WHAT DO ELECTROPHYSIOLOGISTS WANT TO KNOW FROM ECHOCARDIOGRAPHERS

BEFORE, DURING&AFTERCARDIAC RESYNCHRONIZATION THERAPY?

Mary Ong‐Go, MD, FPCP, FPCC, FACC

OUTLINE• What is CRT• Who needs CRT• What does the guidelines say about CRT• What do electrophysiologists want fromechocardiographers

CARDIAC DYSSYNCHRONY

AtrioventricularInterventricularIntraventricular

Gorcsan J et al, Journal of the American Society of Echocardiography 2008 (21).

2012 ACCF/AHA/HRS Focused Update Incorporated into the ACCF/AHA/HRS 2008 Guidelines for Device‐Based Therapy of Cardiac 

Rhythm Abnormalities

INDICATIONS FOR CRT IN PATIENTS IN SINUS RHYTHM[2013 ESC Guidelines on Cardiac Pacing & CRT]

RECOMMENDATIONS CLASS LEVEL REF

1) LBBB with QRS duration >150ms.CRT is recommended in chronic HF patients and LVEF <35% who remain in NYHA functional class II, III and ambulatory IV despite adequate medical treatment. d

I A 48‐64

2) LBBB with QRS duration 120‐150ms.CRT is recommended in chronic HF patients and LVEF <35% who remain in NYHA functional class II, III and ambulatory IV despite adequate medical treatment. d

I B 48‐64

3) Non‐LBBB with QRS duration >150msCRT should be considered in chronic HF patients and LVEF <35% who remain in NYHA functional class II, III and ambulatory IV despite adequate medical treatment. d

IIa B 48‐64

INDICATIONS FOR CRT IN PATIENTS IN SINUS RHYTHM[2013 ESC Guidelines on Cardiac Pacing & CRT]

RECOMMENDATIONS CLASSa LEVELb REFc

4) Non‐LBBB with QRS duration 120‐150ms.CRT may be considered in chronic HF patients and LVEF <35% who remain in NYHA functional class II, III and ambulatory IV despite adequate medical treatment. d

IIb B 48‐64

5) CRT in patients with chronic HF with QRS duration <120ms is not recommended.

III B 65,66

a Class of Recommendation.b Level of evidencec Reference(s) supporting recommendation(s)Patients should generally not be implanted during admission for acute decompensated HF. In such patients,guideline‐indicated medical treatment should be optimized and the patient reviewed as an out‐patient afterstabilitization. It is recognized that this may not always be possible.

Galderisi M et al, Cardiovascular Ultrasound 2007 (5).

Galderisi M et al, Cardiovascular Ultrasound 2007 (5).

INTERVENTRICULAR  DYSSYNCHRONY

Calculation of interventricular mechanical delay by standard Doppler method. The time from ECG Q wave toonset of LVOT (=211ms) (left panel) is longer than the time occuring from Q to onset of RVOT (=122ms). Theresulting IVMD is of 89ms, thus indicating a significant interventricular dyssynchrony.

Galderisi M et al, Cardiovascular Ultrasound 2007 (5).

INTRAVENTRICULAR DYSSYNCHRONY

Septal‐to‐posterior wall motion delay (SPWMD). SPWMD in a normal subject (left panel) and in a patient withCHF and LBBB.

Modified from Agler DA et al, Journal of the American Society of Echocardiography 2007 (20).

Routine M‐mode (A) at midventricular level and color‐coded tissue Doppler M‐mode (B) demonstrating septalto posterior wall delay of 180 milliseconds, consistent with significant dyssynchrony (>130ms).

Gorcsan J et al, Journal of the American Society of Echocardiography 2008 (21).

Methodology for measuring lateral wall post‐systolic displacement. It is measured as the difference of the timeinterval from QRS onset to maximal systolic displacement of the basal LV lateral wall (assessed by M‐mode in theapical 4‐chamber view) (upper panel) and the time interval from QRS onset to the beginning of transmitral Evelocity (assessed by pulsed Doppler of mitral inflow) (lower panel). In this example, the positive value of thedifference indicates the co‐existence of segmental post‐systolic contraction and diastolic relaxation.

