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Imaging dyssynchrony Tissue Doppler echocardiography

Rania El-Husseiny, MD Critical Care Medicine

Cairo University ECRA 2013

Imaging dyssynchrony

Over the past decade, cardiac resynchronization

therapy (CRT) has changed the treatment of

patients with end-stage, drug-refractory heart

failure. ¹

1- Bax JJ, Gorcsan J. Echocardiography and Noninvasive Imaging in Cardiac Resynchronization Therapy. Results of the PROSPECT (Predictors of Response to Cardiac Resynchronization Therapy) Study in Perspective. J Am Coll Cardiol. 2009;53(21):1933-1943.

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Imaging dyssynchrony

Evidence of multiple large trials (≈4.000 patients)

and numerous small studies have demonstrated the

benefit of CRT on heart failure symptoms, exercise

capacity, and systolic left ventricular function. ¹

1- Bax JJ, Gorcsan J. Echocardiography and Noninvasive Imaging in Cardiac Resynchronization Therapy. Results of the PROSPECT (Predictors

of Response to Cardiac Resynchronization Therapy) Study in Perspective. J Am Coll Cardiol. 2009;53(21):1933-1943.

Imaging dyssynchrony

20% to 30% of patients do not respond to CRT.¹

A need for additional selection criteria to identify potential responders.

The presence of substantial left ventricular (LV) dyssynchrony is a major predictor of response to CRT.

1. Leclercq C, Kass DA. Retiming the failing heart: principles and current clinical status of cardiac resynchronization. J Am Coll Cardiol 2002;39:194–201.

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Imaging dyssynchrony

Imaging dyssynchrony

Mechanical dyssynchrony is not necessarily related to

electrical dyssynchrony. ¹

Incidence:

40% of patients with dilated cardiomyopathy and QRS

duration ˃ 120 ms,

70% of patients with QRS duration ˃ 150 ms.² 1. Kass DA. Predicting cardiac resynchronization response by QRS duration: the long and short of it. J Am Coll Cardiol 2003;42:2125–7.

2. 2. Haghjoo M, et al. Prevalence of mechanical dyssynchrony in heart failure patients with different QRS durations. Pacing Clin Electrophysiol. 2007;30:616 –22.

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Imaging dyssynchrony

MECHANICAL DYSSYNCHRONY

I- Atrioventricular (AV) dyssynchrony

II- Interventricular dyssynchrony.

III- Intraventricular dyssynchrony.

Atrioventricular (AV) dyssynchrony

LVFT/RR is <40%.

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Inter-ventricular dyssynchrony

Normal <20 msec Cutoff ≥ 40 msec¹

Interventricular dyssynchrony

1. Penicka M, et al. Improvement of left ventricular function after cardiac resynchronization therapy is predicted by tissue Doppler imaging

echocardiography. Circulation. 2004;109(8):978-83.

Cutoff >56 mse¹

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Intraventricular dyssynchrony

≥ 130 ms M-mode ]7[to posterior wall motion delay Septal

≥ 60 ms Tissue velocity imaging ]8[delay Tsto lateral Septal

> 65 ms Tissue velocity imaging ]9[basal LV segments4 in TsMax delay in

≥ 36.5 ms Tissue velocity imaging ]10[basal LV segments6 of TsSD of

≥ 100 ms Tissue velocity imaging ]11[basal and mid LV segments12 in TsMax delay in

≥ 32.6 ms Tissue velocity imaging ]12[Index) Dyssynchronybasal and mid LV segments (12 in TsSD of

≥ 130 ms 2D speckle tracking Anteroseptal to posterior time to peak strain difference (radial

]13[strain)

> 60 ms Colour –Tissue Doppler imaging

SD of time-to peak longitudinal strain in 12 basal and mid LV ]14[segments

Intraventricular dyssynchrony SPWMD

Normally SPWMD is less than 40 ms. The cut-off value is≥ 130 msec.

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Intraventricular dyssynchrony SPWMD

Normally SPWMD is less than 40 ms. The cut-off value is≥ 130 msec.

