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Larsen K, Zhao C, Keyak J, Sha Q, Paez D, Zhang X, Hung GU, Zou J, Peix A, Zhou W. A new method of modeling the multi-stage decision-making process of CRT using machine learning with uncertainty quantification. ARXIV 2024:arXiv:2309.08415v4. [PMID: 38463497 PMCID: PMC10925379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
AIMS The purpose of this study is to create a multi-stage machine learning model to predict cardiac resynchronization therapy (CRT) response for heart failure (HF) patients. This model exploits uncertainty quantification to recommend additional collection of single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI) variables if baseline clinical variables and features from electrocardiogram (ECG) are not sufficient. METHODS 218 patients who underwent rest-gated SPECT MPI were enrolled in this study. CRT response was defined as an increase in left ventricular ejection fraction (LVEF) > 5% at a 6+-1 month follow-up. A multi-stage ML model was created by combining two ensemble models: Ensemble 1 was trained with clinical variables and ECG; Ensemble 2 included Ensemble 1 plus SPECT MPI features. Uncertainty quantification from Ensemble 1 allowed for multi-stage decision-making to determine if the acquisition of SPECT data for a patient is necessary. The performance of the multi-stage model was compared with that of Ensemble models 1 and 2. RESULTS The response rate for CRT was 55.5% (n = 121) with overall male gender 61.0% (n = 133), an average age of 62.0+-11.8, and LVEF of 27.7+-11.0. The multi-stage model performed similarly to Ensemble 2 (which utilized the additional SPECT data) with AUC of 0.75 vs. 0.77, accuracy of 0.71 vs. 0.69, sensitivity of 0.70 vs. 0.72, and specificity 0.72 vs. 0.65, respectively. However, the multi-stage model only required SPECT MPI data for 52.7% of the patients across all folds. CONCLUSIONS By using rule-based logic stemming from uncertainty quantification, the multi-stage model was able to reduce the need for additional SPECT MPI data acquisition without sacrificing performance.
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Rodrigues I, Abreu A, Oliveira M, Cunha PS, Clara HS, Osório P, Lousinha A, Valente B, Portugal G, Rio P, Morais LA, Santos V, Carmo MM, Ferreira RC. Impact on long-term cardiovascular outcomes of different cardiac resynchronization therapy response criteria. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Rodrigues I, Abreu A, Oliveira M, Cunha PS, Clara HS, Osório P, Lousinha A, Valente B, Portugal G, Rio P, Morais LA, Santos V, Carmo MM, Ferreira RC. Impact on long-term cardiovascular outcomes of different cardiac resynchronization therapy response criteria. Rev Port Cardiol 2018; 37:961-969. [DOI: 10.1016/j.repc.2018.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 02/03/2018] [Accepted: 02/18/2018] [Indexed: 12/31/2022] Open
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Abstract
Randomized, controlled trials have shown that cardiac resynchronization therapy (CRT) is beneficial in patients with heart failure, impaired left ventricular (LV) systolic function, and a wide QRS complex. Other studies have shown that targeting the LV pacing site can also improve patient outcomes. Cardiovascular magnetic resonance (CMR) is a radiation-free imaging modality that provides unparalleled spatial resolution. In addition, emerging data suggest that targeted LV lead deployment over viable myocardium improves the outcome of patients undergoing CRT. This review explores the role of CMR in the preoperative workup of patients undergoing CRT.
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The Role of Cardiovascular Magnetic Resonance in Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2016; 7:619-33. [PMID: 26596807 DOI: 10.1016/j.ccep.2015.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Randomized, controlled trials have shown that cardiac resynchronization therapy (CRT) is beneficial in patients with heart failure, impaired left ventricular (LV) systolic function, and a wide QRS complex. Other studies have shown that targeting the LV pacing site can also improve patient outcomes. Cardiovascular magnetic resonance (CMR) is a radiation-free imaging modality that provides unparalleled spatial resolution. In addition, emerging data suggest that targeted LV lead deployment over viable myocardium improves the outcome of patients undergoing CRT. This review explores the role of CMR in the preoperative workup of patients undergoing CRT.
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Ahmed W, Samy W, Tayeh O, Behairy N, Abd El Fattah A. Left ventricular scar impact on left ventricular synchronization parameters and outcomes of cardiac resynchronization therapy. Int J Cardiol 2016; 222:665-670. [PMID: 27517660 DOI: 10.1016/j.ijcard.2016.07.158] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/26/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Left ventricular scar, including global scar and lateral wall, plays an important role in predicting response to cardiac resynchronization therapy (CRT). MATERIALS AND METHODS Thirty patients underwent CRT implantation. Assessment of left ventricular (LV) dyssynchrony was done through Gated SPECT LV phase analysis. Pre-implantation cardiac magnetic resonance (CMR) with late gadolinium enhancement technique to examine LV scar burden. Echocardiographic examination of LV end-systolic volume (LVES) prior to CRT and 6 months later. RESULTS Thirty patients received CRT (mean age 58.7±9.0, 24 males). Reverse LV remodeling (decline ≥15% from baseline VES) was documented in 19 patients. Temporal changes in LV dyssynchrony parameters were correlated to LV reverse remodeling. Applying ROC for predicting CRT non-response showed a cutoff 36.5% of global LV scar burden had a sensitivity of 81.8% and specificity of 68.4%. A cutoff for lateral wall scar burden 40.5% of whole lateral wall had a sensitivity of 72.7% and specificity of 68.4%. CONCLUSION Reverse LV remodeling is associated with temporal improvements in LV dyssynchrony parameters. LV scar had an unfavorable impact on CRT response. Both global and lateral wall scar burden could predict CRT nonresponse status.
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Affiliation(s)
- Walid Ahmed
- Critical Care Medicine Department, Cairo University, Egypt.
| | - Wael Samy
- Critical Care Medicine Department, Cairo University, Egypt.
| | - Osama Tayeh
- Critical Care Medicine Department, Cairo University, Egypt.
