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Santos MR, Silva MS, Guerreiro SL, Gomes DA, Rocha BM, Cunha GL, Freitas PN, Abecasis JM, Santos AC, Saraiva CC, Mendes M, Ferreira AM. Assessment of myocardial strain patterns in patients with left bundle branch block using cardiac magnetic resonance. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2024:10.1007/s10554-024-03049-3. [PMID: 38376720 DOI: 10.1007/s10554-024-03049-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/05/2024] [Indexed: 02/21/2024]
Abstract
Recently, a classification with four types of septal longitudinal strain patterns was described using echocardiography, suggesting a pathophysiological continuum of left bundle branch block (LBBB)-induced left ventricle (LV) remodeling. The aim of this study was to assess the feasibility of classifying these strain patterns using cardiovascular magnetic resonance (CMR), and to evaluate their association with LV remodeling and myocardial scar. Single center registry included LBBB patients with septal flash (SF) referred to CMR to assess the cause of LV systolic dysfunction. Semi-automated feature-tracking cardiac resonance (FT-CMR) was used to quantify myocardial strain and detect the four strain patterns. A total of 115 patients were studied (age 66 ± 11 years, 57% men, 28% with ischemic heart disease). In longitudinal strain analysis, 23 patients (20%) were classified in stage LBBB-1, 37 (32.1%) in LBBB-2, 25 (21.7%) in LBBB-3, and 30 (26%) in LBBB-4. Patients at higher stages had more prominent septal flash, higher LV volumes, lower LV ejection fraction, and lower absolute strain values (p < 0.05 for all). Late gadolinium enhancement (LGE) was found in 55% of the patients (n = 63). No differences were found between the strain patterns regarding the presence, distribution or location of LGE. Among patients with LBBB, there was a good association between strain patterns assessed by FT-CMR analysis and the degree of LV remodeling and LV dysfunction. This association seems to be independent from the presence and distribution of LGE.
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Affiliation(s)
- Marina Raquel Santos
- Hospital Dr. Nélio Mendonça, Funchal, Portugal.
- CHLO - Hospital de Santa Cruz, Lisbon, Portugal.
| | - Mariana Santos Silva
- CHLO - Hospital de Santa Cruz, Lisbon, Portugal
- Centro Hospitalar Barreiro/Montijo, Setúbal, Portugal
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Larsen CK, Smiseth OA, Duchenne J, Galli E, Aalen JM, Lederlin M, Bogaert J, Kongsgaard E, Linde C, Penicka M, Donal E, Voigt JU, Hopp E. Cardiac Magnetic Resonance Identifies Responders to Cardiac Resynchronization Therapy with an Assessment of Septal Scar and Left Ventricular Dyssynchrony. J Clin Med 2023; 12:7182. [PMID: 38002795 PMCID: PMC10672328 DOI: 10.3390/jcm12227182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/15/2023] [Accepted: 11/18/2023] [Indexed: 11/26/2023] Open
Abstract
Background: The response to cardiac resynchronization therapy (CRT) depends on septal viability and correction of abnormal septal motion. This study investigates if cardiac magnetic resonance (CMR) as a single modality can identify CRT responders with combined imaging of pathological septal motion (septal flash) and septal scar. Methods: In a prospective, multicenter, observational study of 136 CRT recipients, septal scar was assessed using late gadolinium enhancement (LGE) (n = 127) and septal flash visually from cine CMR sequences. The primary endpoint was CRT response, defined as ≥15% reduction in LV end-systolic volume with echocardiography after 6 months. The secondary endpoint was heart transplantation or death of any cause assessed after 39 ± 13 months. Results: Septal scar and septal flash were independent predictors of CRT response in multivariable analysis (both p < 0.001), while QRS duration and morphology were not. The combined approach of septal scar and septal flash predicted CRT response with an area under the curve of 0.86 (95% confidence interval (CI): 0.78-0.94) and was a strong predictor of long-term survival without heart transplantation (hazard ratio 0.27, 95% CI: 0.10-0.79). The accuracy of the approach was similar in the subgroup with intermediate (130-150 ms) QRS duration. The combined approach was superior to septal scar and septal flash alone (p < 0.01). Conclusions: The combined assessment of septal scar and septal flash using CMR as a single-image modality identifies CRT responders with high accuracy and predicts long-term survival.
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Affiliation(s)
- Camilla Kjellstad Larsen
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway; (C.K.L.); (O.A.S.); (J.M.A.)
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
| | - Otto A. Smiseth
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway; (C.K.L.); (O.A.S.); (J.M.A.)
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
| | - Jürgen Duchenne
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium (J.-U.V.)
- Department of Cardiovascular Sciences, KU Leuven—University of Leuven, 3000 Leuven, Belgium
| | - Elena Galli
- Department of Cardiology, University Hospital of Rennes, 35000 Rennes, France; (E.G.); (E.D.)
| | - John Moene Aalen
- Institute for Surgical Research and Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway; (C.K.L.); (O.A.S.); (J.M.A.)
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
| | - Mathieu Lederlin
- Department of Radiology, University Hospital of Rennes, 35000 Rennes, France;
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Erik Kongsgaard
- Department of Cardiology, Oslo University Hospital, 0027 Oslo, Norway;
| | - Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, 171 64 Solna, Sweden;
| | | | - Erwan Donal
- Department of Cardiology, University Hospital of Rennes, 35000 Rennes, France; (E.G.); (E.D.)
