Working Group of

Heart Failure and Cardiac Function

How to evaluate and treatdyssynchrony ?

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

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

Live from Liège

STEPWISE SELECTION

1. Aortic pre-ejection time > 140 ms

STEPWISE SELECTION

1. Aortic pre-ejection time > 140 ms

2. Interventricular delay > 40 ms

STEPWISE SELECTION

1. Aortic pre-ejection time > 140 ms

2. Interventricular delay > 40 ms

3. Septal-to-posterior delay > 130 ms

STEPWISE SELECTION

1. Aortic pre-ejection time > 140 ms

2. Interventricular delay > 40 ms

3. Septal-to-posterior delay > 130 ms

4. LV filling time < 40 % of cardiac cycle

STEPWISE SELECTION

1. Aortic pre-ejection time > 140 ms

2. Interventricular delay > 40 ms

3. Septal-to-posterior delay > 130 ms

4. LV filling time < 40 % of cardiac cycle

5. DTI TPS

- Septal-to-lateral delay > 60 ms

STEPWISE SELECTION

1. Aortic pre-ejection time > 140 ms

2. Interventricular delay > 40 ms

3. Septal-to-posterior delay > 130 ms

4. LV filling time < 40 % of cardiac cycle

5. DTI TPS

- Septal-to-lateral delay > 60 ms

- LV dispersion (4 segments) > 65 ms

STEPWISE SELECTION

1. Aortic pre-ejection time > 140 ms

2. Interventricular delay > 40 ms

3. Septal-to-posterior delay > 130 ms

4. LV filling time < 40 % of cardiac cycle

5. DTI TPS

- Septal-to-lateral delay > 60 ms

- LV dispersion (4 segments) > 65 ms

- Standard deviation (12 segments) > 31 ms

STEPWISE SELECTION

1. Aortic pre-ejection time > 140 ms

2. Interventricular delay > 40 ms

3. Septal-to-posterior WM delay > 130 ms

4. LV filling time < 40 % of cardiac cycle

5. 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

STEPWISE SELECTIONESC 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

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)

= Normal = Patient = NYHA class III

0

40

80

120

160 VE (L/min)

VCO2 (L/min)

0 54321

VE/VCO2 slope24

2538

How to assess the effects of CRT ?

Working Group ofHeart Failure and Cardiac Function

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)

Evaluation of CRTInvasive : 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

• 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).

Definition of Responder and Non Responder

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

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%)

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)

Lat

Sept Sept

Lat

ECHO and CRTAcute 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