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Abstract
Cardiac resynchronization therapy (CRT) is a standard treatment for patients with heart failure. However, 30-40 % of the patients having CRT do not respond to CRT with improved clinical symptom and cardiac functions. It is important for CRT response that left ventricular (LV) lead is placed away from scar and at or near the site of the latest mechanical activation. Nuclear image-guided approaches for CRT have shown significant clinical value to assess LV myocardial viability and mechanical dyssynchrony, recommend the optimal LV lead position, and navigate the LV lead to the target coronary venous site. All these techniques, once validated and implemented, should impact the current clinical practice.
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Affiliation(s)
- Weihua Zhou
- School of Computing, University of Southern Mississippi, 730 East Beach Blvd, Long Beach, MS, 39560, USA.
| | - Ernest V Garcia
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA.
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Ma CY, Liu S, Yang J, Tang L, Zhang LM, Li N, Yu B. Evaluation of global longitudinal strain of left ventricle and regional longitudinal strain in the region of left ventricular leads predicts the response to cardiac resynchronization therapy in patients with ischemic heart failure. Cell Biochem Biophys 2015; 70:143-8. [PMID: 24619820 DOI: 10.1007/s12013-014-9870-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Myocardium viability in ischemic heart failure (HF) may affect the effect of cardiac resynchronization therapy (CRT). We hypothesized that longitudinal strain of 2D-STE, which reflects myocardium viability, can predict the response to CRT in patients with ischemic HF. 2D-STE was performed in 42 patients with HF, 1 week before and 1 year after CRT. GLS, RLS, and the LV synchrony index (SI), defined as the difference in timing to peak radial strain between LV anterior septal and posterior wall in LV short axis view, were calculated. A decrease in the LV end-systolic volume (LVESV) value of ≥ 15 % 1 year after CRT was defined as response to CRT. Twenty-nine patients responded to CRT (CRT-R group), while 13 patients did not respond and were assigned as CRT-NR group. Pre-CRT RLS and GLS were higher, while SI is lower, in CRT-R patients compared with CRT-NR group (p < 0.001). The ROC curve revealed that RLS of -11.5 % predicted response to CRT with sensitivity of 80.0 % and specificity of 77.9 % (AUC = 0.84, p < 0.001). Further, GLS of -13 % predicted response to CRT with sensitivity of 73.0 % and specificity of 73.4 % (AUC = 0.79, p < 0.001). In conclusion, LV dyssynchrony, GLS, and RLS calculated by 2D-STE can predict long-term response to CRT in patients with ischemic HF.
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Affiliation(s)
- Chun-Yan Ma
- Department of Cardiovascular Ultrasound, The First Affiliated Hospital of China Medical University, 155 Nanjing North Street, Heping, Shenyang, 110001, Liaoning, China,
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Hung GU, Huang JL, Lin WY, Tsai SC, Wang KY, Chen SA, Lloyd MS, Chen J. Impact of right-ventricular apical pacing on the optimal left-ventricular lead positions measured by phase analysis of SPECT myocardial perfusion imaging. Eur J Nucl Med Mol Imaging 2014; 41:1224-31. [PMID: 24577949 DOI: 10.1007/s00259-014-2693-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/02/2014] [Indexed: 11/27/2022]
Abstract
PURPOSE The use of SPECT phase analysis to optimize left-ventricular (LV) lead positions for cardiac resynchronization therapy (CRT) was performed at baseline, but CRT works as simultaneous right ventricular (RV) and LV pacing. The aim of this study was to assess the impact of RV apical (RVA) pacing on optimal LV lead positions measured by SPECT phase analysis. METHODS This study prospectively enrolled 46 patients. Two SPECT myocardial perfusion scans were acquired under sinus rhythm with complete left bundle branch block and RVA pacing, respectively, following a single injection of (99m)Tc-sestamibi. LV dyssynchrony parameters and optimal LV lead positions were measured by the phase analysis technique and then compared between the two scans. RESULTS The LV dyssynchrony parameters were significantly larger with RVA pacing than with sinus rhythm (p ~0.01). In 39 of the 46 patients, the optimal LV lead positions were the same between RVA pacing and sinus rhythm (kappa = 0.861). In 6 of the remaining 7 patients, the optimal LV lead positions were along the same radial direction, but RVA pacing shifted the optimal LV lead positions toward the base. CONCLUSION The optimal LV lead positions measured by SPECT phase analysis were consistent, no matter whether the SPECT images were acquired under sinus rhythm or RVA pacing. In some patients, RVA pacing shifted the optimal LV lead positions toward the base. This study supports the use of baseline SPECT myocardial perfusion imaging to optimize LV lead positions to increase CRT efficacy.
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Affiliation(s)
- Guang-Uei Hung
- Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
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10
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Lin X, Xu H, Zhao X, Chen J. Sites of latest mechanical activation as assessed by SPECT myocardial perfusion imaging in ischemic and dilated cardiomyopathy patients with LBBB. Eur J Nucl Med Mol Imaging 2014; 41:1232-9. [PMID: 24577952 DOI: 10.1007/s00259-014-2718-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 01/29/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Sites of latest mechanical activation (SOLA) have been recognized as optimal left-ventricular (LV) lead positions for cardiac resynchronization therapy (CRT). This study was aimed to investigate SOLA in ischemic cardiomyopathy (ICM) and dilated cardiomyopathy (DCM) patients with left bundle branch block (LBBB). METHODS Sixty-four consecutive LBBB patients (47 DCM, 17 ICM), who met the standard indications for CRT and underwent resting SPECT myocardial perfusion imaging (MPI), were selected. Phase analysis was used to assess LV dyssynchrony and SOLA. The Emory Cardiac Toolbox was used to measure perfusion defects. LV dyssynchrony and SOLA were compared between the DCM patients with wide (≥150 ms) and moderate (120-150 ms) QRS durations (QRSd). The relationship between SOLA and perfusion defects was analyzed in the ICM patients. RESULTS The DCM patients with wide QRSd had significantly more LV dyssynchrony than those with moderate QRSd. Lateral SOLA were significantly more frequent in the DCM patients with wide QRSd than those with moderate QRSd (96% vs. 62%, p = 0.010). In the ICM patients, SOLA were either in the scar segments (82%) or in the segments immediately adjacent to the scar segments (18%), regardless of QRSd. CONCLUSION Lateral SOLA were more frequent in the DCM patients with wide QRSd than those with moderate QRSd. Such relationship was not observed in the ICM patients, where SOLA were associated with scar location rather than QRSd. These findings support the use of SPECT MPI to aid the selection of potential CRT responders and guide LV lead placement.