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium (J.-U.V.)
- Department of Cardiovascular Sciences, KU Leuven—University of Leuven, 3000 Leuven, Belgium
| | - Einar Hopp
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, 0027 Oslo, Norway
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The role of cardiac magnetic resonance in identifying appropriate candidates for cardiac resynchronization therapy - a systematic review of the literature. Heart Fail Rev 2022; 27:2095-2118. [PMID: 36045189 DOI: 10.1007/s10741-022-10263-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2022] [Indexed: 11/04/2022]
Abstract
Despite the strict indications for cardiac resynchronization therapy (CRT) implantation, a significant proportion of patients will fail to adequately respond to the treatment. This systematic review aims to present the existing evidence about the role of cardiac magnetic resonance (CMR) in identifying patients who are likely to respond better to the CRT. A systematic search in the MedLine database and Cochrane Library from their inception to August 2021 was performed, without any limitations, by two independent investigators. We considered eligible observational studies or randomized clinical trials (RCTs) that enrolled patients > 18 years old with heart failure (HF) of ischaemic or non-ischaemic aetiology and provided data about the association of baseline CMR variables with clinical or echocardiographic response to CRT for at least 3 months. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA Statement). Following our search strategy, 47 studies were finally included in our review. CMR appears to have an additive role in identifying the subgroup of patients who will respond better to CRT. Specifically, the presence and the extent of myocardial scar were associated with increased non-response rates, while those with no scar respond better. Furthermore, existing data show that scar location can be associated with CRT response rates. CMR-derived markers of mechanical desynchrony can also be used as predictors of CRT response. CMR data can be used to optimize the position of the left ventricular lead during the CRT implantation procedure. Specifically, positioning the left ventricular lead in a branch of the coronary sinus that feeds an area with transmural scar was associated with poorer response to CRT. CMR can be used as a non-invasive optimization tool to identify patients who are more likely to achieve better clinical and echocardiographic response following CRT implantation.
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Villegas-Martinez M, Krogh MR, Andersen ØS, Sletten OJ, Wajdan A, Odland HH, Elle OJ, Remme EW. Tracking Early Systolic Motion for Assessing Acute Response to Cardiac Resynchronization Therapy in Real Time. Front Physiol 2022; 13:903784. [PMID: 35721553 PMCID: PMC9201723 DOI: 10.3389/fphys.2022.903784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/13/2022] [Indexed: 11/17/2022] Open
Abstract
An abnormal systolic motion is frequently observed in patients with left bundle branch block (LBBB), and it has been proposed as a predictor of response to cardiac resynchronization therapy (CRT). Our goal was to investigate if this motion can be monitored with miniaturized sensors feasible for clinical use to identify response to CRT in real time. Motion sensors were attached to the septum and the left ventricular (LV) lateral wall of eighteen anesthetized dogs. Recordings were performed during baseline, after induction of LBBB, and during biventricular pacing. The abnormal contraction pattern in LBBB was quantified by the septal flash index (SFI) equal to the early systolic shortening of the LV septal-to-lateral wall diameter divided by the maximum shortening achieved during ejection. In baseline, with normal electrical activation, there was limited early-systolic shortening and SFI was low (9 ± 8%). After induction of LBBB, this shortening and the SFI significantly increased (88 ± 34%, p < 0.001). Subsequently, CRT reduced it approximately back to baseline values (13 ± 13%, p < 0.001 vs. LBBB). The study showed the feasibility of using miniaturized sensors for continuous monitoring of the abnormal systolic motion of the LV in LBBB and how such sensors can be used to assess response to pacing in real time to guide CRT implantation.
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Affiliation(s)
- Manuel Villegas-Martinez
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Magnus Reinsfelt Krogh
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | | | - Ole Jakob Sletten
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
- Department of Cardiology and Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Ali Wajdan
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Hans Henrik Odland
- Department of Cardiology and Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Ole Jakob Elle
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Espen W. Remme
- The Intervention Centre, Oslo University Hospital, Oslo, Norway
- Institute for Surgical Research, Oslo University Hospital, Oslo, Norway
- *Correspondence: Espen W. Remme,
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Bennett S, Tafuro J, Duckett S, Heatlie G, Patwala A, Barker D, Cubukcu A, Ahmed FZ, Kwok CS. Septal Flash as a Predictor of Cardiac Resynchronization Therapy Response: A Systematic Review and Meta-Analysis. J Cardiovasc Echogr 2021; 31:198-206. [PMID: 35284222 PMCID: PMC8893106 DOI: 10.4103/jcecho.jcecho_45_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 08/09/2021] [Accepted: 11/06/2021] [Indexed: 11/04/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) in heart failure patients has been shown to improve patient outcomes in some but not all patients. A few studies have identified that septal flash on imaging is associated with response to CRT, but there has yet to be systematic review to evaluate the consistency of the finding across the literature. A search of MEDLINE and EMBASE was conducted to identify studies, which evaluate septal flash and its association with CRT response. Studies that met the inclusion criteria were statistically pooled with random-effects meta-analysis and heterogeneity was assessed using the I2 statistic. A total of nine studies were included with 2307 participants (mean age 76 years, 67% male). Septal flash on imaging before CRT implantation was seen in 53% of patients and the proportion of CRT responders from the included studies varied from 52% to 77%. In patients who were CRT responders, septal flash was seen in 40% of patients compared to 10% in those deemed to be CRT nonresponders. Meta-analysis of eight of the nine included studies suggests that the presence of septal flash at preimplant was associated with an increased likelihood of CRT response (relative risk 2.55 95% confidence interval 2.04-3.19, P < 0.001, I2 = 51%). Septal flash was also reported to be associated with left ventricular reverse remodeling, but the association with survival and symptomatic improvement was less clear. Septal flash is a well-defined and distinctive contraction pattern that is easily recognizable on cardiac imaging. Septal flash may be associated with CRT response and should be evaluated in the patients that are considered for CRT devices.
