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Cardiac resynchronisation: Patients selection and issues after devise implantation Victoria Delgado,MD,PhD Leiden University Medical Center The Netherlands
Cardiac resynchronisation: Patients selection and issues after devise implantation
Victoria Delgado,MD,PhDLeiden University Medical Center
The Netherlands
CRT: Inclusion criteria
•
NYHA III-IV•
LVEF <35%
•
QRS >120 ms
Epstein et al. ACC/AHA/HRS 2008
30-40% non-response
NYHA II
Narrow QRS
RBBB
How to define response to CRT
Auger et al. Am Heart J 2010
Clinical (+) and Echo (+) (n=268)
Clinical (+) and Echo (‐) (n=102)
P‐value
Ischemic etiology 57.5% 69.6% 0.021
QRS (ms) 159 ±
31 148 ±
31 0.004
Radial LV dyssynchrony (ms)
171 ±
105 90 ±
77 <0.001
Auger et al. Am Heart J 2010
CRT Response
LV dysysnchrony
Location and extent of scar tissue
Suitable cardiac vein
Before CRT implantation
CARDIAC DYSSYNCHRONY
CARE‐HF trial. Richardson EHJ 2007 Gorcsan et al. Circ 2010
Interventricular dyssynchrony LV dyssynchrony
QRS duration and CRT response
QRS duration vs. pattern of activation
Jia et al. Heart&Rhythm 2006
Case 1NYHA III
LVEF 32%QRS 131 ms
Case 2NYHA III
LVEF 33%QRS 173 ms
Pitzalis et al. JACC 2002
Bax et al. JACC 2004
Yu et al. Circ 2004Achilli et al. PACE 2006
Suffoleto et a. Circ 2006
Ajmone Marsan H&R 2008
CARDIAC DYSSYNCHRONY ASSESSMENT WITH ECHOCARDIOGRAPHY
INTERVENTRICULAR DYSSYNCHRONY
RV Pre‐ejection time: 143 ms LV Pre‐ejection time: 196 ms
Interventricular mechanical delay > 40 msCleland et al. New Engl J Med 2005
LV MECHANICAL DYSSYNCHRONY ASSESSMENTM-mode:
•
Septal to Posterior wall delay ≥130 ms
•
CRT-response: ↓LVESV ≥15%
•
Ischemic HF?
•
↑Variability
?
Pitzalis et al. JACC 2002; Díaz‐Infante et al. AJC 2007
≥130 ms
LV MECHANICAL DYSSYNCHRONY ASSESSMENT
Tissue Doppler Imaging•
Evaluates the motion of the myocardial tissue
•
Myocardial velocity: fundamental parameter
•
Methodology:
Pulsed-wave TDI Color-coded TDI
S’
E’A’
S’
E’
A’
Inter and intraventricular dyssynchrony with pulsed wave TDI
Penicka et al. Circulation 2004
LV MECHANICAL DYSSYNCHRONY ASSESSMENT
LV dyssynchrony (opposing walls) > 65 ms
Bax et al. J Am Coll Cardiol 2004
LV MECHANICAL DYSSYNCHRONY ASSESSMENT
LV dyssynchrony (opposing walls) > 65 ms
Bax et al. J Am Coll Cardiol 2004
Influenced by tethering and translational motion
Under/Overestimate active component of myocardial function
Active myocardial deformation
Strain
Rate•
Strain = amount of myocardial deformation
•
Strain Rate (SR) = rate of myocardial deformation
SR = (s‐1)V1 – V2∆L
V1
V2
LVV1
V2∆L
(+) = Thickening / lengthening(‐) = Thinning / shortening
Ultrasound Techniques of Strain and SR Imaging
1‐Dimensional
2‐DimensionalTissue Velocity Imaging (TVI)
Speckle TrackingDoppler
Non‐Doppler
Perk G. et al. JASE
2007;20:234‐243
LV MECHANICAL DYSSYNCHRONY ASSESSMENT
Yu et al. Am J Cardiol 2007
Response to CRTTDI-strain
LV MECHANICAL DYSSYNCHRONY ASSESSMENT
LV MECHANICAL DYSSYNCHRONY ASSESSMENT
Suffoletto et al. Circ 2006; Delgado et al. J Am Coll Cardiol 2008
Anteroseptal-to-posterior wall delay > 130 msSens 83% Spec 80%
LV MECHANICAL DYSSYNCHRONY ASSESSMENT
3-dimensional echocardiography
LV MECHANICAL DYSSYNCHRONY ASSESSMENT
3-dimensional echocardiography
Ts-12 segments >33 ms
Van de Veire et al. Heart 2008
LV MECHANICAL DYSSYNCHRONY ASSESSMENT3-dimensional echocardiography
LV MECHANICAL DYSSYNCHRONY ASSESSMENT3-dimensional echocardiography
Time dispersion -16 segments >6.4 %
Ajmone Marsan et al. H&R 2008
LV MECHANICAL DYSSYNCHRONY ASSESSMENT3-dimensional echocardiography
vs. response to CRT
N = 166
Global χ2
square
Clinical variables
Clinical variables
+1 modality
Clinical variables
+2 modalities
P < 0.001
P < 0.001
Auger et al. Am J Cardiol in press
CRT Response
LV dysysnchrony
Location and extent of scar tissue
Suitable cardiac vein
Before CRT implantation
MYOCARDIAL SCARMRI: scar transmurality and total scar burden assessment
Total scar burden >1.2 No response
Ypenburg et al. AJC 2007
apical mid basal
Lv dyssynchrony + Myocardial scar vs.