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Affiliation(s)
- Xianhe Lin
- Department of Cardiology, Anhui Medical University, 218 Jixi Road, Hefei, Anhui, 230022, China
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Petretta M, Petretta A, Pellegrino T, Nappi C, Cantoni V, Cuocolo A. Role of nuclear cardiology for guiding device therapy in patients with heart failure. World J Meta-Anal 2014; 2:1-16. [DOI: 10.13105/wjma.v2.i1.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Revised: 11/20/2013] [Accepted: 12/19/2013] [Indexed: 02/05/2023] Open
Abstract
Heart failure is a dynamic condition with high morbidity and mortality and its prognosis should be reassessed frequently, particularly in patients for whom critical treatment decisions may depend on the results of prognostication. In patients with heart failure, nuclear cardiology techniques are useful to establish the etiology and the severity of the disease, while fewer studies have explored the potential capability of nuclear cardiology to guide cardiac resynchronization therapy (CRT) and to select patients for implantable cardioverter defibrillators (ICD). Left ventricular synchrony may be assessed by radionuclide angiography or gated single-photon emission computed tomography myocardial perfusion scintigraphy. These modalities have shown promise as predictors of CRT outcome using phase analysis. Combined assessment of myocardial viability and left ventricular dyssynchrony is feasible using positron emission tomography and could improve conventional response prediction criteria for CRT. Preliminary data also exists on integrated positron emission tomography/computed tomography approach for assessing myocardial viability, identifying the location of biventricular pacemaker leads, and obtaining left ventricular functional data, including contractile phase analysis. Finally, cardiac imaging with autonomic radiotracers may be useful in predicting CRT response and for identifying patients at risk for sudden cardiac death, therefore potentially offering a way to select patients for both CRT and ICD therapy. Prospective trials where imaging is combined with image-test driven therapy are needed to better define the role of nuclear cardiology for guiding device therapy in patients with heart failure.
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O'Donnell D, Lin T, Swale M, Rae P, Flannery D, Srivastava PM. Long-term clinical response to cardiac resynchronisation therapy under a multidisciplinary model. Intern Med J 2013; 43:1216-23. [PMID: 24015775 DOI: 10.1111/imj.12284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2013] [Accepted: 08/13/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiac resynchronisation therapy (CRT) is established in the management of cardiac failure in patients with systolic dysfunction. Clinical response to CRT is not uniform, and response has been difficult to predict. AIM Patient management within a high volume, multidisciplinary service focused on optimal delivery of CRT would improve response rates. METHODS Four hundred and thirty-five consecutive patients who underwent CRT under a multidisciplinary heart failure service were enrolled prospectively over a 5-year period. Medically optimised, symptomatic patients with an ejection fraction (EF) <35%, widened QRS or abnormal dyssynchrony index were included. Left ventricular lead position was targeted anatomically to the segment of latest mechanical activation, and electrically to a site with maximal intrinsic intracardiac electrogram separation. Routine device and clinical follow up, as well as CRT optimisations, were performed at baseline and at 3-monthly intervals. Responders were defined as having an absolute reduction in left ventricular end-diastolic diameter >10% and an improvement in EF >5%. RESULTS With a mean follow up of 53 ± 11 months, response rate to CRT was 81%. Mean EF improved from 26 ± 10% to 37 ± 11%, and mean left ventricular end-diastolic diameter reduced from 68.6 ± 9.2 mm to 57.8 ± 9.3 mm. Predictors of response were sinus rhythm, high dyssynchrony index and intrinsic electrical dyssynchrony >80 ms. Successful LV lead implantation at initial procedure was achieved in 99.1%, and at latest follow up 94.6% of initial LV leads were still active. CONCLUSION CRT undertaken with a unit focus on optimal LV lead positioning and device optimisation, along with a multidisciplinary follow-up model, results in an excellent response rate to CRT.
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Affiliation(s)
- D O'Donnell
- Department of Cardiology, Austin Health, Melbourne, Victoria, Australia
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van der Heide JA, Aly MFA, Kleijn SA, van Dijk J, Kamp O. A new quantification method for mechanical dyssynchrony with three-dimensional echocardiography; segmental time and volume loss for prediction of response to cardiac resynchronisation therapy. Int J Cardiovasc Imaging 2013; 28:1895-904. [PMID: 22302648 PMCID: PMC3485531 DOI: 10.1007/s10554-012-0019-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2011] [Accepted: 01/17/2012] [Indexed: 01/22/2023]
Abstract
A novel method to assess left ventricular (LV) mechanical dyssynchrony using three-dimensional echocardiography (3DE) and semi-automated border detection was investigated, which might be superior in prediction of response to cardiac resynchronisation therapy (CRT) compared to traditional measures that rely solely on segmental time-to-contraction. Twenty-eight heart failure patients underwent real-time 3DE before CRT and at 6–12 months follow-up. Analysis of 3DE was performed using TomTec Research-Arena software featuring semi-automated endocardial border detection. The following echocardiographic parameters were calculated in a 16-segment model: areas under segmental time-volume-curves (STV); delay between contraction of the earliest and latest segment (L-E); and standard deviation of segmental time-to-contraction (SDI). Response to CRT was defined as ≥10% decrease in LV end-systolic volume at follow-up. Baseline Pre-STV had a higher sensitivity than SDI for prediction of response (94 vs 67%, respectively), with equal specificity (78%) and a higher area under receiver operator characteristic curve. In contrast, L-E had a sensitivity of 83% and a specificity of 56%. Using 3DE, methods that combine segmental time-to-contraction with segmental contractility might improve LV dyssynchrony assessment compared to traditional methods based on segmental time-to-contraction alone. Pre-STV might be a better predictor of response to CRT than SDI.