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Affiliation(s)
- Sadie Bennett
- Department of Cardiology, Heart and Lung Clinic, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Jacopo Tafuro
- Department of Cardiology, Heart and Lung Clinic, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Simon Duckett
- Department of Cardiology, Heart and Lung Clinic, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Grant Heatlie
- Department of Cardiology, Heart and Lung Clinic, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Ashish Patwala
- Department of Cardiology, Heart and Lung Clinic, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Diane Barker
- Department of Cardiology, Heart and Lung Clinic, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Arzu Cubukcu
- Department of Cardiology, Macclesfield District General Hospital, Macclesfield, UK
| | - Fozia Zahir Ahmed
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Chun Shing Kwok
- Department of Cardiology, Heart and Lung Clinic, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- Primary Care and Health Sciences, Keele University, Keele, UK
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Wang H, He Y, Du X, Yao R, Chang S, Guo F, Bai Z, Lv Q, Liu X, Dong J, Ma C. Differentiation between left bundle branch block (LBBB) preceded dilated cardiomyopathy and dilated cardiomyopathy preceded LBBB by cardiac magnetic resonance imaging. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:847-855. [PMID: 32638387 DOI: 10.1111/pace.14007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 06/01/2020] [Accepted: 07/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Dilated cardiomyopathy (DCM) may be a result of or the cause of left bundle branch block (LBBB) in patients with DCM and LBBB. It is almost impossible from the history alone to know which came first in clinical work. METHODS Patients with LBBB and DCM who had cardiac magnetic resonance (CMR) examination were analyzed. Occurrence sequence of DCM and LBBB was determined by chart reviewing. Diastolic lateral/septal wall thickness ratio (DLSWTR) and lateral wall thickening (LWT) were compared between patients with different time sequences. Response to CRT was analyzed according to medical history and CMR manifestation. RESULTS Sixty-three patients were divided into two groups by cluster analysis. DLSWTR and LWT were significantly higher in group 1 (preserved lateral wall thickness and function), compared to those in group 2 (reduced lateral wall thickness and function) (1.06 ± 0.13 vs. 0.8 ± 0.12, 34.57 ± 11.48% vs. 11.18 ± 5.56%, respectively, both P < .001). Occurrence sequence was clear in 14 patients and further analyzed. In group 1, seven patients were clearly having no evidence of DCM when LBBB was first diagnosed (defined as LBBB-precede-DCM) and in group 2, seven patients did not have LBBB when DCM was diagnosed (defined as DCM-precede-LBBB). Among 10 patients who received CRT therapy, all seven patients in group 1 responded well whereas none of three patients in group 2 responded well. CONCLUSIONS Occurrence sequence of DCM and LBBB can be discriminated by CMR. Preserved lateral wall morphology and function in CMR suggested LBBB preceded to DCM. Such features may be predictors of good response to CRT.
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Affiliation(s)
- Hui Wang
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang, Beijing, P. R. China
| | - Yi He
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang, Beijing, P. R. China
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang, Beijing, P. R. China.,Heart Health Research Center (HHRC), Beijing, P. R. China
| | - Rui Yao
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, P. R. China
| | - Sanshuai Chang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang, Beijing, P. R. China
| | - Fei Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang, Beijing, P. R. China
| | - Zhongle Bai
- Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, P. R. China
| | - Qiang Lv
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang, Beijing, P. R. China
| | - Xiaohui Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang, Beijing, P. R. China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang, Beijing, P. R. China.,Department of Cardiology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, P. R. China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Chaoyang, Beijing, P. R. China
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Calle S, Delens C, Kamoen V, De Pooter J, Timmermans F. Septal flash: At the heart of cardiac dyssynchrony. Trends Cardiovasc Med 2020; 30:115-122. [DOI: 10.1016/j.tcm.2019.03.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/31/2019] [Accepted: 03/31/2019] [Indexed: 11/29/2022]
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Aalen JM, Remme EW, Larsen CK, Andersen OS, Krogh M, Duchenne J, Hopp E, Ross S, Beela AS, Kongsgaard E, Bergsland J, Odland HH, Skulstad H, Opdahl A, Voigt JU, Smiseth OA. Mechanism of Abnormal Septal Motion in Left Bundle Branch Block. JACC Cardiovasc Imaging 2019; 12:2402-2413. [DOI: 10.1016/j.jcmg.2018.11.030] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 11/05/2018] [Accepted: 11/30/2018] [Indexed: 12/28/2022]
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9
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Editorial commentary: Septal flash - what is behind the flashy name? Trends Cardiovasc Med 2019; 30:123-124. [PMID: 31010721 DOI: 10.1016/j.tcm.2019.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 04/12/2019] [Indexed: 11/24/2022]
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Mele D, Bertini M, Malagù M, Nardozza M, Ferrari R. Current role of echocardiography in cardiac resynchronization therapy. Heart Fail Rev 2018; 22:699-722. [PMID: 28714039 DOI: 10.1007/s10741-017-9636-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure and left ventricular systolic dysfunction. Patients are usually assessed by echocardiography, which provides a number of anatomical and functional information used for cardiac dyssynchrony assessment, prognostic stratification, identification of the optimal site of pacing in the left ventricle, optimization of the CRT device, and patient follow-up. Compared to other cardiac imaging techniques, echocardiography has the advantage to be non-invasive, repeatable, and safe, without exposure to ionizing radiation or nefrotoxic contrast. In this article, we review current evidence about the role of echocardiography before, during, and after the implantation of a CRT device.
