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“Incontri Pitagorici di Cardiologia 2010” “Πυθαγόρειοι κάνουμε συναντήσεις καρδιολογίας”

“Incontri Pitagorici di Cardiologia 2010” “Πυθαγόρειοι κάνουμε συναντήσεις καρδιολογίας” VIIIa Edizione. La selezione dei pazienti candidati alla Terapia Resincronizzante Cardiaca M Cristina Porciani Firenze.

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“Incontri Pitagorici di Cardiologia 2010” “Πυθαγόρειοι κάνουμε συναντήσεις καρδιολογίας”

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  1. “Incontri Pitagorici di Cardiologia 2010” “Πυθαγόρειοι κάνουμε συναντήσεις καρδιολογίας” VIIIa Edizione La selezione dei pazienti candidati alla Terapia Resincronizzante Cardiaca M Cristina Porciani Firenze

  2. IthasbeenwellestablishedthatCRT isabletoimproveclinical and hemodinamicparameters in patientswithheartfailure and LBBB

  3. CRT reduces HF hospitalizations McAlister FA et al, AnnInternMed. 2004;.

  4. CRT improves quality of life McAlister FA et al, AnnInternMed. 2004;.

  5. CRT reduces mortality Cleland JGF et al NEJM 2005

  6. CRT reverses LV remodeling Sutton MG Circulation 2003 t

  7. Reverse remodeling induced by CRT Baseline CRT 3 months 6months

  8. GuidelinesofACC/AHA (2009) Biventricular Stimulation in PatientsWithMedicallyRefractory Heart Failure NYHA III-IV, IdiopathicorIschemicCardiomyopathy, QRS 120 ms, andEF  35% 1Circulation 2002

  9. RATIONALE OF CRT LBBB discordinate contraction ventricular dysfunction

  10. Electrical asinchrony Mechanical asynchrony

  11. Reduction of QRS duration occurs only in responders Lecoq G et al Eur Heart J 2005

  12. % Ghio S et al Eur Heart J 2004;25:571-578

  13. Echocardiographic Data Before and After Cardiac Resynchronization Therapy QRS > 120ms QRS< 120ms Achilli A et al JACC 2003

  14. Mechanical Resynchronization Does Not Require Electrical Synchrony in the Dilated Failing Heart With Left Bundle-Branch Block Electrical epicardial activation map of whole heart for 3 pacing modes Leclerq C et al Circulation 2002

  15. Mechanical Resynchronization Does Not Require Electrical Synchrony in the Dilated Failing Heart With Left Bundle-Branch Block Mechanical LV activation map of whole heart for 3 pacing modes Leclerq C et al Circulation 2002

  16. it appears that Mechanical rather than electrical synchrony seems most important for functional improvement with CRT

  17. Interventricularasynchrony

  18. TDI is useful in recording the chronology and the entity of the velocity curves of miocardium segments

  19. Ts Ts-SDCut-off 33ms the Standard Deviationofthe 6 basal and the 6 mid LV segmentalTsassystolicasynchronyparameter

  20. septaltolateraldelay • cut-off 60 ms Baxet al. AM J Cardiol 2003;92:1238-40

  21. TSI (Tissue Synchronization Imaging) Yu et al. JACC 2005; 45:677-84.

  22. Results of the PROSPECT study No single measure of mechanical dyssynchrony may be recommended to improve pt selection forCRT Methodology to determine mechanical dyssynchrony needs further elaboration QRS remains the selection criterium of dyssynchrony to identify for CRT Circulation 2008

  23. From the initial focus on electricalmarkers, interest shiftedtowarda more directassessmentofmechanicaldyssynchronybymeansoftissue Doppler imaging (TDI). From the initial focus on electrical markers, recent interest has shifted toward a more direct assessment of mechanical dyssynchrony by means of tissue Doppler imaging (TDI). fromthe directassessmentofmechanicaldyssynchrony , attentionagainshiftedtoward QRS

  24. Electricalasynchrony+ - + Mechanicalasynchrony - + + Porcianiet al Echocardiography 2010

  25. Porcianiet al Echocardiography 2010

  26. The question is Since it is electrical activation that produces myocardial contraction that in turn is necessary for cardiac movement, why would they be any different?

  27. The answer should be ►Problems with measuring electrical ayncrony ►Electromechanical interaction ►Complex nature of electrical and mechanical aynchrony

  28. Problems with measuring electrical synchrony Signal averaged electrocardiography detects potentials too low to appear on the standard 12 lead electrocardiogram Xiao Br Heart J 1994

  29. Surgical Ventricular Restoration Improves Mechanical Intraventricular Dyssynchrony in Ischemic Cardiomyopathy Narrow QRS Di Donato et al Circulation 2004

  30. Surgical Ventricular Restoration Improves Mechanical Intraventricular Dyssynchrony in Ischemic Cardiomyopathy Narrow QRS Di Donato et al Circulation 2004

  31. Concordance Between Mechanical and Electrical Dyssynchrony in Heart Failure Patients: A Function of the Underlying Cardiomyopathy? Tournoux F. JCE, 2007

  32. What’s about mechanichal dyssynchrony? Henein MY Heart 1999

  33. Combined Longitudinal and Radial Dyssynchrony Predicts Ventricular Response After Resynchronization Therapy Longitudinal asynchrony (TDI) Radial asynchrony (Speckle-tracking radial strain) Gorcsan J. JACC 2007

  34. ) Gorcsan J. JACC 2007

  35. Porcianiet al PACE 2008

  36. Normal RV ejection RV filling LV ejection LV filling IVCT IVRT LBBB RV ejection RV filling LV ejection LV filling IVCT IVRT

  37. Total isovolumicTimeIndex a – b R-R

  38. Myocardial Performance Index (MPI)

  39. Porcianiet al J Card Med 2010

  40. Porcianiet al J Card Med 2010

  41. Porcianiet al J Card Med 2010

  42. CONCLUSIONS Whichis the best?

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