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Affiliation(s)
- J. A. van der Heide
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - M. F. A. Aly
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - S. A. Kleijn
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - J. van Dijk
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
| | - O. Kamp
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
- Department of Cardiology, Institute for Cardiovascular Research (IcaR-VU), VU Medical Center, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
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Boidol J, Średniawa B, Kowalski O, Szulik M, Mazurek M, Sokal A, Pruszkowska-Skrzep P, Kukulski T, Kalarus Z, Lenarczyk R. Many response criteria are poor predictors of outcomes after cardiac resynchronization therapy: validation using data from the randomized trial. ACTA ACUST UNITED AC 2013; 15:835-44. [DOI: 10.1093/europace/eus390] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Joanna Boidol
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Beata Średniawa
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Oskar Kowalski
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Mariola Szulik
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Michał Mazurek
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Adam Sokal
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Patrycja Pruszkowska-Skrzep
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Tomasz Kukulski
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
| | - Radosław Lenarczyk
- Department of Cardiology, Congenital Heart Disease and Electrotherapy, Silesian Medical University, Silesian Centre for Heart Diseases, Skłodowskiej-Curie Street 9, 41-800 Zabrze, Poland
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Daubert JC, Saxon L, Adamson PB, Auricchio A, Berger RD, Beshai JF, Breithard O, Brignole M, Cleland J, DeLurgio DB, Dickstein K, Exner DV, Gold M, Grimm RA, Hayes DL, Israel C, Leclercq C, Linde C, Lindenfeld J, Merkely B, Mont L, Murgatroyd F, Prinzen F, Saba SF, Shinbane JS, Singh J, Tang AS, Vardas PE, Wilkoff BL, Zamorano JL, Anand I, Blomström-Lundqvist C, Boehmer JP, Calkins H, Cazeau S, Delgado V, Estes NAM, Haines D, Kusumoto F, Leyva P, Ruschitzka F, Stevenson LW, Torp-Pedersen CT. 2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Europace 2013; 14:1236-86. [PMID: 22930717 DOI: 10.1093/europace/eus222] [Citation(s) in RCA: 196] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
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Foell D, Jung BA, Germann E, Staehle F, Bode C, Hennig J, Markl M. Segmental myocardial velocities in dilated cardiomyopathy with and without left bundle branch block. J Magn Reson Imaging 2012; 37:119-26. [DOI: 10.1002/jmri.23803] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 08/03/2012] [Indexed: 11/07/2022] Open
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Daubert JC, Saxon L, Adamson PB, Auricchio A, Berger RD, Beshai JF, Breithard O, Brignole M, Cleland J, Delurgio DB, Dickstein K, Exner DV, Gold M, Grimm RA, Hayes DL, Israel C, Leclercq C, Linde C, Lindenfeld J, Merkely B, Mont L, Murgatroyd F, Prinzen F, Saba SF, Shinbane JS, Singh J, Tang AS, Vardas PE, Wilkoff BL, Zamorano JL. 2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management. Heart Rhythm 2012; 9:1524-76. [PMID: 22939223 DOI: 10.1016/j.hrthm.2012.07.025] [Citation(s) in RCA: 186] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Indexed: 11/30/2022]
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Seo MK, Park EA, Kim HK, Lee W, Kim YJ, Kim KH, Kim KB, Sohn DW, Ahn H, Park JH. Electrocardiographic QRS duration reflects right ventricular remodeling in patients undergoing corrective surgery for isolated tricuspid regurgitation: a comparative study with cardiac magnetic resonance imaging. Clin Cardiol 2012; 35:692-9. [PMID: 22744830 DOI: 10.1002/clc.22030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 05/21/2012] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The role of electrocardiogram (ECG) is unclear for the longitudinal follow-up of patients who undergo corrective surgery for isolated severe tricuspid regurgitation (TR). HYPOTHESIS This study sought to investigate the usefulness of changes in QRS duration of ECG after TR surgery in predicting right ventricular (RV) reverse remodeling as determined by cardiac magnetic resonance imaging (CMR). METHODS We enrolled 30 consecutive TR patients (27 women, aged 57.8 ± 9.6 years) who had undergone prior left-sided valve surgery. A computer-assisted analysis was performed for objective calculation of QRS duration before and after surgery. RESULTS At a median CMR follow-up of 27.5 months postsurgery, QRS duration was cut by 14.6%, from 110.4 ± 14.6 msec to 96.9 ± 11.9 msec (P < 0.001), while CMR showed a decrease in RV end-diastolic volume index (RV-EDVI) from 179.5 ± 59.7 to 119.1 ± 30.4 mL/m(2) (P < 0.001). QRS duration correlated significantly with RV-EDVI and RV end-systolic volume index (r = 0.65, P < 0.001 and r = 0.53, P < 0.001, respectively), and a percent change in QRS duration was significantly correlated with a percent change in RV-EDVI (r = 0.40, P = 0.03). When significant RV reverse remodeling was defined as a reduction in RV-EDVI ≥20% following TR surgery, the sensitivity and specificity for significant RV reverse remodeling were 75% and 78%, respectively, with a 9% reduction in QRS duration (P = 0.01, area underneath the receiver operator curve [AUC] = 0.81). CONCLUSIONS The extent of changes in postoperative QRS duration can be used as a useful, inexpensive, and simple index reflecting the occurrence of significant RV reverse remodeling in patients undergoing corrective TR surgery.