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Affiliation(s)
- Donato Mele
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy. .,Noninvasive Cardiology Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Ferrara, Cona, Italy.
| | - Matteo Bertini
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Michele Malagù
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Marianna Nardozza
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy
| | - Roberto Ferrari
- Centro Cardiologico Universitario and LTTA Centre, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, E.S. Health Science Foundation, Cotignola, RA, Italy
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Jackson T, Amraoui S, Sohal M, Sammut E, Behar JM, Claridge S, Webb J, Sienecwicz B, Razavi R, Rinaldi CA, Carr-White G. The interaction of QRS duration with cardiac magnetic resonance derived scar and mechanical dyssynchrony in systolic heart failure: Implications for cardiac resynchronization therapy. IJC HEART & VASCULATURE 2018; 18:81-85. [PMID: 29750182 PMCID: PMC5941225 DOI: 10.1016/j.ijcha.2017.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 11/20/2017] [Indexed: 11/06/2022]
Abstract
Background Trials using echocardiographic mechanical dyssynchrony (MD) parameters in narrow QRS patients have shown a negative response to CRT. We hypothesized MD in these patients may relate to myocardial scar rather than electrical dyssynchrony. Methods We determined the prevalence of cardiac magnetic resonance (CMR) derived measures of MD in 130 systolic heart failure patients with both broad (≥ 130 ms - BQRS) and narrow QRS duration (< 130 ms - NQRS). We assessed whether late gadolinium enhancement derived scar might explain the presence of MD amongst narrow QRS patients. Dyssynchrony was calculated on the basis of a systolic dyssynchrony index (SDI). Results Fifty-nine patients (45%) had a NQRS and the remaining had QRS ≥ 130 ms (BQRS group). 25% of NQRS patients had MD based on SDI. In all narrow and broad QRS patients with MD there was a significantly lower scar volume than those without MD (7.4 ± 10.5% vs 13.7 ± 13.3% vs. p < 0.01). This was the case in the BQRS group with a significantly lower scar burden in patients with MD (5.0 ± 7.7% vs 15.4 ± 15.6%, p < 0.01). Notably in the NQRS group this difference was absent with an equal scar burden in patients with MD 13.3 ± 13.9% and without MD 12.5 ± 11%, p = 0.92. Conclusions 25% of patients with systolic heart failure and a NQRS (< 130 ms) have CMR derived mechanical dyssynchrony. Our findings suggest MD in this group may be secondary to myocardial scar rather than electrical dyssynchrony and therefore not amenable to correction by CRT. This may give insight into non-response and potential harm from CRT in this group.
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Affiliation(s)
- Tom Jackson
- King's College London, London, United Kingdom
| | | | - Manav Sohal
- King's College London, London, United Kingdom
| | - Eva Sammut
- King's College London, London, United Kingdom
| | | | | | | | | | - Reza Razavi
- King's College London, London, United Kingdom
| | - Christopher Aldo Rinaldi
- King's College London, London, United Kingdom.,Guy's and St. Thomas' Hospitals, London, United Kingdom
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12
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Jackson T, Lenarczyk R, Sterlinski M, Sokal A, Francis D, Whinnett Z, Van Heuverswyn F, Vanderheyden M, Heynens J, Stegemann B, Cornelussen R, Rinaldi CA. Left ventricular scar and the acute hemodynamic effects of multivein and multipolar pacing in cardiac resynchronization. IJC HEART & VASCULATURE 2018; 19:14-19. [PMID: 29946558 PMCID: PMC6016076 DOI: 10.1016/j.ijcha.2018.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 03/21/2018] [Indexed: 12/14/2022]
Abstract
Background We sought to determine whether presence, amount and distribution of scar impacts the degree of acute hemodynamic response (AHR) with multisite pacing. Multi-vein pacing (MVP) or multipolar pacing (MPP) with a multi-electrode left ventricular (LV) lead may offer benefits over conventional biventricular pacing in patients with myocardial scar. Methods In this multi-center study left bundle branch block patients underwent an hemodynamic pacing study measuring LV dP/dtmax. Patients had cardiac magnetic resonance scar imaging to assess the effect of scar presence, amount and distribution on AHR. Results 24 patients (QRS 171 ± 20 ms) completed the study (83% male). An ischemic etiology was present in 58% and the mean scar volume was 6.0 ± 7.0%. Overall discounting scar, MPP and MVP showed no significant AHR increase compared to an optimized “best BiV” (BestBiV) site. In a minority of patients (6/24) receiver-operator characteristic analysis of scar volume (cut off 8.48%) predicted a small AHR improvement with MPP (sensitivity 83%, specificity 94%) but not MVP. Patients with scar volume > 8.48% had a MPP-BestBiV of 3 ± 6.3% vs. −6.4 ± 7.7% for those below the cutoff. There was a significant correlation between the difference in AHR and scar volume for MPP-BestBiV (R = 0.49, p = 0.02) but not MVP-BestBiV(R = 0.111, p = 0.62). The multielectrode lead positioned in scar predicted MPP AHR improvement (p = 0.04). Conclusions Multisite pacing with MPP and MVP shows no AHR benefit in all-comers compared to optimized BestBiV pacing. There was a minority of patients with significant scar volume in relation to the LV site that exhibited a small AHR improvement with MPP. (Study identifier NCT01883141)
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Key Words
- AHR, acute hemodynamic response
- Acute hemodynamic response
- BiV, biventricular
- CI, confidence interval
