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Left Ventricular Twist Mechanics in Heart Failure:

Left Ventricular Twist Mechanics in Heart Failure: Evolving Role in the Assessment of Cardiac Dyssynchrony. M Bertini, PP Sengupta, G Nucifora, V Delgado, ACT Ng, N Ajmone Marsan, M Shanks, RJ van Bommel, MJ Schalij, J Narula, JJ Bax. JACC Cardiovascular Imaging 2009. Disclosures.

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Left Ventricular Twist Mechanics in Heart Failure:

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  1. Left Ventricular Twist Mechanics in Heart Failure: Evolving Role in the Assessment of Cardiac Dyssynchrony M Bertini, PP Sengupta, G Nucifora, V Delgado, ACT Ng, N Ajmone Marsan, M Shanks, RJ van Bommel, MJ Schalij, J Narula, JJ Bax JACC Cardiovascular Imaging 2009

  2. Disclosures • Jeroen Bax received grants from Medtronic, Boston Scientific, Biotronik, St. Jude Medical, BMS medical imaging, Edwards Lifesciences & GE Healthcare • Martin Schalij received grants from Biotronik, Medtronic & Boston Scientific

  3. Introduction • The opposite rotation of LV apex and base leads to a LV systolic wringing motion during systole referred to as twist. • LV twist contributes significantly to LV systolic function • LV twist is an important aspect of cardiac mechanics that may be useful to characterize HF patients and effects of CRT on HF • Objects of the Review: • Overview of physiology of LV rotational mechanics; • Discussion on different LV twist patterns in systolic HF; • The evolving role of LV twist as a marker of LV dyssynchrony • for understanding response to CRT.

  4. Normal LV Twist Mechanics • LV Twist is affected by: • Preload (directly related to LV end-diastolic volume) • Afterload (inversely related to LV end-systolic volume) • Contractility (directly related to positive inotropic interventions) • Increase gradually from infancy to adulthood

  5. LV Twist in the Dyssynchronous, Failing Ventricle • Ischemic vs. Non-ischemic Failing Ventricle: • LV twist is more reduced in HF as compared to acute myocardial infarction • Different mechanisms underlying the reduction in LV twist: • In HF patients, LV twist impairment results from a long-standing process, • with a rearrangement of LV myofibers and loss of the specific LV architecture. • In acute myocardial infarction, the LV twist reduction may result from • an acute impairment in rotation of the LV region that is involved in the infarction.

  6. LV Twist in the Dyssynchronous, Failing Ventricle Relation LV Twist-Dyssynchrony: Deleterious effects of asynchronous ventricular activation on LV performance and the relation between the LV activation pattern and LV twist RV pacing may determine a dyssynchronous mechanical activation and a deterioration of LV twist

  7. LV Twist in CRT • Sade et al. (Am J Cardiol 2008): 33 HF pts • LV twist reduced in HF as compared to normal • Improvement of LVEF immediately after CRT • Improvement of LV twist immediately after CRT • Zhang et al. (Heart 2008): 39 HF pts • LV twist reduced in HF as compared to normal • Improvement of LVEF 3 months after CRT • No improvement of LV twist 3 months after CRT • Bertini et al. (J Am Coll Cardiol 2009): 80 HF pts • LV twist reduced in HF as compared to normal • Improvement of LVEF immediately after and 6 months after CRT • Improvement of LV twist immediately after and 6 months after CRT

  8. LV Twist in CRT Responders vs. Non-responders LV twist progressively improved in responders Gradual deterioration of LV twist in non-responders

  9. LV Twist in CRT LV Twist and LV Lead Position Postero-lateral LV leads positioned in mid-ventricular and apical as compared to basal regions had a larger increase in systolic function with a significant increase in LV twist

  10. Conclusions  LV twist mechanics is a promising tool for characterizing the pathophysiology of HF. In advanced systolic HF, the rotational parameters are severely deteriorated and may be improved by restoring electro-mechanical activation through CRT. LV lead position is important for modifying the extent of LV twist after CRT; in particular pacing sites which provide the greatest improvement of LV twist likely determine the largest reversal of LV remodeling after CRT  

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