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Affiliation(s)
- Myung-Ki Seo
- Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Heydari B, Jerosch-Herold M, Kwong RY. Imaging for planning of cardiac resynchronization therapy. JACC Cardiovasc Imaging 2012; 5:93-110. [PMID: 22239899 DOI: 10.1016/j.jcmg.2011.11.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 11/14/2011] [Accepted: 11/15/2011] [Indexed: 10/14/2022]
Abstract
Cardiac resynchronization therapy (CRT) is a novel therapy for patients with refractory heart failure (HF). Large clinical trials evaluating CRT have demonstrated significant improvements in cardiac survival, decreases in recurrent HF hospitalization, and improvements in indexes of quality of life. Although numerous mechanisms are involved in CRT's therapeutic effects, correction of both interventricular and intraventricular mechanical dyssynchrony has been postulated as the key mechanism. To date, most large randomized controlled trials evaluating CRT have identified dyssynchronous patients on the basis of prolongation of the QRS complex from the baseline electrocardiogram. Concerns have been raised regarding the use of this measure for patient selection, stemming from a significant 30% to 40% nonresponse rate to CRT. Because of the cost and invasive nature of CRT, optimal patient selection for this therapy has become a priority for HF specialists and electrophysiologists. Cardiac imaging modalities have attempted to fulfill this need to improve patient selection by identifying mechanical dyssynchrony. Although early echocardiographic studies reported promising results, more recent larger scale studies have curtailed this enthusiasm, with a lack of established selection criteria for CRT in the current practice guidelines. This review summarizes the evidence to date and the potential role of imaging modalities in the selection and care of patients with HF referred for CRT.
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Affiliation(s)
- Bobak Heydari
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Gowda ST, Ahmad A, Younoszai A, Du W, Singh HR, Pettersen MD, Grimm RA, Boyle GJ. Left Ventricular Systolic Dyssynchrony in Pediatric and Adolescent Patients with Congestive Heart Failure. J Am Soc Echocardiogr 2012; 25:486-93. [DOI: 10.1016/j.echo.2012.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Indexed: 10/28/2022]
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Hotta VT, Martinelli Filho M, Mathias W, Vieira MLC. New equation for prediction of reverse remodeling after cardiac resynchronization therapy. Echocardiography 2012; 29:678-87. [PMID: 22348339 DOI: 10.1111/j.1540-8175.2011.01658.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To integrate data from two-dimensional echocardiography (2D ECHO), three-dimensional echocardiography (3D ECHO), and tissue Doppler imaging (TDI) for prediction of left ventricular (LV) reverse remodeling (LVRR) after cardiac resynchronization therapy (CRT). It was also compared the evaluation of cardiac dyssynchrony by TDI and 3D ECHO. METHODS Twenty-four consecutive patients with heart failure, sinus rhythm, QRS ≥ 120 msec, functional class III or IV and LV ejection fraction (LVEF) ≤ 0.35 underwent CRT. 2D ECHO, 3D ECHO with systolic dyssynchrony index (SDI) analysis, and TDI were performed before, 3 and 6 months after CRT. Cardiac dyssynchrony analyses by TDI and SDI were compared with the Pearson's correlation test. Before CRT, a univariate analysis of baseline characteristics was performed for the construction of a logistic regression model to identify the best predictors of LVRR. RESULTS After 3 months of CRT, there was a moderate correlation between TDI and SDI (r = 0.52). At other time points, there was no strong correlation. Nine of twenty-four (38%) patients presented with LVRR 6 months after CRT. After logistic regression analysis, SDI (SDI > 11%) was the only independent factor in the prediction of LVRR 6 months of CRT (sensitivity = 0.89 and specificity = 0.73). After construction of receiver operator characteristic (ROC) curves, an equation was established to predict LVRR: LVRR =-0.4LVDD (mm) + 0.5LVEF (%) + 1.1SDI (%), with responders presenting values >0 (sensitivity = 0.67 and specificity = 0.87). CONCLUSIONS In this study, there was no strong correlation between TDI and SDI. An equation is proposed for the prediction of LVRR after CRT. Although larger trials are needed to validate these findings, this equation may be useful to candidates for CRT.
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Birnie D, de Kemp RA, Tang AS, Ruddy TD, Gollob MH, Guo A, Williams K, Thomson K, DaSilva JN, Beanlands RS. Reduced septal glucose metabolism predicts response to cardiac resynchronization therapy. J Nucl Cardiol 2012; 19:73-83. [PMID: 22160630 DOI: 10.1007/s12350-011-9483-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 11/05/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND Up to 50% of patients do not respond to Cardiac Resynchronization Therapy (CRT). Recent work has focused on quantifying mechanical dyssynchrony and left ventricular scar. Septal reverse-mismatch (R-MM) (reduced FDG uptake vs perfusion) has been observed in patients with cardiomyopathy and prolonged QRS duration. We hypothesized that a greater quantity of septal R-MM would indicate a greater potential for reversibility of the cardiomyopathy, when the dyssynchrony is improved with CRT. Therefore, this study's objective was to assess whether greater septal R-MM pattern predicts response to CRT. METHODS AND RESULTS Forty-nine patients had pre-implant Rubidium-82 and Fluorine-18-fluorodeoxyglucose PET scanning. Total and regional left ventricular scar size and extent of R-MM were calculated. Response to CRT was defined as ≥10% improvement in left ventricular end-systolic volume or ≥5% absolute ejection fraction improvement. In the non-ischemic cardiomyopathy subset non-responders had significantly less septal R-MM than responders (13.1% compared to 27.1%, P = .012). There were correlations between the extent of septal R-MM and the increase in ejection fraction (r = 0.692, P = .0004) and reduction in left ventricular end-systolic volume (r = -0.579, P = .004). For each 5% absolute increase in extent of septal R-MM the odds ratio of being a responder was 2.17 (95% CI 1.15, 4.11, P = .017). Extent of septal R-MM displayed high sensitivity and specificity (area under curve = 0.855, P = .017) to predict response. CONCLUSIONS In patients with non-ischemic cardiomyopathy, greater extent of septal glucose metabolic R-MM pattern, predicted response to CRT. This parameter may be useful for identifying patients who benefit from CRT.