Intraventricular dyssynchrony Tissue velocity imaging

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Intraventricular dyssynchrony Tissue velocity imaging

Intraventricular dyssynchrony Tissue velocity imaging

• longitudinal velocities of basal (or basal and mid) myocardial

segments are measured from standard apical views.

• Measurements of longitudinal velocities from 2, 4, 6 and 12

myocardial segments have been described

Tissue velocity- derived dyssynchrony parameters

time delays between

opposing walls

standard deviations of time-to-peak systolic velocities

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Intraventricular dyssynchrony TS Lateral to septal

Normal value <50 msec Cutoff value≥60-65 msec¹΄²

1. Cleland JG, Dauber JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005;352(15):1539–49. 2. Bax JJ, et al. Left ventricular dyssynchrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation. Am J Cardiol. 2003;92:1238 –1240.

Intraventricular dyssynchrony TS- maximal delay (12 segments)

Normal<90 msec Cutoff value≥100 msec¹

1. Notabartolo D, et al. Usefulness of the peak velocity difference by tissue Doppler imaging technique as an effective predictor of response to cardiac resynchronization therapy. Am J Cardiol 2004;94(6):817–20.

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Intraventricular dyssynchrony Dyssynchrony index

Yu CM, et al. Predictors of left ventricular reverse remodeling after cardiac resynchronization therapy for heart failure secondary to idiopathic dilated or ischemic cardiomyopathy. Am J Cardiol. 2003;91:684–688.

Intraventricular dyssynchrony

imagingDeformation

• Have the potential of distinguishing active

contraction from passive motion caused by

tethering of adjacent myocardial regions.

• Can be obtained from color Tissue Doppler or

two-dimensional speckle tracking images.

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Intraventricular dyssynchrony strain

Intraventricular dyssynchrony strain

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Intraventricular dyssynchrony speckle tracking (2-D Strain)

Idea

Intraventricular dyssynchrony anteroseptal-posterior difference in peak radial strain

Cutoff value≥130 msec¹

1. Suffoletto M, et al. Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation. 2006;113:960–968.

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Intraventricular dyssynchrony

Apical rocking and septal flash

Intraventricular dyssynchrony

Both apical rocking and septal flash have been shown to have

predictive value for a CRT response which is superior to velocity-

based dyssynchrony parameters.¹΄²

1. Voigt JU, Schneider TM, Korder S, Szulik M, Gürel E, Daniel WG, Rademakers F, Flachskampf FA. Apical transverse motion as surrogate

parameter to determine regional left ventricular function inhomogeneities: a new, integrative approach to left ventricular asynchrony

assessment. Eur Heart J. 2009;30(8):959-68.

2. Szulik M, Tillekaerts M, Vangeel V, Ganame J, Willems R, Lenarczyk R, Rademakers F, Kalarus Z, Kukulski T, Voigt JU. . Assessment of apical

rocking: a new, integrative approach for selection of candidates for cardiac resynchronization therapy. Eur J Echocardiogr. 2010;11(10):863-9.

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Imaging dyssynchrony

Current indications for CRT:

Class Ia

LVEF ≤ 35%,

sinus rhythm,

LBBB with a QRS duration ≥ 150 ms,

NYHA class II, III, or ambulatory IV symptoms on goal-directed medical treatment. ¹΄²

1- Device-Based Therapy Guideline Focused Update. Circulation. 2012;126:00-00.

2- 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy.

Imaging dyssynchrony Conclusions

• Data from several observational studies suggest that baseline

LV mechanical dyssynchrony and acute resynchronization

effect after CRT are independent determinants of CRT

response and long-term outcome.

• Selection of HF patients for CRT based on LV mechanical

dyssynchrony assessed with imaging techniques is currently

not recommended in recent guidelines.

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Imaging dyssynchrony Conclusions

• Several imaging techniques were evaluated (magnetic

resonance imaging, speckle tracking echocardiography,

strain imaging, nuclear imaging) and yielded several

parameters of LV mechanical dyssynchrony that have

demonstrated to be independent determinants of CRT

response and long-term outcome in several

observational studies.

Imaging dyssynchrony Conclusions

The real value of these novel technologies

remains to be determined in randomized trials

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Thank you