- CMR, cardiac magnetic resonance
- CMR-LGE, cardiac magnetic resonance late gadolinium enhancement
- CRT, cardiac resynchronization therapy
- Cardiac resynchronization therapy
- ECG, electrocardiogram
- HF, heart failure
- LBBB, left bundle branch block
- LV, left ventricular
- Left ventricular scar
- MEL, multielectrode lead
- MPP, multipolar pacing
- MVP, multivein pacing
- Multisite pacing
- OR, odds ratio
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Affiliation(s)
- Tom Jackson
- Department of Cardiology, Guy's & St. Thomas' Hospitals & King's College London, London, United Kingdom
| | - Radoslaw Lenarczyk
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Zabrze, Poland
| | | | - Adam Sokal
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Zabrze, Poland
| | - Darrell Francis
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Zachary Whinnett
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | | | - Joeri Heynens
- Medtronic Inc., Bakken Research Centre, Maastricht, The Netherlands
| | | | | | - Christopher Aldo Rinaldi
- Department of Cardiology, Guy's & St. Thomas' Hospitals & King's College London, London, United Kingdom
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13
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Li K, Qian Z, Hou X, Wang Y, Qiu Y, Sheng Y, Qian X, Zhou Y, Zou J. The incidence and outcomes of delayed response to cardiac resynchronization therapy. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 41:73-80. [PMID: 29222875 DOI: 10.1111/pace.13252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 11/05/2017] [Accepted: 11/28/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The incidence and clinical outcomes of delayed response to cardiac resynchronization therapy (CRT) have not been well clarified. We aimed to observe the incidence and prognosis of delayed response and to identify its possible mechanisms. METHODS A total of 115 CRT patients were retrospectively analyzed in our study. Patients who met the enrollment criteria were divided into two groups: group A, conventional responders who showed response at 1-year follow-up, and group B, delayed responders who showed response after 1-year follow-up. CRT response was defined as an absolute increase of ≥10% in left ventricular ejection fraction. RESULTS Fifty-two patients (61 ± 12 years, 37 male) experienced conventional response to CRT and 17 patients (63 ± 11 years, 10 male) experienced delayed response. The mean follow-up time was 5.2 ± 2.4 years. The incidence of delayed response was 14.8% (17/115). All-cause mortality and hospitalization rates for heart failure were similar for delayed and conventional responders. Multivariate logistic regression analysis revealed that scar burden > 35% was an independent predictor of CRT delayed response (odds ratio 8.794, P = 0.038). CONCLUSIONS A significant proportion of patients demonstrated delayed response to CRT. The delayed responders had a good prognosis that was similar to that of conventional responders. More scar burden might be related to the incidence of delayed response.
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Affiliation(s)
- Kebei Li
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Cardiology, The First People's Hospital of Zhangjiagang, Affiliated Hospital of Soochow University, Zhangjiagang, Jiangsu, China
| | - Zhiyong Qian
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiaofeng Hou
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yao Wang
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yuanhao Qiu
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yufeng Sheng
- Department of Cardiology, The First People's Hospital of Zhangjiagang, Affiliated Hospital of Soochow University, Zhangjiagang, Jiangsu, China
| | - Xuesong Qian
- Department of Cardiology, The First People's Hospital of Zhangjiagang, Affiliated Hospital of Soochow University, Zhangjiagang, Jiangsu, China
| | - Yong Zhou
- Department of Cardiology, The First People's Hospital of Zhangjiagang, Affiliated Hospital of Soochow University, Zhangjiagang, Jiangsu, China
| | - Jiangang Zou
- Department of Cardiology, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
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14
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Myocardial strain computed at multiple spatial scales from tagged magnetic resonance imaging: Estimating cardiac biomarkers for CRT patients. Med Image Anal 2017; 43:169-185. [PMID: 29112879 DOI: 10.1016/j.media.2017.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 08/11/2017] [Accepted: 10/11/2017] [Indexed: 12/24/2022]
Abstract
Abnormal cardiac motion can indicate different forms of disease, which can manifest at different spatial scales in the myocardium. Many studies have sought to characterise particular motion abnormalities associated with specific diseases, and to utilise motion information to improve diagnoses. However, the importance of spatial scale in the analysis of cardiac deformation has not been extensively investigated. We build on recent work on the analysis of myocardial strains at different spatial scales using a cardiac motion atlas to find the optimal scales for estimating different cardiac biomarkers. We apply a multi-scale strain analysis to a 43 patient cohort of cardiac resynchronisation therapy (CRT) patients using tagged magnetic resonance imaging data for (1) predicting response to CRT, (2) identifying septal flash, (3) estimating QRS duration, and (4) identifying the presence of ischaemia. A repeated, stratified cross-validation is used to demonstrate the importance of spatial scale in our analysis, revealing different optimal spatial scales for the estimation of different biomarkers.
