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Donato Mele

Lo studio della dissincronia: come valutarla nella pratica clinica di tutti i giorni. Donato Mele. ECHO FOR INDICATION TO CRT. Current guidelines do not consider echo for implant indication. ECHO FOR INDICATION TO CRT. Current guidelines do not consider echo for implant indication.

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Donato Mele

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  1. Lo studio della dissincronia: come valutarla nella pratica clinica di tutti i giorni Donato Mele

  2. ECHO FOR INDICATION TO CRT • Current guidelines do not consider echo for implant indication.

  3. ECHO FOR INDICATION TO CRT • Current guidelines do not consider echo for implant indication. • If echo is used to indicate CRT beyond guidelines, selection of the most appropriate parameter can be problematic due to the number of existing indexes.

  4. ECHO FOR INDICATION TO CRT • Current guidelines do not consider echo for implant indication. • If echo is used to indicate CRT beyond guidelines, selection of the most appropriate parameter can be problematic due to the number of existing indexes. • Also, sophisticated indexes of mechanical dyssynchrony require a high level of expertise and appropriate technology, which is not available everywhere.

  5. Do conventional, non-sophisticated techniques still play a role?

  6. A-V DYSSYNCHRONY

  7. MECHANISMS CONSEQUENCES LBBB Long AV delay ( PR interval) Tachycardia shorter filling time Anticipated atrial contraction Prolonged IVRT reduced LV filling Delayed mitral valve opening Anticipated mitral valve closure Reduced RR interval reduced SV, EF, CO, dP/dt Reduced diastolic filling time Cardiac Dyssynchrony and LV Diastolic Filling Time

  8. HEART FAILURE WITH PROLONGED PR INTERVAL EFFECT OF AV DELAY OPTIMIZATION Increased diastolic filling period with A-wave appearance Reduction of diastolic mitral insufficiency Too short Optimized Nishimura et al. JACC 1995 Kataoka et al., PACE 1991

  9. INTERVENTRICULAR DYSSYNCHRONY

  10. Qp Right Ventricular Electro-mechanical Delay Qa PULMONARY OUTFLOW Left Ventricular Electro- mechanical Delay AORTIC OUTFLOW Inter-Ventricular Dyssynchony: Qa-Qp

  11. Patient Selection: The Care-HF study Qa is inclusion criterion for patients with a QRS width between 120-150 msec (11%of all pts) • HF NYHA III/IV pts • LVEF < 35 % • LVEDD>30 mm/m • Optimal medical Tx • QRS ≥ 120 ms If QRS > 150 ms Placebo 1 randomization 1 If QRS 120-150 ms CRT (PM Biv) • 2 of 3 Echo criteria satisfied: • Qa-Qp > 40 ms • Qa > 140 ms • delayed PL wall activation Cleland JD et al, Eur J Heart Failure 2001

  12. Inter-Ventricular Dyssynchony: Qa-Qp Qp Right Ventricular Electro-mechanical Delay PULMONARY OUTFLOW JACC 2005; 46: 2153-67 Qa “Most evidence suggests that interventricular dyssynchrony is not useful in the prediction of response to CRT.” Left Ventricular Electro- mechanical Delay AORTIC OUTFLOW

  13. INTRAVENTRICULAR DYSSYNCHRONY

  14. No thickening can be identified Sept. PW The M-mode Index Marcus et al, JACC 2005; 46: 2208-2214 • Limitations: • Only 2 LV walls are considered, which may not include the latest contracting one. • Feasibility can be limited (45%), especially with non-contracting fibrous septa.

  15. M-mode echo: Q - lateral wall peak contraction Q-LW > Q mitral E-wave Contraction during diastole (LV filling) Can be confidently used if LBBB is present.

  16. Jansen et al, Am J Cardiol 2007

  17. Jansen et al, Am J Cardiol 2007

  18. Aortic Pre-ejection Interval • Aortic Pre-ejection interval (Qa) measured from Q-wave on ECG to aortic valve opening • Normal = 93±14 ms1 • Dyssynchronous = ?; 133 ±30 ms in presence of LBBB,1 140 ms proposed2 Data Sources: 1. Grines C, et al. Circulation 1989; 79: 845-853 2. Cleland JGF, et al. Eur J Heart Fail 2001;3:481-489 Intraventricular asynchrony Qa can be affected by load (hypertension!)

  19. Soliman et al, AJC 2007

  20. How to evaluate dyssynchrony in clinical practice • Atrio-ventricular dyssynchrony • Presence of diastolic mitral regurgitation Interventricular dyssynchrony • Qa-Qp (conventional Doppler) Intraventricular dyssynchrony • SPWMD (M-mode) • LWPSD (M-mode) • IVT (conventional Doppler) • Qa (conventional Doppler) Diastolic impairement •  LV filling time •  E/E’ • Restrictive filling

  21. Importance of HF Etiology

  22. Predictors of lack of response to resynchronization therapy Diaz-Infante E, Am J Cardiol. 2005;95:1436-40 From 197 consecutive patients scheduled to receive CRT, 143 fulfilled the inclusion criteria. Mean age was 68 +/- 7 years and 79% were men. Heart failure was due to ischemic heart disease in 49 patients (34%). Mean QRS duration was 165 +/- 26 ms, and left ventricular ejection fraction was 27 +/- 7%. Nonresponder patients were defined as those who died of heart failure, underwent heart transplantation, or did not increase the distance walked in 6 minutes >10%. At 6-month follow-up, there were 28 nonresponders (20%). Among nonresponders, 2 patients received a heart transplantation and 9 patients died of heart failure. In logistic regression analysis, independent predictors of lack of response to CRT were: -ischemic heart disease (OR 2.9, 95%CI 1.2 to 7; p = 0.023) -severe mitral regurgitation (OR 3.5, 95%CI 1.3 to 9; p = 0.014) -LV end-diastolic diameter 75 mm (OR 3.1, 95%CI 1.1 to 8; p = 0.026). Patients with these 3 predictors had a probability response of 27%.

