Que peut-on encore demander à l'échocardiographiste? (Dr C. Goffinet)
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This document discusses methods for measuring cardiac dyssynchrony and optimizing cardiac resynchronization therapy (CRT). It summarizes various echocardiography techniques for assessing interventricular, intraventricular, and atrioventricular dyssynchrony. It also reviews factors that influence response to CRT beyond dyssynchrony, such as QRS duration, viability, and lead positioning. The document then examines methods for optimizing CRT, including adjusting atrioventricular and interventricular delays using echocardiography and algorithms to maximize cardiac filling and reduce dyssynchrony.
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Que peut-on encore demander à l'échocardiographiste? (Dr C. Goffinet)
- 1. Que peut-on encore demander à l’échographiste? C.Goffinet
- 2. Que peut-on encore demander à l’échographiste? •Asynchronisme ventriculaire •Réponse CRT •Optimisation CRT
- 3. Mesurer l’asynchronisme? 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy Selection of HF patients for CRT based on LV mechanical dyssynchrony assessed with imaging techniques is uncertain and should therefore not be used as a selection criterion for CRT. However, data from several observational studies suggest that baseline LV mechanical dyssynchrony and acute resynchronization effect after CRT are independent determinants of CRT response and long-term outcome. En Belgique… 2.3. Pour une thérapie de resynchronisation le patient doit présenter : Une classe NYHA III insuffisance cardiaque (malgré une thérapie médicamenteuse optimale) Un complexe QRS compris en 120ms et 149ms avec un asynchronisme documenté ou un complexe QRS > 150ms Un LBBB (left bundle branch block)
- 4. Clinical factors influencing the likelihood to respond to CRT. Authors/Task Force Members et al. Eur Heart J 2013;34:2281-2329 CRT in heart failure with a narrow QRS (<130ms) complex. EchoCRT trial. NEJM 2013
- 5. CRT: mécanisme? Yu C-M, Chau E, Sanderson J, et al.Yu C-M, Chau E, Sanderson J, et al. CirculationCirculation 2002;105:438-4452002;105:438-445 IntraventricularIntraventricular SynchronySynchrony AtrioventricularAtrioventricular SynchronySynchrony InterventricularInterventricular SynchronySynchrony ↓↓ LALA PressurePressure ↑↑ LV DiastolicLV Diastolic FillingFilling ↑↑ RV StrokeRV Stroke VolumeVolume ↓↓ LVESVLVESV ↓↓ LVEDVLVEDV Reverse RemodelingReverse Remodeling Cardiac ResynchronizationCardiac Resynchronization ↓↓ MRMR↑↑ dP/dt,dP/dt, ↑↑ EF,EF, ↑↑ COCO ((↑↑ Pulse Pressure)Pulse Pressure)
- 6. Circulation Volume 117(20):2608-2616 May 20, 2008 Results of the Predictors of Response to CRT (PROSPECT) Trial by Eugene S. Chung, Angel R. Leon, Luigi Tavazzi, Jing-Ping Sun, Petros Nihoyannopoulos, John Merlino, William T. Abraham, Stefano Ghio, Christophe Leclercq, Jeroen J. Bax, Cheuk-Man Yu, John Gorcsan, Martin St John Sutton, Johan De Sutter, and Jaime Murillo
- 7. • M 71ans • Cardiomyopathie non ischémique avec FE <35% • BBGcomplet (144ms) • R/médical optimal depuis 6 mois • NYHA III Cas clinique
- 8. Comment mesurer l’asynchronisme? – Atrio-ventriculaire : E+A/RR <40% 489/100ms = 49%
- 10. intraventriculaire Septal to posterior wall motion delay M-mode >130ms Septal to lateral Ts delay Tissue velocity imaging >60ms Max delay in Ts in 4 basal LV segments Tissue velocity imaging >65ms SD of Ts of 6 basal LV segments Tissue velocity imaging >36,5ms Max delay in Ts in 12 basal and mid LV segments Tissue velocity imaging >100ms SD of Ts in 12 basal and mid LV segments (Dyssynchrony Index) Tissue velocity imaging >32,6ms Anteroseptal to posterior time to peak strain difference (radial strain) Speckle tracking >130ms SD of time-to peak longitudinal strain in 12 basal and mid LV segments Coloour-TDI SD of time-to peak longitudinal strain in 12 basal and mid LV segments (systolic dyssynchrony index) 3D echo >5,6%
- 11. Comment mesurer l’asynchronisme M-Mode Delai >130ms ? 110ms
- 12. TDI • Dépendance de l’angle • Trop de variabilité inter et intra-obs 60ms
- 13. Speckle tracking : 2D strain Longitudinal / transverse strain radial/circomférentiel Étude STAR Dyssynchrony by speckle-tracking echocardiography and response to cardiac resynchronization therapy: results of the Speckle Tracking and Resynchronization (STAR) study HTanaka, European Heart Journal (2010) 31, 1690
- 14. Speckle tracking : 2D strain Délai : 171ms
- 15. Speckle tracking : 2D strain Relationship between improvement in left ventricular dyssynchrony and contractile function and clinical outcome with CRT: MADIT-CRT trail EHJ 2011, Pouleur AC
- 16. 2D strain et dobutamine? • Apical rocking? Dynamic relationship of left-ventricular dyssynchrony and contractile reserve in patients undergoing cardiac resynchronization therapy. Stankovic I Eur Heart J. 2013 Aug 4.
