Download Mechanical dyssynchrony provides the clue Erwan DONAL

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ESC 2012
“CRT: Optimising Selection and Success”
Mechanical dyssynchrony provides
the clue
Erwan DONAL
Cardiologie – CHU Rennes
[email protected]
Why do we still believe in Imaging for
selection of patients for CRT?
30% of non-response still today
Prediction of response based on QRSduration: sub-optimal
Electro-mechanical coupling highly different
from a LBBB patient to another broad QRS
sub-optimal prediction of response
according to baseline QRS duration
Response and nonresponse to CRT according to baseline QRS duration
Cut-off of 163ms:
Sensitivity 57%
Specificity 53%
AUC 0.58 / 626 pts
Delgado, V. et al. Circulation 2011;123:640-655
LBBB
=
QRS duration ≥120 milliseconds;
QS or rS in lead V1;
broad R waves in leads I, aVL, V5, or V6;
and absent q waves in leads V5 and V6
≠
RBBB and
intra ventricular conduction delays
even with broad QRS
Gold, Thebault…Daubert. REVERSE Trial. Circulation. 2012; 126: 822-829
Interest in imaging mechanical
dyssynchrony
11 – 38% patients having QRS > 120 ms don’t
have any mechanical dyssynchrony
How to assess Mechanical
Dyssynchrony?
Even More
Challengin g
for routine:
Radial strain,
3D, 3D Strain
M-Mode, DTI,
Longitunal 2D
strain
SIMPLE
Pulse Doppler
SIMPLE
Mitral Inflow
Mitral inflow duration should exceed
40% of the cycle lenght (RR).
Short mitral inflow
with a fusion of E
and A waves
LBBB
CRT
Inter Ventricular Mechanical delay (IVMD)
SIMPLE
Significative if > 45ms
ECG
Ao
Aortic Outflow
Pulmonary outflow
Pulm
Q - Ao = 150 ms
Q - Pulm = 100 ms
IVMD
= 50 ms
Q-Ao> 140 msec
(evocative of intra LV dyssynchrony)
BEFORE BIV pacing
C
D
A
Right (RV )and left ventricular (LV) outflow tract pulse Doppler:
Before C: LV pre-ejection time (PEI)=150ms ; D: RV PEI = 88ms
Transmitral pulse Doppler:
Inter
Ventricular
delay
= 64ms
A:>>
E and
A are
fused, LV filling
= 22%
RR
6month POST BIV
B:After:
normalF:
mitral
inflow
withE:
LVRV
filling
LV PEI
= 144;
PEI=105
= 44% RR
>> inter Ventricular delay = 39ms
B
E
F
Intra LV dyssynchrony : radial, longitudinal directions
SIMPLE
Mid Septal Flash
R Wave
Septum
Inferolateral
End of
T-wave
LVeDD 55mm
LV EF 33%
LVeDD 44mm
LVeSVol 82ml
Pre-BiV
pacing
Septal
flash
LV EF 62%
LVeSVol 45ml
Post-BiV
pacing
De Boeck B W et al. Eur J Heart Fail 2008;10:281-290
Value of 2D-S
LONGITUDINAL
Septal
Septal
Ao V Closure
Antero-lateral
Antero-lateral Wall
Wall
Look at Timing in each wall!
Feasibility of speckle-tracking analysis in consecutive patients
LV synchrony and
Contractile function
assessed by speckle
tracking appeared to be
more robust than utilizing
Doppler-based
techniques
Pouleur A et al. Eur Heart J 2011;32:1720-1729
Effect of asynchronous ventricular activation on mechanical dyssynchrony (DYS) indices.
Lumens J et al. Circ Cardiovasc Imaging 2012;5:491-499
RADIAL
more
challenging
Radial Speckle tracking analysis (2D-S)
Ao V Closure
Infero-lateral Wall
Septal
Multi-parametric Evaluation
Lafitte S et al. Eur Heart J 2009;30:2880-2887
132 CRT-candidates (LVEF, 19±6%; QRS width, 170±22 ms), 4 mechanical
dyssynchrony indices (septal systolic rebound stretch [SRSsept], IVMD, Strain-SL, and
SPWMD) quantified at baseline.
CRT response :6-month percent change of LV end-systolic volume.
The power to predict CRT response differs between
indices of mechanical dyssynchrony.
SRSsept and IVMD better represent LV dyssynchrony
amenable to CRT
and better predict CRT response than the indices
assessing time-to-peak deformation or motion.
Circ Cardiovasc Imaging. 2012;5:491-499.
Multi-parametric Evaluation
Do not imply only to look at
dyssynchrony but also at:
Degree of LV enlargement,
Sphericity index
Mitral Regurgitation
Right Heart Function
Contractile Reserve
Irreversible advanced heart failure
Mechanical dyssynchrony provides the clue
The puzzle of nonresponse to CRT:
Mechanical dyssynchrony
is part of it …
Still no acceptance of
mechanical
dyssynchrony indices
in guidelines
simples key messages: typical LBBB with
large QRS are the best candidates
Gorcsan J Circulation 2011;123:10-12