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Affiliation(s)
- David Birnie
- University of Ottawa Heart Institute, 40 Ruskin Road, Ottawa, ON K1Y 4W7, Canada.
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Donahue T, Niazi I, Leon A, Stucky M, Herrmann K. Acute and Chronic Response to CRT in Narrow QRS Patients. J Cardiovasc Transl Res 2011; 5:232-41. [DOI: 10.1007/s12265-011-9338-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 11/24/2011] [Indexed: 10/14/2022]
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25
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Mele D, Ascione L, Caso P, Manuppelli V, Martiniello AR, Nipote C. Ruolo attuale dell’ecocardiografia nella terapia di resincronizzazione cardiaca. J Cardiovasc Echogr 2011. [DOI: 10.1016/j.jcecho.2011.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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26
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Chen J, Garcia EV, Bax JJ, Iskandrian AE, Borges-Neto S, Soman P. SPECT myocardial perfusion imaging for the assessment of left ventricular mechanical dyssynchrony. J Nucl Cardiol 2011; 18:685-94. [PMID: 21567281 PMCID: PMC3285448 DOI: 10.1007/s12350-011-9392-x] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Phase analysis of gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) is an evolving technique for measuring LV mechanical dyssynchrony. Since its inception in 2005, it has undergone considerable technical development and clinical evaluation. This article reviews the background, the technical and clinical characteristics, and evolving clinical applications of phase analysis of gated SPECT MPI in patients requiring cardiac resynchronization therapy or implantable cardioverter defibrillator therapy and in assessing LV diastolic dyssynchrony.
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Affiliation(s)
- Ji Chen
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1364 Clifton Road NE, Atlanta, GA 30322, USA.
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Föll D, Jung B, Germann E, Hennig J, Bode C, Markl M. Magnetic resonance tissue phase mapping: Analysis of age-related and pathologically altered left ventricular radial and long-axis dyssynchrony. J Magn Reson Imaging 2011; 34:518-25. [DOI: 10.1002/jmri.22641] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 04/06/2011] [Indexed: 11/07/2022] Open
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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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Chen J, Boogers MJ, Boogers MM, Bax JJ, Soman P, Garcia EV. The use of nuclear imaging for cardiac resynchronization therapy. Curr Cardiol Rep 2011; 12:185-91. [PMID: 20425175 PMCID: PMC2848349 DOI: 10.1007/s11886-010-0086-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cardiac resynchronization therapy (CRT) has shown benefits in patients with end-stage heart failure, depressed left ventricular (LV) ejection fraction (≤ 35%), and prolonged QRS duration (≥ 120 ms). However, based on the conventional criteria, 20% to 40% of patients fail to respond to CRT. Studies have focused on important parameters for predicting CRT response, such as LV dyssynchrony, scar burden, LV lead position, and site of latest activation. Phase analysis allows nuclear cardiology modalities, such as gated blood-pool imaging and gated myocardial perfusion single photon emission computed tomography (GMPS), to assess LV dyssynchrony. Most importantly, GMPS with phase analysis has the potential of assessing LV dyssynchrony, scar burden, and site of late activation from a single acquisition, so that this technique may provide a one-stop shop for predicting CRT response. This article provides a summary on the role of nuclear cardiology in selecting patients for CRT, with emphasis on GMPS with phase analysis.
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Affiliation(s)
- Ji Chen
- Department of Radiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
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30
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SPECT and Cardiac Resynchronization Therapy. CURRENT CARDIOVASCULAR IMAGING REPORTS 2011. [DOI: 10.1007/s12410-011-9075-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Burns KV, Kaufman CL, Kelly AS, Parah JS, Dengel DR, Bank AJ. Torsion and Dyssynchrony Differences Between Chronically Paced and Non-Paced Heart Failure Patients. J Card Fail 2011; 17:495-502. [DOI: 10.1016/j.cardfail.2011.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 02/22/2011] [Accepted: 02/24/2011] [Indexed: 11/27/2022]
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[Role of imaging in cardiac resynchronization therapy]. Herzschrittmacherther Elektrophysiol 2011; 22:4-10. [PMID: 21344234 DOI: 10.1007/s00399-011-0116-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Several multicenter randomized clinical trials have established cardiac resynchronization as a safe and effective way to treat heart failure patients. This is reflected in the Focus Update of the European guidelines that describes a class IA indication in patients with NYHA class II-IV heart failure with LVEF≤35% and QRS≥120 ms (NYHA III/IV) or ≥150 ms (NYHA II). If applied in clinical practice, this patient selection results in ineffective treatment in about one third of patients implanted. Since the pathophysiological basis of the disease, a disorganized electromechanical function in patients with left bundle branch block (LBBB), is amenable to analysis with imaging methods, imaging has always played an important role in patient selection. None of the parameters used proved to be reliable for the prediction of cardiac resynchronization therapy success in the multicenter PROSPECT trial. Following the publication of PROSPECT in 2008, several new studies using echocardiography and cardiac magnetic resonance imaging were published. New publications are evaluated and analyzed in the context of earlier ones.
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Sung RK, Foster E. Assessment of Systolic Dyssynchrony for Cardiac Resynchronization Therapy Is Not Clinically Useful. Circulation 2011; 123:656-62. [DOI: 10.1161/circulationaha.110.954420] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Raphael K. Sung
- From the Division of Cardiology, University of California, San Francisco
| | - Elyse Foster
- From the Division of Cardiology, University of California, San Francisco
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Current and future role of cardiovascular magnetic resonance in cardiac resynchronization therapy. Heart Fail Rev 2011; 16:251-62. [DOI: 10.1007/s10741-010-9213-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Leyva F. Cardiac resynchronization therapy guided by cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2010; 12:64. [PMID: 21062491 PMCID: PMC2994940 DOI: 10.1186/1532-429x-12-64] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2010] [Accepted: 11/09/2010] [Indexed: 12/12/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for patients with symptomatic heart failure, severely impaired left ventricular (LV) systolic dysfunction and a wide (> 120 ms) complex. As with any other treatment, the response to CRT is variable. The degree of pre-implant mechanical dyssynchrony, scar burden and scar localization to the vicinity of the LV pacing stimulus are known to influence response and outcome. In addition to its recognized role in the assessment of LV structure and function as well as myocardial scar, cardiovascular magnetic resonance (CMR) can be used to quantify global and regional LV dyssynchrony. This review focuses on the role of CMR in the assessment of patients undergoing CRT, with emphasis on risk stratification and LV lead deployment.