LV reverse remodeling
Ajmone Marsan et al. Eur Heart J 2009
Lv dyssynchrony
ISCH HF patient Synchronous patient
Ajmone Marsan et al. Eur Heart J 2009
Myocardial scar
Ajmone Marsan et al. Eur Heart J 2009
LV dyssynchrony + Myocardial scar vs.
LV reverse remodeling
OR 95% CI P-value
LV dyssynchrony 6.3 3.1-9.9 <0.001
Scar extent 0.52 0.43-0.87 <0.001
Ajmone Marsan et al. Eur Heart J 2009
MYOCARDIAL SCAR AND ECHOCARDIOGRAPHY
2D strain Myocardial perfusion
Myocardial scar vs. prognosis
Delgado et al. Circulation 2011
N = 397 ISCH HF
•
LV dyssynchrony •
Latest site of activation
•
Myocardial scar
Long‐term survival
t ≥130 ms
Radial LV dyssynchrony
Delgado et al. Circulation 2011
Latest activated LV areas
Delgado et al. Circulation 2011
Myocardial scar
≥16.5%
Delgado et al. Circulation 2011
•
LV dyssynchrony
All-cause mortality - LV Dyssynchrony
0 12 24 360
20
40
60
80
100
Log rank p<0.001
Patients at risk 397 270 173 100Follow-up (months)
Even
t-fr
ee s
urvi
val (
%)
≥130 ms
<130 ms
Delgado et al. Circulation 2011
•
LV lead position
All-cause mortality- LV lead position
0 12 24 360
20
40
60
80
100
Log rank p<0.001
Patients at risk 397 270 173 100Follow-up (months)
Even
t-fre
e su
rviv
al (%
)
Concordant
Discordant
Delgado et al. Circulation 2011
•
LV myocardial scar
All-cause mortality - Myocardial scar
0 12 24 360
20
40
60
80
100
Log rank p<0.001
Patients at risk 397 270 173 100Follow-up (months)
Even
t-fr
ee s
urvi
val (
%)
Radial strain ≥16.5%
Radial strain <16.5%
Delgado et al. Circulation 2011
Clinical variablesLV dyssynchrony
Clinical variablesLV dyssynchronyLV lead position
Clinical variablesLV dyssynchronyLV lead positionMyocardial scar
0
25
50
75
100
125
72.2
88.7105.2
p=0.004
p<0.001
p<0.001 p<0.001 p<0.001
Globa
l Chi‐squ
are
Delgado et al. Circulation 2011
Why to optimise AV and VV delay?
How to optimise?
When to optimise?
After CRT implantation
Reasons of non‐response to CRT
Mullens et al. JACC 2009
Post implant optimisation: AV‐VV delay
Why to optimise AV delay?
Maximise the benefit of CRT
Optimal AV synchrony
Best LA contribution to LV filling
Optimal duration of isovolumic contraction phase
Maximum stroke volume
Barold et al. Europace 2008
Post implant optimisation: AV‐VV delay
Barold et al. Europace 2008
Too long AV delay
Atrial contraction too early (superimposition on early diastolic LV‐filling phase)
Shortening of LV diastolic filling time
Reduced stroke volume
Diastolic mitral regugitation
Reduced preload LV end‐diastolic pressure
Post implant optimisation: AV‐VV delay
Barold et al. Europace 2008
Too short AV delay
Premature LV contraction
LA contraction against closed mitral valve(truncated A‐wave)
Reduced stroke volume
LV filling time lengthens (separated E and A waves)
Reduced preload LV end‐diastolic pressure
Post implant optimisation: AV‐VV delay
How to optimise AV delay?
