Download Working Group of Heart Failure and Cardiac Function

Working Group of
Heart Failure and Cardiac Function
How to evaluate and treat
dyssynchrony ?
P Lancellotti , LA Piérard , Liège , BE
PATIENT’S HISTORY
Idiopathic cardiomyopathy
- LV Ejection fraction = 21 %
- End-diastolic volume = 341 ml
- End-systolic volume = 269 ml
QRS width = 118 ms
NYHA class III  NYHA class II under maximal tolerated treatment
Lisinopril 10 mg , Carvedilol 12.5 mg x 2, Spironolactone 25 mg
Live from Liège
STEPWISE SELECTION
1. Aortic pre-ejection time > 140 ms
STEPWISE SELECTION
1. Aortic pre-ejection time > 140 ms
2. Interventricular delay > 40 ms
STEPWISE SELECTION
1. Aortic pre-ejection time > 140 ms
2. Interventricular delay > 40 ms
3. Septal-to-posterior delay > 130 ms
STEPWISE SELECTION
1. Aortic pre-ejection time > 140 ms
2. Interventricular delay > 40 ms
3. Septal-to-posterior delay > 130 ms
4. LV filling time < 40 % of cardiac cycle
STEPWISE SELECTION
1. Aortic pre-ejection time > 140 ms
2. Interventricular delay > 40 ms
3. Septal-to-posterior delay > 130 ms
4. LV filling time < 40 % of cardiac cycle
5. DTI TPS
-
Septal-to-lateral delay > 60 ms
STEPWISE SELECTION
1. Aortic pre-ejection time > 140 ms
2. Interventricular delay > 40 ms
3. Septal-to-posterior delay > 130 ms
4. LV filling time < 40 % of cardiac cycle
5. DTI TPS
-
Septal-to-lateral delay > 60 ms
-
LV dispersion (4 segments) > 65 ms
STEPWISE SELECTION
1. Aortic pre-ejection time > 140 ms
2. Interventricular delay > 40 ms
3. Septal-to-posterior delay > 130 ms
4. LV filling time < 40 % of cardiac cycle
5. DTI TPS
-
Septal-to-lateral delay > 60 ms
-
LV dispersion (4 segments) > 65 ms
-
Standard deviation (12 segments) > 31 ms
STEPWISE SELECTION
1. Aortic pre-ejection time > 140 ms
2. Interventricular delay > 40 ms
3. Septal-to-posterior WM delay > 130 ms
4. LV filling time < 40 % of cardiac cycle
5. DTI Time to Peak Systolic velocity
-
Septal-to-lateral delay > 60 ms
-
LV dispersion (4 segments) > 65 ms
-
Standard deviation (12 segments) > 31 ms
-
Inter + Intra V delay > 102 ms
STEPWISE SELECTION
ESC Guidelines
° NYHA III-IV, QRS > 120 ms, EF < 35 %, Optimal treatment
Major criteria (high sensitivity and specificity) (At least 1)
° Intraventricular asynchrony
- LV dispersion  65 ms (lateral wall latest activated )
- TPS SD 12  31 ms (ischemic disease)
° Inter + Intra V delay > 102 ms
Minor criteria (low sensitivity or specificity) (At least 3)
° Septal-to-posterior delay > 130 ms
° Interventricular delay > 40 ms
° Aortic pre-ejection time > 140 ms
° LV filling time < 40 % of cardiac cycle
° Diastolic mitral regurgitation
IMPLANTATION : YES or NO ?
NYHA class II  Not recommended in the ESC guidelines
QRS width < 120 ms  Not recommended in the ESC guidelines
« Paradoxical » asynchrony with severe septal delay
- Position of the right ventricular lead ?
- Position of the left ventricular lead ?
Good exercise capacity  Peak VO2 : 28 ml/kg/min (Weber A)
160 VE (L/min)
24
VE/VCO2 slope
120
25
38
80
40
0
0
1
2
3
4
5
VCO2 (L/min)
= Normal
= Patient
= NYHA class III
Working Group of
Heart Failure and Cardiac Function
How to assess the effects of CRT ?
1994-2006 : 12 years of CRT
What did we learn ?
• Permanent LV pacing is feasible and safe
• CRT improves functional status and quality of life
• CRT decreases hospitalization rate (inconsistent)
• CRT reverts LV remodeling
• CRT improves survival (CARE-HF)
Evaluation of CRT
Invasive : pressure-volume loops
Exercise capacity : 6-min walk test
treadmill ex. : peak VO2
Holter recording : arrhythmias
heart rate variability
Biology : changes in BNP and neurohormones
Functional status and quality of life
Imaging techniques : Doppler Echo , MRI
Definition of Responder and Non Responder
• Responder : survival +  NYHA class 1 + 10% increase
in peak VO2, 3 to 6 months after CRT)
• Responder :  NYHA class  1
• Responder :  LVESV >15% (>10%)
• Responder: persistent decrease of NYHA class 1,
irrespective of the changes of other parameters.
• Non responder (20 to 30%) :
therapy considered as neutral or not beneficial (no decrease in
NYHA class or QOL score ; need for heart transplant; death due to
progressive, drug-refractory pump failure).
ECHO in CRT
- selection of pts : documentation and quantitation of dyssynergy
- guiding the procedure : best position of RV and venous leads
- optimizing of AV and VV delays
- evaluation of haemodynamic effects : acutely
during follow-up
Acute Effects
 Systolic pressure (6 mmHg)
 Stroke volume (10 to 30%)
 dP/dt max (15 to 35%)
 Arterial pulse pressure
 End-systolic volume
 Functional MR ( ERO and  RV by 30%)
Chronic Effects
 dP/dt max
 LV ejection fraction
 Arterial pulse pressure
 End-diastolic volume
 End-systolic volume : reverse remodeling ( ESV > 15%)
 Functional MR (further 10% at rest and
 of dynamic component)
Lat
Sept
Lat
Sept
ECHO and CRT
Acute and long-term effects on
mechanical resynchronisation
diastolic filling time , stroke volume
mitral regurgitation (at rest and exercise)
LV reverse remodeling
changes in systolic and diastolic function