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Working Group of Heart Failure and Cardiac Function

Working Group of Heart Failure and Cardiac Function. How to evaluate and treat dyssynchrony ? P Lancellotti , LA Piérard , Liège , BE. PATIENT’S HISTORY. Idiopathic cardiomyopathy - LV Ejection fraction = 21 % - End-diastolic volume = 341 ml - End-systolic volume = 269 ml

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Working Group of Heart Failure and Cardiac Function

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  1. Working Group ofHeart Failure and Cardiac Function How to evaluate and treat dyssynchrony ? P Lancellotti , LA Piérard , Liège , BE

  2. PATIENT’S HISTORY Idiopathic cardiomyopathy - LV Ejection fraction = 21 % - End-diastolic volume = 341 ml - End-systolic volume = 269 ml QRS width = 118 ms NYHA class III  NYHA class II under maximal tolerated treatment Lisinopril 10 mg , Carvedilol 12.5 mg x 2, Spironolactone 25 mg

  3. Live from Liège

  4. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms

  5. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms

  6. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms

  7. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms • LV filling time < 40 % of cardiac cycle

  8. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms • LV filling time < 40 % of cardiac cycle • DTI TPS • Septal-to-lateral delay > 60 ms

  9. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms • LV filling time < 40 % of cardiac cycle • DTI TPS • Septal-to-lateral delay > 60 ms • LV dispersion (4 segments) > 65 ms

  10. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms • LV filling time < 40 % of cardiac cycle • DTI TPS • Septal-to-lateral delay > 60 ms • LV dispersion (4 segments) > 65 ms • Standard deviation (12 segments) > 31 ms

  11. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior WM delay > 130 ms • LV filling time < 40 % of cardiac cycle • DTI Time to Peak Systolic velocity • Septal-to-lateral delay > 60 ms • LV dispersion (4 segments) > 65 ms • Standard deviation (12 segments) > 31 ms • Inter + Intra V delay > 102 ms

  12. STEPWISE SELECTION ESC Guidelines ° NYHA III-IV, QRS > 120 ms, EF < 35 %, Optimal treatment Major criteria(high sensitivity and specificity) (At least 1) ° Intraventricular asynchrony -LV dispersion  65 ms (lateral wall latest activated ) - TPS SD 12  31 ms (ischemic disease) ° Inter + Intra V delay > 102 ms Minor criteria(low sensitivity or specificity) (At least 3) ° Septal-to-posterior delay > 130 ms ° Interventricular delay > 40 ms ° Aortic pre-ejection time > 140 ms ° LV filling time < 40 % of cardiac cycle ° Diastolic mitral regurgitation

  13. IMPLANTATION : YES or NO ? NYHA class II  Not recommended in the ESC guidelines QRS width < 120 ms  Not recommended in the ESC guidelines « Paradoxical » asynchrony with severe septal delay - Position of the right ventricular lead ? - Position of the left ventricular lead ? Good exercise capacity  Peak VO2 :28 ml/kg/min (Weber A)

  14. 160 VE (L/min) 24 VE/VCO2slope 120 25 38 80 40 0 5 4 0 3 1 2 VCO2 (L/min) = Normal = Patient = NYHA class III

  15. Working Group ofHeart Failure and Cardiac Function How to assess the effects of CRT ?

  16. 1994-2006 : 12 years of CRT What did we learn ? • Permanent LV pacing is feasible and safe • CRT improves functional status and quality of life • CRT decreases hospitalization rate (inconsistent) • CRT reverts LV remodeling • CRT improves survival (CARE-HF)

  17. Evaluation of CRT Invasive : pressure-volume loops Exercise capacity : 6-min walk test treadmill ex. : peak VO2 Holter recording : arrhythmias heart rate variability Biology : changes in BNP and neurohormones Functional status and quality of life Imaging techniques : Doppler Echo , MRI

  18. Definition of Responder and Non Responder • Responder : survival +  NYHA class 1 + 10% increase in peak VO2, 3 to 6 months after CRT) • Responder :  NYHA class  1 • Responder :  LVESV >15% (>10%) • Responder: persistent decrease of NYHA class 1, irrespective of the changes of other parameters. • Non responder (20 to 30%): therapy considered as neutral or not beneficial (no decrease in NYHA class or QOL score ; need for heart transplant; death due to progressive, drug-refractory pump failure).

  19. ECHO in CRT • selection of pts : documentation and quantitation of dyssynergy • guiding the procedure : best position of RV and venous leads • optimizing of AV and VV delays • evaluation of haemodynamic effects : acutely • during follow-up

  20. Acute Effects • Systolic pressure (6 mmHg) • Stroke volume (10 to 30%) • dP/dt max (15 to 35%) • Arterial pulse pressure • End-systolic volume • Functional MR ( ERO and  RV by 30%)

  21. Chronic Effects • dP/dt max • LV ejection fraction • Arterial pulse pressure • End-diastolic volume • End-systolic volume : reverse remodeling ( ESV > 15%) • Functional MR (further 10% at rest and • of dynamic component)

  22. Lat Lat Sept Sept

  23. ECHO and CRT Acute and long-term effects on mechanical resynchronisation diastolic filling time , stroke volume mitral regurgitation (at rest and exercise) LV reverse remodeling changes in systolic and diastolic function

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