1. 5652Taiwan Heart Rhythm Society Oct. 2012 t VOL. 007(101.02.17)Shih-A ChenShih-Ann Chen -Ann(Taiwan Heart Rhythm Society) t )1004150222610041502226886-2-23821530 :886-2-23821528 1) www.thrs.org.tw I S S N 2 2 2 3 - 0 1 3 0 2) Yenn-JiangYenn-Jiang LinJin-LongJin-Long Huang 3) Po-ChingPo-Ching Chi 4) 101 Wei-HuaWei-Hua TangJan-YowJan-Yow Chen 102 Shih-ChungShih-Chung Huang Bien-Hsien HuangBien-HsienWen-ChinWen-Chin Tsai Shih-TsungShih-Tsung ChengTze-Tze- Fan Chao Hung-YuHung-Yu ChangShuenn-NanShuenn-Nan Chiu 1 - P1 2 - P1(cardiac dyssynchrony)3 - P5 QRSQRS complex4 EKG of the month - P6 Purkinje5 - P6 6 - P7 QRS7 Paradigm Shift in StrokeQRS complex120Prevention for AF - P10 20%8 - P1135%

2. 2 THRS Taiwan Heart Rhythm Society10110VOL. 007 SRI (low signal-to-noise ratio) high intra- and interob- server variability(ventricular interdepedence) M-modeCRT response(tissue Doppler MUSTIC-SRPATH-imageTDI) (strain rate image CHFMIRACLEMIRACLE-ICDCOMPANIONSRI)(tissue synchronization imagingCARE-HRQRS duration160TSI) 30%CRT(Table 1) QRS durationCRT response(Interventricular mechanical delayIVMD)MollemaAJC 2007DelgadoCirculation 2012QRSbaseline QRS durationCRT responseQRS durationIVMD401.,(left ventricular pre-ejection in-endocardialepicardial mappingtervals (LPEI)QRS1402.Left lateral wall contraction (LLWC)M-modeDopplerCRT responseE wave3. Septal-to-posterior wall motion delay (SPWMD)M-mode CRT response130 TDITDIbasalmid-seg- CRT response(Table 2)mentstime to peak systolicCARE-HFIVMD40velocity (Ts) time to onset of systolic velocity (electro- CRTresponse (hazard ration 0.99 95% condience in- 1mechanical delayEMD)dyssyn-terval 0.98 to 1.00) M-modeSPWMD130 2,3chrony indexCRT response )6512akinesis 4(Ts-SD-12)Ts-SD-1232 TDIdyssynchrony index65CRTreverse remodeling5TSITSI92% 6speckle track-TsCRT response 12ing Ts-SD-1231.47 CRT response TDISRITDI (rotation) (radial strain)CRT 8(tethering)SRI response 9(deformation)TDICRT response Table 1: Summary of the Main Clinical Trials of CRT Numbers QRSResponseNYHA functional class LVEF (%) Trials (source)ofdurationRate(%) patients (ms) (%) IIIIV MUSTIC-SR (N Engl J Med. 2001)5817619- 237 100- PATH-CHF (J Am Coll Cardiol. 2002)4117430- 216 5149 MIRACLE (N Engl J Med. 2002) 45316721 64 226 9010 MIRACLE-ICD (JAMA. 2003) 36916222 61 246 8812 COMPANION (N Engl J Med. 2004)1520 160 59218713 CARE-HR (N Engl J Med. 2005) 813 160-257723 3. VOL. 007Taiwan Heart Rhythm Society10110THRS 3Table 2: Studies Evaluating the Role of Cardiac Dyssynchrony to Predict Long-Term Outcome After CRT CardiacPatients Follow-upFirst Author (source) dyssynchronyEnd point HR (95% CI)(n)(months)parameterCleland (N Engl J Med. 2005)813 29.4 IVMD >49.2 ms All-cause mortality0.50 (0.360.70) or hospitalization for heart failureWiesbauer (Eur J Clin Invest. 2009) 200 10 IVMD >60 ms All-cause mortality0.21 (0.070.6)Cho (J Am Coll Cardiol. 2005) 1061711 TDI maximal opposingAll-cause mortality9.02 (2.4233.57) delay (8 LV segments) >91 msZhang (Heart. 2009) 2393720 TDI maximal opposing Cardiovascular 0.46 (0.2700.792) delay 65 ms mortalityCho (Heart. 2010) 167 33 TDI maximal opposing Cardiovascular 2.37 (1.394.04) delay 65 ms mortality andhospitalization forheart failureLeyva (Heart. 2009) 148 30 SD of time to peak Cardiovascular 1.01 (1.001.02) radial motion-MRImortalityHR indicates hazard ratio; CI, condence interval; IVMD, interventricular mechanical delay; and TDI, tissue Doppler imaging.PROSPECT trialdyssynchronyCRT re- pulse-wave Doppler5sponse tissue DopplerCRT intraobserverinterobserver variabilityPROSPECT (Predictors of Response to Cardiac Re- 10Synchronization Therapy) 324 dys-PROSPECTdyssynchronyCRTsynchronyCRTdyssynchrony(Table 3) (speckle (KCCQ Kansas City Cardiomyopathy tracking) PROSPECT studyQuestionnaire)CRT ( (Table 4)CRT15%) IVMD, LVFT (LV filling dyssynchronytime), LVPEI CRTIVMD (+5.18, p=0.02) LVFT (+5.19, p=0.03) (externalIVMD (OR 1.85, p=0.03)validation)dyssynchronyCRTPROSPECTCRT responder, 76%. CRT PROSPECTdys-LVFT () synchronyLVFTTable 3: Dyssynchrony Echocardiographic MethodEchocardiographic Dyssynchrony Measures M-modeSeptal-posterior wall motion delay (130 ms). Pulsed Dopper 1. Interventricular mechanical delay (40 ms). 2. LV lling time relative to RR (40%).3.LV pre-ejection interval (>140 ms). M-model + Pulsed Dopper Left lateral wall contraction overlap with LV lling (0). Tissue Doppler imaging1. Time difference between laterl and septal peak systolic wall velocity (60 ms). 2. SD of time to peak velocity (32 ms). 3. Maximum difference of time to peak velocity (median). 4. Maximum difference of time to onset systolic velocity (median). 5. Delayed longitudinal contraction (2). 6. Maximum difference of time to peak velocity outside IVCT (110 ms). 7. Maximum difference of time to peak displacement (median). 4. 4 THRSTaiwan Heart Rhythm Society10110 VOL. 007Table 4: PROSPECTPROSPECT 20.2%LVEF >35%LVEF35%,37.8%LVEDD