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La selezione dei pazienti candidati alla Terapia Resincronizzante Cardiaca
M Cristina Porciani
Firenze
“Incontri Pitagorici di Cardiologia 2010”“Πυθαγόρειοι κάνουμε συναντήσεις καρδιολογίας” VIIIa Edizione
It has been well established that CRT is able to improve clinical and hemodinamic parameters in patients with heart failure and LBBB
McAlister FA et al, Ann Intern Med. 2004;.
CRT reduces HF hospitalizations
McAlister FA et al, Ann Intern Med. 2004;.
CRT improves quality of life
Cleland JGF et al NEJM 2005
CRT reduces mortality
CRT reverses LV remodeling
tSutton MG Circulation 2003
Reverse remodeling induced by CRT
Baseline
3 months
6months
CRT
1Circulation 2002
Biventricular Stimulation in Patients With Medically Refractory Heart Failure NYHA III-IV, Idiopathic or Ischemic Cardiomyopathy, QRS 120 ms, and EF 35%
Guidelines of ACC/AHA (2009)
RATIONALE OF CRT
LBBB
discordinate contraction
ventricular dysfunction
Electrical asinchrony Mechanical asynchrony
Lecoq G et al Eur Heart J 2005
Reduction of QRS duration occurs only in responders
29,5
57,1
71,1
0
10
20
30
40
50
60
70
80
<120 ms >120<150 ms >150 ms
QRS duration
Intraventricular dyssynchrony
%
Ghio S et al Eur Heart J 2004;25:571-578
Echocardiographic Data Before and After Cardiac Resynchronization Therapy
Achilli A et al JACC 2003
QRS > 120ms QRS< 120ms
Leclerq C et al Circulation 2002
Electrical epicardial activation map of whole heart for 3 pacing modes
Mechanical Resynchronization Does Not Require Electrical Synchrony in the Dilated Failing Heart With Left Bundle-Branch Block
Leclerq C et al Circulation 2002
Mechanical LV activation map of whole heart for 3 pacing modes
Mechanical Resynchronization Does Not Require Electrical Synchrony in the Dilated Failing Heart With Left Bundle-Branch Block
• it appears that
Mechanical rather than electrical synchronyseems most important for functional improvement with CRT
Interventricular asynchrony
TDI is useful in recording the chronology and the entity of the velocity curves of miocardium segments
Ts-SD Cut-off 33ms the Standard Deviation of the 6 basal and the 6 mid LV segmental Ts as systolic asynchrony parameter
Ts
septal to lateral delay
cut-off 60 ms
Bax et al. AM J Cardiol 2003;92:1238-40
Yu et al. JACC 2005; 45:677-84.
TSI (Tissue Synchronization Imaging)
No single measure of mechanical dyssynchrony may be recommended to improve pt selection forCRT
Methodology to determine mechanical dyssynchronyneeds further elaboration
QRS remains the selection criterium of dyssynchrony to identify for CRT
Circulation 2008
Results of the PROSPECT study
from the direct assessment of mechanical dyssynchrony , attention again shifted toward QRS
From the initial focus on electrical markers, interest shifted toward a more direct assessment of mechanical dyssynchrony by means of tissue Doppler imaging (TDI).
Porciani et al Echocardiography 2010
Electrical asynchrony + - + Mechanical asynchrony - + +
Porciani et al Echocardiography 2010
Since it is electrical activation that produces myocardial contraction that in turn is necessary for cardiac movement,why would they be any different?
The question is
►Problems with measuring electrical ayncrony
►Electromechanical interaction
►Complex nature of electrical and mechanical aynchrony
The answer should be
Problems with measuring electrical synchrony
Xiao Br Heart J 1994
Signal averaged electrocardiography detects potentials too low to appear on thestandard 12 lead electrocardiogram
Di Donato et al Circulation 2004
Surgical Ventricular Restoration Improves Mechanical Intraventricular Dyssynchrony in Ischemic Cardiomyopathy
Narrow QRS
Di Donato et al Circulation 2004
Surgical Ventricular Restoration Improves Mechanical Intraventricular Dyssynchrony in Ischemic Cardiomyopathy
Narrow QRS
Tournoux F. JCE, 2007
Concordance Between Mechanical and Electrical Dyssynchronyin Heart Failure Patients: A Function of the Underlying Cardiomyopathy?
What’s about mechanichal dyssynchrony?
Henein MY Heart 1999
Longitudinal asynchrony (TDI)
Radial asynchrony (Speckle-tracking radial strain)
Gorcsan J. JACC 2007
Combined Longitudinal and Radial Dyssynchrony Predicts Ventricular Response After Resynchronization Therapy
)
Gorcsan J. JACC 2007
Porciani et al PACE 2008
RV ejection RV filling
LV ejection LV filling
RV ejection RV filling
LV ejection LV filling
IVCT IVRT
IVCT IVRT
Normal
LBBB
a – bR-R
Total isovolumic Time Index
Myocardial Performance Index (MPI)
Porciani et al J Card Med 2010
Porciani et al J Card Med 2010
Porciani et al J Card Med 2010
CONCLUSIONS
Which is the best?