- 17. Apical rocking Dynamic relationship of left-ventricular dyssynchrony and contractile reserve in patients undergoing cardiac resynchronization therapy. Stankovic I Eur Heart J. 2013 Aug 4.
- 18. 3D • Index d’asynchronisme – Qualité image – Frame rate Delgado V, Bax J. Circulation 2011;123:640-655
- 19. Il n’y a pas que l’asynchronisme – NYHA – Durée QRS – Viabilité – Lead position – Réglage de la CRT
- 20. Reponse à la CRT – Mortalité – Hospitalisation – QOL – 6min walking test – ECHO • Fraction d’éjection • volumes ventriculaires • IM
- 21. Optimisation de CRT Delai AV Bertini M et al. Europace 2009;11:v46-v57
- 22. Optimisation de CRT Ritter formula
- 23. Optimisation de CRT Bertini M et al. Europace 2009;11:v46-v57
- 24. Optimisation de CRT Bertini M et al. Europace 2009;11:v46-v57 Myocardial performance index = ((A-E time) - LV ejection time) / LV ejection time
- 25. Optimisation de CRT Bertini M et al. Europace 2009;11:v46-v57
- 27. Optimisation de CRT Délai AV 120ms VV fixe Follow up Amélioration? Pas de modification Délai AV et ECHO Délai le plus court meilleur remplissage VG (A) ECHO – smart device Optimisation ECHO (stroke volume et asynchronisme) Smart device Durée du QRS Délai VV oui non
- 29. Changes in LVESV : the fixed AVI of 120 ms Ellenbogen et al, Circulation 2010
- 30. Mullens W. et al J Am Coll Cardiol 2009 Should the AV interval be optimized ?
- 31. Bogaard et al, Europace 2012 Effects of AV and VV delay programming on LV pressure rise In 23-33% (A Vsense) In 32-357% (A Vpace) In 45% (VV delay) Useful :
- 32. O. Soliman et al
- 33. Bogaard et al, Europace 2012
- 34. Bogaard et al, Europace 2012 Correlation of characteristics to individual optimal AV and VV delays
Editor's Notes
- Clinical factors influencing the likelihood to respond to CRT.
- This slide shows the three components of Cardiac Resynchronization, which highlight some of the key findings from Yu’s study: Intra-ventricular synchrony As a result of improved synchrony, systole becomes more effective and therefore, ejection fraction (EF), cardiac output (CO) and other parameters of cardiac function are improved. Left ventricular end-systolic volume (LVESV) is reduced. Mitral regurgitation (MR) attributable to distortion of the mitral apparatus is reduced by synchronizing the contractions and left atrial (LA) pressure is reduced. LV end-diastolic pressure and volume (LVEDV) are decreased. Atrioventricular synchrony A second mechanism is the shortening of the isovolumic contraction time (IVCT) after optimization of the atrioventricular delay. The effective diastolic filling time is increased, which in turn increases the stroke volume. In addition, LA pressure is reduced due to decreases in presystolic mitral regurgitation. Interventricular synchrony A less important mechanism is the improvement of interventricular synchrony between the right and left ventricles. This benefit may mediate through ventricular interdependence. This results in the gain in RV cardiac output, thereby augmenting the LV filling, resulting in overall improved cardiac function. The end effect of reverse remodeling will additionally improve cardiac synchrony and decrease secondary mitral regurgitation, forming a positive feedback loop. Benefits are dependent upon pacing In Yu’s study withholding pacing resulted in loss of cardiac benefits. Improvement in diastolic filling time, isovolumic contraction time, and myocardial performance index (MPI) were lost immediately since they were largely dependent upon control of AV synchrony. Benefits on ejection fraction, cardiac output, Quality of Life and walking distance were gradually lost over 4 weeks which suggest that pacing may reverse LV remodeling.