI: 10.1016/j.jacc.2008.11.061] [Citation(s) in RCA: 148] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2008] [Revised: 10/14/2008] [Accepted: 11/02/2008] [Indexed: 11/23/2022]
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