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I have nothing to disclose. 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