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15
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Chen JY, Lin KH, Chang KC, Chou CY. The Shortest QRS Duration of an Electrocardiogram Might Be an Optimal Electrocardiographic Predictor for Response to Cardiac Resynchronization Therapy. Int Heart J 2017; 58:530-535. [PMID: 28701672 DOI: 10.1536/ihj.16-364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jan-Yow Chen
- Division of Cardiology, Department of Medicine, China Medical University Hospital
- School of Medicine, China Medical University
| | - Kuo-Hung Lin
- Division of Cardiology, Department of Medicine, China Medical University Hospital
- School of Medicine, China Medical University
| | - Kuan-Cheng Chang
- Division of Cardiology, Department of Medicine, China Medical University Hospital
- School of Medicine, China Medical University
| | - Che-Yi Chou
- School of Medicine, China Medical University
- Division of General Medicine, Department of Medicine, China Medical University Hospital
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16
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Hyde ER, Behar JM, Crozier A, Claridge S, Jackson T, Sohal M, Gill JS, O'Neill MD, Razavi R, Niederer SA, Rinaldi CA. Improvement of Right Ventricular Hemodynamics with Left Ventricular Endocardial Pacing during Cardiac Resynchronization Therapy. Pacing Clin Electrophysiol 2016; 39:531-41. [PMID: 27001004 PMCID: PMC4913734 DOI: 10.1111/pace.12854] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 02/22/2016] [Accepted: 03/13/2016] [Indexed: 11/30/2022]
Abstract
Background Cardiac resynchronization therapy (CRT) with biventricular epicardial (BV‐CS) or endocardial left ventricular (LV) stimulation (BV‐EN) improves LV hemodynamics. The effect of CRT on right ventricular function is less clear, particularly for BV‐EN. Our objective was to compare the simultaneous acute hemodynamic response (AHR) of the right and left ventricles (RV and LV) with BV‐CS and BV‐EN in order to determine the optimal mode of CRT delivery. Methods Nine patients with previously implanted CRT devices successfully underwent a temporary pacing study. Pressure wires measured the simultaneous AHR in both ventricles during different pacing protocols. Conventional epicardial CRT was delivered in LV‐only (LV‐CS) and BV‐CS configurations and compared with BV‐EN pacing in multiple locations using a roving decapolar catheter. Results Best BV‐EN (optimal AHR of all LV endocardial pacing sites) produced a significantly greater RV AHR compared with LV‐CS and BV‐CS pacing (P < 0.05). RV AHR had a significantly increased standard deviation compared to LV AHR (P < 0.05) with a weak correlation between RV and LV AHR (Spearman rs = −0.06). Compromised biventricular optimization, whereby RV AHR was increased at the expense of a smaller decrease in LV AHR, was achieved in 56% of cases, all with BV‐EN pacing. Conclusions BV‐EN pacing produces significant increases in both LV and RV AHR, above that achievable with conventional epicardial pacing. RV AHR cannot be used as a surrogate for optimizing LV AHR; however, compromised biventricular optimization is possible. The beneficial effect of endocardial LV pacing on RV function may have important clinical benefits beyond conventional CRT.
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Affiliation(s)
- Eoin R Hyde
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Jonathan M Behar
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Andrew Crozier
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Simon Claridge
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Tom Jackson
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Manav Sohal
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Jaswinder S Gill
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Mark D O'Neill
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Reza Razavi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Steven A Niederer
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Christopher A Rinaldi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK.,Department of Cardiology, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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17
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Gąsior Z, Płońska-Gościniak E, Kułach A, Wita K, Mizia-Stec K, Szwed H, Kasprzak J, Tomaszewski A, Sinkiewicz W, Wojciechowska C. Impact of septal flash and left ventricle contractile reserve on positive remodeling during 1 year cardiac resynchronization therapy: the multicenter ViaCRT study. Arch Med Sci 2016; 12:349-52. [PMID: 27186179 PMCID: PMC4848364 DOI: 10.5114/aoms.2016.59260] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 10/24/2014] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Cardiac resynchronization therapy (CRT) has been shown to improve outcomes in patients with systolic heart failure (HFREF). However, the relatively high non-responder rate results in a need for more precise qualification for CRT. The ViaCRT study was designed to determine the role of contractile reserve and dyssynchrony parameters in predicting CRT response. The purpose of this analysis was to determine the effect of baseline septal flash and contractile reserve (CR) on clinical and echocardiographic parameters of response to CRT in 12-month follow-up. MATERIAL AND METHODS One hundred thirty-three guideline-selected CRT candidates (both ischemic and non-ischemic heart failure with reduced ejection fraction) were enrolled in the study. Baseline study population characteristics were: left ventricle ejection fraction (LVEF) 25 ±6%, QRS 165 ±25 ms, NYHA class III (90%) and IV (10%). RESULTS In subjects with septal flash (SF) registered before CRT implantation improvement in LVEF (14 ±2% vs. 8 ±1%, p < 0.05) and left ventricle (LV) systolic (63 ±10 ml vs. 36 ±6 ml, p < 0.05) and diastolic (46 ±10 ml vs. 32 ±7, p < 0.05) volumes was more pronounced than in patients without SF. In patients with CR (defined as LVEF increase by 20% or 4 viable segments) improvement in echo parameters was not significantly different then in the CR- group. Neither SF nor CR was associated with improvement in NYHA class. Subgroup analysis revealed that only in non-ischemic HF patients is presence of septal flash associated with LV function improvement after CRT. CONCLUSIONS In non-ischemic HF patients septal flash is a helpful parameter in prediction of LV remodeling after 12 months of resynchronization therapy.
