Azienda Ospedaliera Universitaria - Ferrara Napoli 2011 Ruolo dell'imaging cardiaco per una corretta...

Azienda OspedalieraUniversitaria - Ferrara Napoli 2011

Ruolo dell'imaging cardiaco per una corretta selezione dei pazienti candidati alla

CRT

Donato Mele


LV dilatation no longer required compared to the 2007 ESC Guidelines.


• The number of non-responders is high (about 30-50% depending on response definition and HF etiology).

• CRT is not without complications (11% periprocedural, 4% device-related according to the 2009 European CRT Survey).

• Economic resources are limited and a wise use of them is expected.

Therefore, today identification of CRT non-responders is a needed health care strategy.

CRT FOR NYHA CLASS II-IV PATIENTS


Can mechanical dyssynchrony help

to identify CRT non-responders?



After initial enthusiasm…



Intra-LV Inter-ventricular

Relative time

Atrio-ventricularGlobal

Segmental

Δ time

Δ time RV vs. LV pre-ejection; Doppler flow

Δ time velocity onset, RV vs. LV; Pulsed TD

Δ time hit the highest point velocity, RV vs. LV; Color TD

LV filling time ÷ total cycle time; Doppler flow

Global

Segmental

Time variability

GlobalQRS to aortic valve opening; Doppler flow

2 segments

3 segments

4 segments

6 segments

8 segments: Peak velocity; Color TD

12 segments: Peak velocity; Color TD

- Max deflection; M-mode- Peak velocity; Color TD

- Velocity onset; Pulsed TD

- Velocity onset; Pulsed TD- Peak velocity; Color TD

- Peak strain/strain rate; Color TD

- Peak velocity; Color TD- Displacement peak; Color TD

16 segments: Ejection; 3D

% basal segments with negative strain rate post aortic valve closure; Color TD

Lateral wall contraction post aortic valve closure; Pulsed TD

12 segment std. dev. oftime to peak velocity; Color TD

Abbreviations:LV = left ventricularRV = right ventricularTD = tissue Doppler

6 segment std dev of strain ÷ mean strain;Color TDTime to peak strain coefficient of variation; custom application

QRS to peak lateral wall deflection; M-mode

QRS to peak velocity; Color coded, Color TD

Absolute time

Averaged peak displacement normalized to cardiac cycle length; custom application

QRS to end of lateral wall contraction; Pulsed TD

Qualitative

5 basal segment; Pulsed TD

- Radial strain; Color TD

The Babel (Dyssynchrony) Tower


Results of the Predictors of Response to CRT (PROSPECT)

Trial Chung ES et al; Circulation 2008.

“Given the modest sensitivity and specificity in this multicenter setting despite training and central analysis, no single echocardiographic measure of dyssynchrony may be recommended to improve patient selection for CRT beyond current guidelines.”

Convecho

DTI


Does mechanical dyssynchrony evaluation

still have a sense

after the PROSPECT study?



BACK TO BASIC: LBBB DYSSYNCHRONY


SPECKLE-TRACKING ECHOCARDIOGRAPHY: Comprehensive assessment of myocardial deformation

Longitudinal deformation

Radialdeformation

• Torsion

Radialdeformation

Circumferentialdeformation

Torsional deformation

Apex

Base

LONGITUDINAL

CIRCUMFERENTIAL

RADIALTORSION


RADIAL STRAIN DYSSYNCHRONY


normal

dyssynchrony

Novel Speckle-Tracking Radial Strain From Routine Black-and-White Echo Images to Quantify Dyssynchrony and Predict Response to CRT

Suffoletto et al, Circulation 2006;113:960-968

6 mid-ventricle myocardial segments

PREDICTIVE VALUE OF RADIAL STRAIN DYSSYNCHRONY


PREDICTIVE VALUE OF RADIAL STRAIN DYSSYNCHRONY

Assessment of Left Ventricular Dyssynchrony by Speckle Tracking Strain Imaging

Comparison Between Longitudinal, Circumferential, and Radial Strain in CRT

Delgado V, JACC 2008

Radial

Longitudinal

Radial


Multicenter prospective study on 132 patients


Usefulness of Echo Dyssynchrony in Pts with Borderline QRS duration to Assist With Selection

for CRTOyenuga et al, JACC Imaging 2010; 2:132-140

Borderline QRS=100-130 ms

Cut-off≥130 msstrain


SPECKLE TRACKING ECHO FOR CARDIAC DYSSYNCHRONY

ADVANTAGES OF THE SPECKLE TRACKING TECHNIQUE:

• Pathophysiologic sound (it assesses myocardial deformation, not motion or displacement)

• Correlates with MRI• More accessible than MRI

ADVANTAGES OF THE RADIAL DYSSYNCHRONY INDEX:

• Easy to apply• Rapid • Highly reproducible• More predictive data compared with MRI


NORMALE ECOCARDIOGRAFIA 3D

systolic dyssynchrony index 11,22%

DISSINCRONO

systolic dyssynchrony index 0,62%


Real-Time 3D Echo in Patient Selection for Cardiac Resynchronization Therapy

Kapetanakis et al, JACC imaging 2011


The issue of LV scar burden

CRT FOR NYHA CLASS III-IV PATIENTS


Effect of Posterolateral Scar Tissue on Clinical and Echocardiographic Improvement After CRT

Bleeker et al - Circulation 2006;113:969-976

40 ischemic HF pts, NYHA class III-IV, LV-EF35%, QRS>120 msec, LBBBTransmural scar: hyperenhancement 51-100% of LV wall thickness

Contrast-enhanced MRI of a patient with transmural scar tissue in the posterolateral wall.

