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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