Modified from Sassone B et al, Americal Journal of Cardiology 2007 (100).

Methodology for measuring pulsed Tissue Doppler derived time to peak 5m and time to onset 5m (left panel).In the right panel measurements of time to peak Sm (upper panel) and of time to onset Sm (lower panel) aredepicted.Am=Myocardial atrial velocity, CTm=Contraction time, Em=Myocardial early diastolic velocity, RTm=Myocardialrelaxation time, Sm=Myocardial systolic velocity.

Modified from Agler DA et al, Journal of the American Society of Echocardiography 2007 (20).

Methodology of calculation of Dyssynchrony Index and Is ability in predicting LV Inverse remodelling. In theupper panel methodology of calculation of Dyssynchrony Index, i.e., the standard deviation of Ts (Ts‐SD) measuredin the basal and mid‐segments visualizable in the apical views. In the lower panel, Ts‐SD shows the ability topredict an effective LV inverse remodeling after CRT (lower panel). Values of TS‐SD>32.6 (black triangles) predictan effective LV reverse remodeling (DLVVs=delta left ventricular end‐systolic volumes) after CRT. Patients with pre‐CRT values of Ts‐SD<32.6 (empty circles) do not present significant LV inverse remodeling at follow‐up).

Modified from Yu CM et al, American Journal of Cardiology 2003 (91).

Strain (%) of basal posterior septum and lateral wall in apical 4‐chamber view. Lateral wall shows an abnormalrelaxation (positive sign of its curve) during systole, with a motion that is opposite to that of the basal posteriorseptum.

Galderisi M et al, Cardiovascular Ultrasound 2007 (5).

Speckle‐tracking imaging demonstrating synchrony of peak segmental radial strain in healthy individual (A) andsevere dyssynchrony in patient with heart failure and left bundle branch block referred for resynchronizationtherapy (B).

Gorcsan J et al, Journal of the American Society of Echocardiography 2008 (21).

Three‐dimensional echocardiographic assessment of segmental volume displacement in patient with normalsynchrony (A) and with significant dyssynchrony (B).

Gorcsan J et al, Journal of the American Society of Echocardiography 2008 (21).

STRAIN DELAY INDEX

Moss AJ, Hall WJ, Cannom DS, et al. New England Journal of Medicine 2009 (361).

SEPTAL REBOUND STRETCH

Ruschitzka F, Abraham WT, Singh JP, et al. New England Journal of Medicine 2013 (369).

DISCOORDINATION INDICES

Tang AS, Wells GA, Talajic M, et al. New England Journal fo Medicine 2010 (363).

WHAT ELECTROPHYSIOLOGISTS WANT:

DURING CRT

SPECKLE TRACKING & ANTEROSEPTAL‐POSTERIOR WALL DELAY (ASPWD)

Linde C, Abraham WT, Gold MR, et al. Journal of the American College of Cardiology 2008 (52).

AV DYSSYNCHRONY

RITTER’S FORMULA

Optimal AV Interval= AV long – (QA short – QA long)

Melzer C, Borges AC, Knebel F, Rchter WS, Combs W, Gaumann G, Theres H. Cardiovascular Ultrasound 2004 (2).

SUMMARY• Cardiac resynchronization therapy is an establishedoption for treatment of patients with congestiveheart failure class II‐IV with dyssynchrony

• Echocardiography plays a pivotal in cardiacdyssynchrony therapy as in other field ofcardiography

SUMMARYBefore CRT:  

identify dyssynchrony and responders using the different echo indices

During CRT: aid in lead placement

After CRT:AV‐VV Optimization  to  improve LV filling and CO

SUMMARY

• With all the progress, better patient selection and improvement of response rate would not just remain a goal but will become a reality for us to better manage heart failure patients with dyssynchrony

THANK YOUJESUS LOVES YOU.

Echo

What 

OUTLINE

SPECKLE TRACKING

Sipahi I, Carrigan TP, Rowland DY et al. Archives of Internal Medicine, 2011 (171).