Percentages of responders to CRT for 4 different patient categories based on the presence or absence of transmural posterolateral scar tissue (Scar+/Scar-) in combination with the presence or absence of baseline LV dyssynchrony ≥65 ms (Dys+/Dys-).

Combined assessment of scar tissue and LV dyssynchrony is needed for best prediction of CRT response.


Leyva et al – Heart 2009;95:1619-1625

148 HF pts, NYHA class III-IV, LV-EF<35%, QRS≥120 msec

Development and validation of a clinical index topredict survival after CRT

DSC Index: Dyssynchrony, Scar (posterolateral location), Creatinine


Effects of global longitudinal strain and total scar burden on response to CRT in patients with ischaemic dilated cardiomyopathy

D’Andrea A et al. Eur J Heart F 2009; 11: 58-67

Average Global longitudinal strain (GLS) correlates closely with MRI total scar burden (r=0.64, P<0.001).

GLS and radial intraventricular dyssynchrony were powerful independent determinants of response to CRT.


The issue of LV pacing site



Pacing a segment with peak radial strain amplitude <10% is associated with poor outcomes of CRT


LV PACING SITE RELATIVE TO SCAR LOCATIONBY ECHOCARDIOGRAPHY

Mele D et al, submitted

Non responders

Responders


The issue of LV contractile reserve


Azienda OspedalieraUniversitaria - Ferrara Roma 2010

Cut-offAutore Parametro End-point

VALUTAZIONE DELLA RISERVA CONTRATTILE DEL VENTRICOLO SINISTRO

Eco-stress con dobutamina a bassa dose

Ciampi Q et al, Eur J Heart Fail 2009

Da Costa A et al, Heart Rhythm 2006

Ypenburg C et al, Am Heart J 2007

Tuccillo B et al , J Interv Card Electrophysiol 2008

LV-EF >7.5% ESV ≥15% a 6 mesi

>25%LV-EFRiduzione eventi di

scompenso cardiaco a 12,18,7 mesi

ESV ≥15% a dopo 11 mesi (mediana)

WMSI ≥0.20

>25%LV-EF ESV ≥15% a 6 mesi

Viareggio 2011


CONCLUSIONS


• The response of the “average” patient to a therapy is not necessarily the response of the individual patient standing before the clinician (C Bernard, 1865).

• Identification of patients with highest probability of CRT response could allow allocate resources to those patients who can really benefit from the treatment.

• Cause of nonresponse to CRT is probably multifactorial: beyond dyssynchrony, factors related to the myocardial substrate play an important role (global scar burden, scar at pacing site and contractile reserve).


STEP I - VALUTARE LE INDICAZIONI ALL’ IMPIANTO (Classe IA)

STEP II - VALUTARE LA PROBABILITA’ DI RISPOSTA A LUNGO TERMINE

• Eziologia non ischemica• QRS>150 ms• Blocco di branca sinistra • Scarso scar burden totale (soprattutto nelle forme ischemiche)• Conservata riserva contrattile globale (soprattutto nelle forme non

ischemiche)• Normale funzione renale

Utile aggiungere la quantificazione della dissincronia meccanica se:• QRS “intermedio” (120-150 msec)• Blocco di branca destra• Blocco di branca sinistra senza evidenza di “bounce” settale• Indicazioni “off-label” (QRS “stretto” <120 msec, FE>35%)

ALTA PROBABILITA’ DI RISPOSTA POSITIVA IN CLASSE NYHA III-IV

• Classe NYHA II-IV• Terapia medica ottimizzata• FE ventricolare sinistra ≤35%• QRS>120 ms (classe NYHA III-IV) o >150 msec (classe NYHA

II)• Ritmo sinusale

STEP III - IDENTIFICARE IL SITO DI PACING OTTIMALE

• Zona più ritardata e vitale (senza cicatrice transmurale)

APPROCCIO A STEP PER LO STUDIO DEI CANDIDATI ALLA CRT


3D Speckle Tracking Echo: ONE STOP-SHOP APPROACH

•LV function•Dyssynchrony (with torsion)•Global scar burden•Target zone characterization•Contractile reserve

Azienda Ospedaliera Universitaria - Ferrara Napoli 2011 Ruolo dell'imaging cardiaco per una corretta...

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