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Affiliation(s)
- Zbigniew Gąsior
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Andrzej Kułach
- 2 Department of Cardiology, SPSK No. 7, Medical University of Silesia, Katowice, GCM, Poland
| | - Krystian Wita
- 1 Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Hanna Szwed
- 2 Department of Coronary Artery Disease, Institute of Cardiology, Warsaw, Poland
| | | | | | - Władysław Sinkiewicz
- 2 Department of Cardiology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Poland
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18
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Sarvari SI, Sitges M, Sanz M, Tolosana Viu JM, Edvardsen T, Stokke TM, Mont L, Bijnens B. Left ventricular dysfunction is related to the presence and extent of a septal flash in patients with right ventricular pacing. Europace 2016; 19:289-296. [DOI: 10.1093/europace/euw020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 01/20/2016] [Indexed: 11/13/2022] Open
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19
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Walmsley J, Huntjens PR, Prinzen FW, Delhaas T, Lumens J. Septal flash and septal rebound stretch have different underlying mechanisms. Am J Physiol Heart Circ Physiol 2016; 310:H394-403. [DOI: 10.1152/ajpheart.00639.2015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 11/16/2015] [Indexed: 11/22/2022]
Abstract
Abnormal left-right motion of the interventricular septum in early systole, known as septal flash (SF), is frequently observed in patients with left bundle branch block (LBBB). Transseptal pressure gradient and early active septal contraction have been proposed as explanations for SF. Similarities in timing (early systole) and location (septum) suggest that SF may be related to septal systolic rebound stretch (SRSsept). We aimed to clarify the mechanisms generating SF and SRSsept. The CircAdapt computer model was used to isolate the effects of timing of activation of the left ventricular free wall (LVFW), right ventricular free wall (RVFW), and septum on SF and SRSsept. LVFW and septal activation times were varied by ±80 ms relative to RVFW activation time. M-mode-derived wall motions and septal strains were computed and used to quantify SF and SRSsept, respectively. SF depended on early activation of the RVFW relative to the LVFW. SF and SRSsept occurred in LBBB-like simulations and against a rising transseptal pressure gradient. When the septum was activated before both LVFW and RVFW, no SF occurred despite the presence of SRSsept. Computer simulations therefore indicate that SF and SRSsept have different underlying mechanisms, even though both can occur in LBBB. The mechanism of leftward motion during SF is early RVFW contraction pulling on and straightening the septum when unopposed by the LVFW. SRSsept is caused by late LVFW contraction following early contraction of the septum. Changes in transseptal pressure gradient are not the main cause of SF in LBBB.
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Affiliation(s)
- John Walmsley
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands; and
| | - Peter R. Huntjens
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands; and
- L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Université de Bordeaux, Pessac, France
| | - Frits W. Prinzen
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands; and
| | - Tammo Delhaas
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands; and
| | - Joost Lumens
- CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands; and
- L'Institut de Rythmologie et Modélisation Cardiaque (IHU-LIRYC), Université de Bordeaux, Pessac, France
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20
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Abstract
Echocardiography is used in cardiac resynchronisation therapy (CRT) to assess cardiac function, and in particular left ventricular (LV) volumetric status, and prediction of response. Despite its widespread applicability, LV volumes determined by echocardiography have inherent measurement errors, interobserver and intraobserver variability, and discrepancies with the gold standard magnetic resonance imaging. Echocardiographic predictors of CRT response are based on mechanical dyssynchrony. However, parameters are mainly tested in single-centre studies or lack feasibility. Speckle tracking echocardiography can guide LV lead placement, improving volumetric response and clinical outcome by guiding lead positioning towards the latest contracting segment. Results on optimisation of CRT device settings using echocardiographic indices have so far been rather disappointing, as results suffer from noise. Defining response by echocardiography seems valid, although re-assessment after 6 months is advisable, as patients can show both continuous improvement as well as deterioration after the initial response. Three-dimensional echocardiography is interesting for future implications, as it can determine volume, dyssynchrony and viability in a single recording, although image quality needs to be adequate. Deformation patterns from the septum and the derived parameters are promising, although validation in a multicentre trial is required. We conclude that echocardiography has a pivotal role in CRT, although clinicians should know its shortcomings.
