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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