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Affiliation(s)
- Francisco Leyva
- Centre for Cardiovascular Sciences, Queen Elizabeth Hospital, University of Birmingham, UK.
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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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Kaufman CL, Kaiser DR, Burns KV, Kelly AS, Bank AJ. Multi-plane mechanical dyssynchrony in cardiac resynchronization therapy. Clin Cardiol 2010; 33:E31-8. [PMID: 20043331 DOI: 10.1002/clc.20529] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The aims of this study were to assess the ability of several echo measures of dyssynchrony to predict CRT response and to characterize the global effect of CRT. HYPOTHESIS We hypothesized that after CRT there would be significant reductions in mechanical dyssynchrony in all 3 orthogonal planes of cardiac motion and that those patients with significant dyssynchrony prior to implant would have the best echocardiographic response. METHODS Standard echocardiograms were performed pre-CRT and post-CRT (138 +/- 63d) in 70 heart failure patients. Longitudinal dyssynchrony was calculated as the standard deviation (SD) of time to peak systolic displacement and velocity of 12 segments from 3 apical views. Using midventricular short axis views and speckle-tracking methods, the SD of time to peak radial and circumferential strain in 6 segments were calculated. Cardiac resynchronization therapy echo response was defined as > or = 15% decrease in left ventricular end-systolic volume. RESULTS Cardiac resynchronization therapy significantly improved systolic function in the longitudinal, radial, and circumferential planes. The CRT echo response rate was 57%. Echo responders (CRT(R)) had significantly (P < .05) more dyssynchrony at baseline as compared to nonresponders (CRT(NR)). Cardiac resynchronization therapy significantly (P < .05) reduced longitudinal and radial, but not circumferential, dyssynchrony in CRT(R). Dyssynchrony was unchanged in CRT(NR). Receiver-operator characteristic (ROC) curve analysis indicated significant, but modest sensitivity and specificity for longitudinal and radial intraventricular dyssynchrony and for interventricular dyssynchrony. Combining radial and longitudinal dyssynchrony measures improved positive prediction of CRT response. CONCLUSIONS Cardiac resynchronization therapy improves left ventricular function in 3 orthogonal planes of motion. Longitudinal, radial, and interventricular dyssynchrony modestly predict reverse remodeling.
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Miyazaki C, Redfield MM, Powell BD, Lin GM, Herges RM, Hodge DO, Olson LJ, Hayes DL, Espinosa RE, Rea RF, Bruce CJ, Nelson SM, Miller FA, Oh JK. Dyssynchrony indices to predict response to cardiac resynchronization therapy: a comprehensive prospective single-center study. Circ Heart Fail 2010; 3:565-73. [PMID: 20647479 DOI: 10.1161/circheartfailure.108.848085] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Whether mechanical dyssynchrony indices predict reverse remodeling (RR) or clinical response to cardiac resynchronization therapy (CRT) remains controversial. This prospective study evaluated whether echocardiographic dyssynchrony indices predict RR or clinical response after CRT. METHODS AND RESULTS Of 184 patients with heart failure with anticipated CRT who were prospectively enrolled, 131 with wide QRS and left ventricular ejection fraction <35% had 6-month follow-up after CRT implantation. Fourteen dyssynchrony indices (feasibility) by M-mode (94%), tissue velocity (96%), tissue Doppler strain (92%), 2D speckle strain (65% to 86%), 3D echocardiography (79%), and timing intervals (98%) were evaluated. RR (end-systolic volume reduction ≥15%) occurred in 55% and more frequently in patients without (71%) than in patients with (42%) ischemic cardiomyopathy (P=0.002). Overall, only M-mode, tissue Doppler strain, and total isovolumic time had a receiver operating characteristic area under the curve (AUC) greater than the line of no information, but none of these were strongly predictive of RR (AUC, 0.63 to 0.71). In nonischemic cardiomyopathy, no dyssynchrony index predicted RR. In ischemic cardiomyopathy, M-mode (AUC, 0.67), tissue Doppler strain (AUC, 0.79), and isovolumic time (AUC, 0.76) -derived indices predicted RR (P<0.05 for all), although the incremental value was modest. No indices predicted clinical response assessed by Minnesota Living with Heart Failure Questionnaire, 6-minute walk distance, and peak oxygen consumption. CONCLUSIONS These findings are consistent with the Predictors of Response to CRT study and do not support use of these dyssynchrony indices to guide use of CRT.
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Affiliation(s)
- Chinami Miyazaki
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minn 55905, USA
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Fornwalt BK, Sprague WW, BeDell P, Suever JD, Gerritse B, Merlino JD, Fyfe DA, León AR, Oshinski JN. Agreement is poor among current criteria used to define response to cardiac resynchronization therapy. Circulation 2010; 121:1985-91. [PMID: 20421518 DOI: 10.1161/circulationaha.109.910778] [Citation(s) in RCA: 229] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Numerous criteria believed to define a positive response to cardiac resynchronization therapy have been used in the literature. No study has investigated agreement among these response criteria. We hypothesized that the agreement among the various response criteria would be poor. METHODS AND RESULTS A literature search was conducted with the keywords "cardiac resynchronization" and "response." The 50 publications with the most citations were reviewed. After the exclusion of editorials and reviews, 17 different primary response criteria were identified from 26 relevant articles. The agreement among 15 of these 17 response criteria was assessed in 426 patients from the Predictors of Response to Cardiac Resynchronization Therapy (PROSPECT) study with Cohen's kappa-coefficient (2 response criteria were not calculable from PROSPECT data). The overall response rate ranged from 32% to 91% for the 15 response criteria. Ninety-nine percent of patients showed a positive response according to at least 1 of the 15 criteria, whereas 94% were classified as a nonresponder by at least 1 criterion. kappa-Values were calculated for all 105 possible comparisons among the 15 response criteria and classified into standard ranges: Poor agreement (kappa< or =0.4), moderate agreement (0.4<kappa<0.75), and strong agreement (kappa> or =0.75). Seventy-five percent of the comparisons showed poor agreement, 21% showed moderate agreement, and only 4% showed strong agreement. CONCLUSIONS The 26 most-cited publications on predicting response to cardiac resynchronization therapy define response using 17 different criteria. Agreement between different methods to define response to cardiac resynchronization therapy is poor 75% of the time and strong only 4% of the time, which severely limits the ability to generalize results over multiple studies.