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21
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Remme EW, Niederer S, Gjesdal O, Russell K, Hyde ER, Smith N, Smiseth OA. Factors determining the magnitude of the pre-ejection leftward septal motion in left bundle branch block. Europace 2015; 18:1905-1913. [PMID: 26612883 PMCID: PMC5291191 DOI: 10.1093/europace/euv381] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 10/21/2015] [Indexed: 11/13/2022] Open
Abstract
Aims An abnormal large leftward septal motion prior to ejection is frequently observed in left bundle branch block (LBBB) patients. This motion has been proposed as a predictor of response to cardiac resynchronization therapy (CRT). Our goal was to investigate factors that influence its magnitude. Methods and results Left (LVP) and right ventricular (RVP) pressures and left ventricular (LV) volume were measured in eight canines. After induction of LBBB, LVP and, hence, the transmural septal pressure (PLV–RV = LVP–RVP) increased more slowly (P < 0.01) during the phase when septum moved leftwards. A biventricular finite-element LBBB simulation model confirmed that the magnitude of septal leftward motion depended on reduced rise of PLV–RV. The model showed that leftward septal motion was decreased with shorter activation delay, reduced global or right ventricular (RV) contractility, septal infarction, or when the septum was already displaced into the LV at end diastole by RV volume overload. Both experiments and simulations showed that pre-ejection septal hypercontraction occurs, in part, because the septum performs more of the work pushing blood towards the mitral valve leaflets to close them as the normal lateral wall contribution to this push is lost. Conclusions Left bundle branch block lowers afterload against pre-ejection septal contraction, expressed as slowed rise of PLV–RV, which is a main cause and determinant of the magnitude of leftward septal motion. The motion may be small or absent due to septal infarct, impaired global or RV contractility or RV volume overload, which should be kept in mind if this motion is to be used in evaluation of CRT response.
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Affiliation(s)
- Espen W Remme
- Institute for Surgical Research, Oslo University Hospital, 0372 Oslo, Norway .,Centre for Cardiological Innovation, Oslo University Hospital, Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Oslo, Norway.,KG Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway
| | - Steven Niederer
- Department of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Ola Gjesdal
- Institute for Surgical Research, Oslo University Hospital, 0372 Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Kristoffer Russell
- Institute for Surgical Research, Oslo University Hospital, 0372 Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Eoin R Hyde
- Department of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Nicolas Smith
- Department of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
| | - Otto A Smiseth
- Institute for Surgical Research, Oslo University Hospital, 0372 Oslo, Norway.,Centre for Cardiological Innovation, Oslo University Hospital, Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Oslo, Norway.,KG Jebsen Cardiac Research Centre, University of Oslo, Oslo, Norway
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22
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Daoulah A, Alsheikh-Ali AA, Al-Faifi SM, Ocheltree SR, Haq E, Asrar FM, Fathey A, Haneef AA, Al Mousily F, O ES, Lotfi A. Cardiac resynchronization therapy in patients with postero-lateral scar by cardiac magnetic resonance: A systematic review and meta-analysis. J Electrocardiol 2015; 48:783-90. [DOI: 10.1016/j.jelectrocard.2015.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Indexed: 10/23/2022]
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23
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Hartlage GR, Suever JD, Clement-Guinaudeau S, Strickland PT, Ghasemzadeh N, Magrath RP, Parikh A, Lerakis S, Hoskins MH, Leon AR, Lloyd MS, Oshinski JN. Prediction of response to cardiac resynchronization therapy using left ventricular pacing lead position and cardiovascular magnetic resonance derived wall motion patterns: a prospective cohort study. J Cardiovasc Magn Reson 2015; 17:57. [PMID: 26170046 PMCID: PMC4501253 DOI: 10.1186/s12968-015-0158-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 06/22/2015] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately. Recently, a "U-shaped" (type II) wall motion pattern identified by cardiovascular magnetic resonance (CMR) has been associated with improved CRT response compared to a homogenous (type I) wall motion pattern. There is also evidence that a left ventricular (LV) lead localized to the latest contracting LV site predicts superior response, compared to an LV lead localized remotely from the latest contracting LV site. METHODS We prospectively evaluated patients undergoing CRT with pre-procedural CMR to determine the presence of type I and type II wall motion patterns and pre-procedural echocardiography to determine end systolic volume (ESV). We assessed the final LV lead position on post-procedural fluoroscopic images to determine whether the lead was positioned concordant to or remote from the latest contracting LV site. CRT response was defined as a ≥ 15% reduction in ESV on a 6 month follow-up echocardiogram. RESULTS The study included 33 patients meeting conventional indications for CRT with a mean New York Heart Association class of 2.8 ± 0.4 and mean LV ejection fraction of 28 ± 9%. Overall, 55% of patients were echocardiographic responders by ESV criteria. Patients with both a type II pattern and an LV lead concordant to the latest contracting site (T2CL) had a response rate of 92%, compared to a response rate of 33% for those without T2CL (p = 0.003). T2CL was the only independent predictor of response on multivariate analysis (odds ratio 18, 95% confidence interval 1.6-206; p = 0.018). T2CL resulted in significant incremental improvement in prediction of echocardiographic response (increase in the area under the receiver operator curve from 0.69 to 0.84; p = 0.038). CONCLUSIONS The presence of a type II wall motion pattern on CMR and a concordant LV lead predicts superior CRT response. Improving patient selection by evaluating wall motion pattern and targeting LV lead placement may ultimately improve the response rate to CRT.
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Affiliation(s)
- Gregory R Hartlage
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Jonathan D Suever
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA, USA.
| | | | - Patrick T Strickland
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Nima Ghasemzadeh
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - R Patrick Magrath
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA, USA.
| | - Ankit Parikh
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Stamatios Lerakis
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Michael H Hoskins
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Angel R Leon
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Michael S Lloyd
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA.
| | - John N Oshinski
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA.
- Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA, USA.
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24
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Huntjens PR, Walmsley J, Wu V, Delhaas T, Axel L, Lumens J. Assessment of Septal Motion Abnormalities in Left Bundle Branch Block Patients Using Computer Simulations. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/978-3-319-20309-6_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
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