  23. Residual/silent ischemia should be excluded (by echo/nuclear stress test) and revascularization performed before implant. If revascularization is not possible (high-risk/unfeasible PTCA/bypass), non-response to CRT is more likely to occur, although CRT may reduce angina. Coronary artery disease is a progressive disease (a de novo ischemia may develop) and may independently drive prognosis. Effect of CRT on LV remodeling and diastolic dysfunction is less compared to non-ischemic patients. CRT in ischemic patients

  24. Effect of Posterolateral Scar Tissue on Clinical and Echocardiographic Improvement After CRT Bleeker et al - Circulation. 2006;113:969-976 40 ischemic HF pts, NYHA class III-IV, LV-EF35%, QRS>120 msec, LBBB

  25. Septal scar (from White) Posterolateral scar (from Bleeker) Various scars (from White) SCAR TISSUE and PREDICTION OF RESPONSE TO CRT PARAMETER ECG Evidence of anterior infarct MRI Transmural posterolateral scar Transmural septal scar Percent total scar > 15% Total scar burden < 1.20 Mioc. perfusion 201Tl SPECT Global scar burden N of segments with trasmural scar Scar density near the lead Mioc. Perfusion 99Tc SPECT Total scar score >15 Scar in LV pacing region END-POINT peakVO2 (baseline to 6 m) Death, NYHA, 6-MWT NYHA, 6-MWT, EF, QoL score as above ESV Relative EF  >15% as above as above Death, NYHA, 6MWT as above FOLLOW-UP 6 m 6 m 3 m as above 6 m 11 m (median) as above as above 6 m as above AUTHOR Reynold, PACE 2004 Bleeker, Circ. 2006 White, JACC 2006 as above Ypenburg, AJC 2007 Adelstein, AHJ 2007 as above as above Ypenburg, EHJ 2007 as above

  26. Preserved viability Poor viability VIABILITY and PREDICTION OF RESPONSE TO CRT PARAMETER CONTRAST ECHO Perfusion score index (PSI) ≥1 NUCLEAR IMAGING 18F-FDG SPECT (11 viable segments or more) Gated-SPECT (tech-99m) (10 viable segments or more) END-POINT LV performance, exercise tolerance, LV-EDD LV-EF Death, NYHA, 6MWT FOLLOW-UP 6 m 6 m 6 m AUTHOR Hummel, H Rhythm 2006 Ypenbug, JN Med 2006 Ypenburg, EHJ 2007

  27. Sustained Reverse Left Ventricular Structural Remodeling With Cardiac Resynchronization at One Year Is a Function of Etiology Quantitative Doppler Echocardiographic Evidence From the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) Sutton et al, Circulation 2006;113:266-272.

  28. Importance of HF Etiology In ischemic heart failure the mechanical effects of CRT may be less or even absent, depending on the extension of transmural myocardial scars and myocardial viability. Also, occurrence of cardiac events after CRT may be related to uncorrected residual myocardial ischemia.

  29. CONCLUSIONS

  30. How to Identify CRT Responders in Clinical Practice

  31. VALUTARE LE INDICAZIONI ALL’ IMPIANTO Classe NYHA III-IV Terapia medica ottimizzata FE ventricolare sinistra ≤35% Evidenza di dissincronia ventricolare

  32. VALUTARE LE INDICAZIONI ALL’ IMPIANTO Classe NYHA III-IV Terapia medica ottimizzata FE ventricolare sinistra ≤35% Evidenza di dissincronia ventricolare

  33. VALUTARE LE INDICAZIONI ALL’ IMPIANTO Classe NYHA III-IV Terapia medica ottimizzata FE ventricolare sinistra ≤35% Evidenza di dissincronia ventricolare VALUTARE LA PROBABILITA’ DI RISPOSTA A LUNGO TERMINE ALTA PROBABILITA’ DI RISPOSTA POSITIVA SE EZIOLOGIA ISCHEMICA ESCLUDERE Eziologia non ischemica dello scompenso Blocco di branca sinistra Riserva contrattile globale del ventricolo sinistro conservata Pattern di riempimento ventricolare non restrittivo Ipertensione polmonare <50 mmHg Normale funzione renale Ischemia residua Ampie cicatrici transmurali Scarsa vitalità residua Insufficienza mitralica severa Considerare rivascolarizzazione e/o chirurgia della mitrale o trapianto

  34. VALUTARE LE INDICAZIONI ALL’ IMPIANTO Classe NYHA III-IV Terapia medica ottimizzata FE ventricolare sinistra ≤35% Evidenza di dissincronia ventricolare VALUTARE LA PROBABILITA’ DI RISPOSTA A LUNGO TERMINE ALTA PROBABILITA’ DI RISPOSTA POSITIVA SE EZIOLOGIA ISCHEMICA ESCLUDERE Eziologia non ischemica dello scompenso Blocco di branca sinistra Riserva contrattile globale del ventricolo sinistro conservata Pattern di riempimento ventricolare non restrittivo Ipertensione polmonare <50 mmHg Normale funzione renale Ischemia residua Ampie cicatrici transmurali Scarsa vitalità residua Insufficienza mitralica severa Considerare rivascolarizzazione e/o chirurgia della mitrale o trapianto VALUTARE IL SITO DI PACING Sito con maggiore ritardo elettro-meccanico: - identificabile - dotato di riserva contrattile - raggiungibile per via transvenosa SI NO IMPIANTO TRANSVENOSO IMPIANTO EPICARDICO

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