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Affiliation(s)
- Brandon K Fornwalt
- Emory University School of Medicine, Department of Radiology, Atlanta, GA 30322, USA.
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Patient assessment for cardiac resynchronization therapy: Past, present and future of imaging techniques. Can J Cardiol 2010; 26:27-34. [PMID: 20101354 DOI: 10.1016/s0828-282x(10)70332-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
It has been proposed that dyssynchrony assessment before cardiac resynchronization therapy (CRT) implantation could help predict response to CRT. It is known that up to 40% of patients who receive a CRT device for established indications do not respond to CRT. Great expectations came from the Predictors of Response to Cardiac Resynchronization Therapy (PROSPECT) study, which would finally identify the ultimate echocardiographic dyssynchrony criteria to help select responders. The recently published PROSPECT trial failed to identify an ideal parameter of dyssynchrony. Patient selection for CRT should involve a multimodal approach, and new promising tools are being investigated in that view. The present review integrated new data coming from the exciting field of imaging with currently available evidence to generate a stepwise approach to patient selection.
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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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Popovic ZB, Thomas JD. In search of a holy grail: predicting cardiac resynchronization therapy outcomes by echocardiography. Circ Cardiovasc Imaging 2009; 1:3-5. [PMID: 19808508 DOI: 10.1161/circimaging.108.797175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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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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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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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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Mlynarski R, Sosnowski M, Wlodyka A, Kargul W, Tendera M. A user-friendly method of cardiac venous system visualization in 64-slice computed tomography. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:323-9. [PMID: 19272061 DOI: 10.1111/j.1540-8159.2008.02239.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previsualization of the cardiac venous system is very important for some techniques, for example, cardiac resynchronization therapy (CRT). The aim of this study was to propose a new, user-friendly method of cardiac venous system visualization in 64-slice computed tomography (CT). METHODS In 112 patients (66 M) aged 58 +/- 11 standard deviation, a 64-slice CT with a retrospective electrocardiogram gating was performed due to a suspicion of ischemic heart disease. Special attention was paid to the requirements for image reconstruction useful for CRT. RESULTS In 74% of the patients, it was possible to obtain similar images to those during the CRT implantation procedure within anterior-posterior, left anterior oblique, and right anterior oblique views. The coronary sinus was clearly visible in all cases, the ostium measured 12.9 +/- 5.9 mm, and the angle of entrance 99 +/- 12 degrees. In all patients it was possible to demonstrate more than one vein; in 95%, at least one vein was clearly visible in the target area. Among the target veins, the posterolateral vein was visible most frequently (78%) in the cases as well as the lateral vein (78%). CONCLUSION The proposed scheme in 64-slice computed tomography enables images to be generated similar to the intraoperative fluoroscopy, which can be useful in techniques where previsualization of the cardiac venous system is recommended.
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Affiliation(s)
- Rafal Mlynarski
- Department of Electrocardiology, Medical University of Silesia, ul Ziolowa 45/47, Katowice, Poland.
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Hawkins NM, Petrie MC, Burgess MI, McMurray JJ. Selecting Patients for Cardiac Resynchronization Therapy. J Am Coll Cardiol 2009; 53:1944-59. [DOI: 10.1016/j.jacc.2008.11.062] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 10/14/2008] [Accepted: 11/02/2008] [Indexed: 10/20/2022]
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Abraham T, Kass D, Tonti G, Tomassoni GF, Abraham WT, Bax JJ, Marwick TH. Imaging Cardiac Resynchronization Therapy. JACC Cardiovasc Imaging 2009; 2:486-97. [DOI: 10.1016/j.jcmg.2009.01.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Revised: 12/30/2008] [Accepted: 01/09/2009] [Indexed: 10/20/2022]
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Mele D, Toselli T, Capasso F, Stabile G, Piacenti M, Piepoli M, Giatti S, Klersy C, Sallusti L, Ferrari R. Comparison of myocardial deformation and velocity dyssynchrony for identification of responders to cardiac resynchronization therapy. Eur J Heart Fail 2009; 11:391-9. [DOI: 10.1093/eurjhf/hfp032] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Donato Mele
- Azienda Ospedaliero-Universitaria, Ferrara and Fondazione Salvatore Maugeri, Brescia; Corso Giovecca 203 44100 Ferrara Italy
| | - Tiziano Toselli
- Azienda Ospedaliero-Universitaria, Ferrara and Fondazione Salvatore Maugeri, Brescia; Corso Giovecca 203 44100 Ferrara Italy
| | - Fabio Capasso
- Cardiac Unit, Casa di Cura S. Michele; Maddaloni Italy
| | | | | | | | - Sara Giatti
- Azienda Ospedaliero-Universitaria, Ferrara and Fondazione Salvatore Maugeri, Brescia; Corso Giovecca 203 44100 Ferrara Italy
| | - Catherine Klersy
- Biometry and Clinical Epidemiology Service; Fondazione IRCCS Policlinico S. Matteo; Pavia Italy
| | | | - Roberto Ferrari
- Azienda Ospedaliero-Universitaria, Ferrara and Fondazione Salvatore Maugeri, Brescia; Corso Giovecca 203 44100 Ferrara Italy
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