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“Incontri Pitagorici di Cardiologia 2010”
“Πυθαγόρειοι κάνουμε συναντήσεις καρδιολογίας”
VIIIa Edizione
La selezione dei pazienti candidati alla
Terapia Resincronizzante Cardiaca
M Cristina Porciani
Firenze
It has been well established that CRT is able to
improve clinical and hemodinamic parameters in
patients with heart failure and LBBB
CRT reduces HF hospitalizations
McAlister FA et al, Ann Intern Med. 2004;.
CRT improves quality of life
McAlister FA et al, Ann Intern Med. 2004;.
CRT reduces mortality
Cleland JGF et al NEJM 2005
CRT reverses LV remodeling
t
Sutton
MG Circulation 2003
Reverse remodeling induced by CRT
Baseline
CRT
3 months
6months
Guidelines of ACC/AHA (2009)
Biventricular Stimulation in Patients With
Medically Refractory Heart Failure NYHA IIIIV, Idiopathic or Ischemic Cardiomyopathy,
QRS 120 ms, and EF  35%
1Circulation
2002
RATIONALE OF CRT
LBBB
discordinate contraction
ventricular dysfunction
Electrical asinchrony
Mechanical asynchrony
Reduction of QRS duration occurs only
in responders
Lecoq G et al Eur Heart J 2005
Intraventricular dyssynchrony
%
80
71,1
70
57,1
60
50
40
29,5
30
20
10
0
<120 ms
>120<150 ms
>150 ms
QRS duration
Ghio S et al Eur Heart J 2004;25:571-578
Echocardiographic Data Before and After Cardiac Resynchronization Therapy
QRS > 120ms
QRS< 120ms
Achilli A et al JACC 2003
Mechanical Resynchronization Does Not Require Electrical Synchrony in the
Dilated Failing Heart With Left Bundle-Branch Block
Electrical epicardial activation map of whole heart for 3
pacing modes
Leclerq C et al Circulation 2002
Mechanical Resynchronization Does Not Require Electrical Synchrony in the
Dilated Failing Heart With Left Bundle-Branch Block
Mechanical LV activation map of whole heart for 3 pacing
modes
Leclerq C et al Circulation 2002
• it appears that
Mechanical rather than electrical synchrony
seems most important for functional
improvement with CRT
Interventricular asynchrony
TDI is useful in recording the chronology and the entity of the velocity
curves of miocardium segments
Ts-SD
Cut-off 33ms
Ts
the Standard Deviation of the 6 basal and the 6 mid LV segmental Ts
as systolic asynchrony parameter
septal to lateral delay
cut-off 60 ms
Bax et al. AM J Cardiol 2003;92:1238-40
TSI (Tissue Synchronization Imaging)
Yu et al. JACC 2005; 45:677-84.
Results of the PROSPECT study
No single measure of mechanical dyssynchrony may be
recommended to improve pt selection forCRT
Methodology to determine mechanical dyssynchrony
needs further elaboration
QRS remains the selection criterium of
dyssynchrony to identify for CRT
Circulation 2008
From the initial focus on electrical markers, interest shifted
toward a more direct assessment of mechanical dyssynchrony by
means of tissue Doppler imaging (TDI).
from the direct assessment of mechanical dyssynchrony ,
attention again shifted toward QRS
Electrical asynchrony
Mechanical asynchrony
+
-
+
+
+
Porciani et al Echocardiography 2010
Porciani et al Echocardiography 2010
The question is
Since it is electrical activation that produces
myocardial contraction that in turn is necessary for
cardiac movement,
why would they be any different?
The answer should be
►Problems with measuring electrical ayncrony
►Electromechanical interaction
►Complex
aynchrony
nature of electrical and mechanical
Problems with measuring electrical synchrony
Signal averaged electrocardiography detects potentials too low to appear on the
standard 12 lead electrocardiogram
Xiao Br Heart J 1994
Surgical Ventricular Restoration Improves Mechanical Intraventricular
Dyssynchrony in Ischemic Cardiomyopathy
Narrow QRS
Di Donato et al Circulation 2004
Surgical Ventricular Restoration Improves Mechanical Intraventricular
Dyssynchrony in Ischemic Cardiomyopathy
Narrow QRS
Di Donato et al Circulation 2004
Concordance Between Mechanical and Electrical Dyssynchrony
in Heart Failure Patients: A Function of the Underlying Cardiomyopathy?
Tournoux F. JCE, 2007
What’s about mechanichal dyssynchrony?
Henein MY Heart 1999
Combined Longitudinal and Radial Dyssynchrony Predicts Ventricular
Response After Resynchronization Therapy
Longitudinal asynchrony (TDI)
Radial asynchrony (Speckle-tracking radial strain)
Gorcsan J. JACC 2007
)
Gorcsan J. JACC 2007
Porciani et al PACE 2008
Normal
RV ejection
RV filling
LV ejection
IVCT
LV filling
IVRT
LBBB
RV ejection
RV filling
LV ejection
IVCT
LV filling
IVRT
Total isovolumic Time Index
a–b
R-R
Myocardial Performance Index (MPI)
Porciani et al J Card Med 2010
Porciani et al J Card Med 2010
Porciani et al J Card Med 2010
CONCLUSIONS
Which is the best?