•
Optimisation of diastolic filling time:
–
Iterative method (“gold standard”, eg CARE‐HF)
–
Ritter method (DDD pacing, Europace 1994)
–
Simplified mitral inflow method
(Meluzin, PACE 2004)
•
Optimisation of markers of systolic function:
–
Doppler derived VTI of the LVOT
–
Acute dP/dT changes
Post implant optimisation: AV‐VV delay
Iterative method
•
A long AV delay is programmed and reduced 20 ms steps until the A‐wave truncates.
•
The interval then is increased 10 ms increments and the shortest
AV without truncation of A‐wave is selected.
Post implant optimisation: AV‐VV delay
Ritter’s method
•
Two extreme AV delays are programmed:•
Short AV1
= truncated A‐wave•
Long AV2
= without A‐wave attenuation
•
For each, the time between the onset of
QRS and completion of A‐ wave is calculated
•
AV‐optimal: AVshort
+ [(AVlong
+ QAlong
) – (AVshort
+ QAshort
)]
Post implant optimisation: AV‐VV delay
Pulsed wave Doppler LVOT VTI
•
The AV delay is incrementally adjusted to maximise echocardiographic cardiac output
CSALVOTVTILVOT
Stroke volume = CSALVOT
X VTILVOT Cardiac output = SV x Heart rate
Post implant optimisation: AV‐VV delay
Pulsed wave Doppler LVOT VTI
•
Limitations:
•
Less reproducible
•
Difficult to place the sample volume at the
same position each time.
Post implant optimisation: AV‐VV delay
Acute dP/dt changes
•
The peak rate of rise of LV pressure during the isovolumic
contraction is a sensitive index of LV contractility.
Post implant optimisation: AV‐VV delay
Why to optimise VV interval?
•
Controversial
•
It may compensate for less than optimal LV lead position
•
It may correct for individual heterogeneous ventricular activation patterns
•
Evidence:1
INSYNC III study demonstrated incremental benefit by tailoring echocardiographically the VV interval.
Leon et al. J Am Coll Cardiol 2005
Post implant optimisation: AV‐VV delay
How to optimise VV delay?
•
Optimisation of markers of systolic function:
–
Doppler derived VTI of the LVOT
•
Evaluating Intraventricular dyssynchrony:
–
TDI
Post implant optimisation: AV‐VV delay
Doppler derived VTI of the LVOT
Post implant optimisation: AV‐VV delay
TDI‐
evaluation of LV dyssynchrony
Pre‐CRT Pre‐RV
Biv Pre‐LV
Post implant optimisation: AV‐VV delay
Vidal et al. Am J Cardiol 2007
N = 100 CRT patients
81% men, 70 ±
8 yrs
CRT optimisation:
AV delay: the longest LV filling time among 120, 140 and 160 ms
VV delay: VTI‐LVOT + intraventricular dyssynchorny (TDI)
6‐month follow‐up:
Responder: clinical end‐points
Post implant optimisation: AV‐VV delay
Vidal et al. Am J Cardiol 2007
At 6 month follow‐up, 98 patients were alive
Changes in clinical parameters:
Post implant optimisation: AV‐VV delay
Vidal et al. Am J Cardiol 2007
At 6 month follow‐up, 98 patients were alive
Changes in echocardiographic parameters:
Post implant optimisation: AV‐VV delay
When to optimise?
•
RCT data: only AV delay optimisation
–
MIRACLE: pre‐discharge, 3‐, 6‐
and 9‐months
–
CARE‐HF: pre‐discharge, 3‐, 9‐
and 18‐months
•
AV delay changes over time:
–
LV remodeling
–
56 –
82% of patients required re‐optimisation
over 3‐16 months
•
Only for non‐responders? additional studies needed
•
Comprehensive evaluation pre‐implantation of all
pathophysiological
determinants of CRT response.
•
AV delay optimisation leads to acute hemodynamic benefit
•
VV delay optimisation….questionable
Conclusions
