Heart failure
Usefulness of Left Ventricular Systolic Dyssynchrony by Real-Time Three-Dimensional Echocardiography to Predict Long-Term Response to Cardiac Resynchronization Therapy

https://doi.org/10.1016/j.amjcard.2009.01.372Get rights and content

Real-time 3-dimensional echocardiography (RT3DE) allows simultaneous timing of regional volumetric changes as a net result of longitudinal, radial, circumferential left ventricular (LV) contraction, hence LV systolic dyssynchrony. We sought to examine real-time 3-dimensional echocardiographically derived dyssynchrony for prediction of long-term response to cardiac resynchronization therapy (CRT) in a prospective study. Ninety consecutive patients with heart failure (mean age 60 ± 12 years, 73% men, New York Heart Association class III in 97%) underwent clinical and echocardiographic assessments at baseline and at 12 months after CRT including real-time 3-dimensional echocardiographically derived LV systolic dyssynchrony index. The systolic dyssynchrony index (SDI) was defined as the SD of time to minimum systolic volume of the 16 LV segments, expressed in percent RR duration. CRT response was defined as a >15% decrease in LV end-systolic volume on real-time 3-dimensional echocardiogram. After 12 months of CRT, 68 patients (76%) were responders. Feasibility of the SDI was 94%. An SDI >10% predicted CRT response with good sensitivity (96%), specificity (88%), positive likelihood ratio (8), and negative likelihood ratio (0.05). Patients with an SDI >10% had mean change (−21%, −31%, 39% vs −13%, −10%, 10%) in LV end-diastolic volume, LV end-systolic volume, and LV ejection fraction, respectively, compared with baseline versus patients with an SDI <10% (p <0.01). Mean acquisition and analysis duration of single-patient RT3DE was 8 minutes (range 6 to 13). Interobserver variabilities of LV end-systolic volume and SDI were 5% and 11%, respectively. In conclusion, RT3DE provides accurate identification of reverse volumetric LV remodeling after CRT. From these accurate volumetric data, RT3DE provides more intuitive assessment of dyssynchrony and response to CRT as a simple, reproducible, and fast technique. CRT can be individually tailored using RT3DE and seems very effective in patients with heat failure with real-time 3-dimensional echocardiographic evidence of dyssynchrony.

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Population

The study comprised 90 consecutive patients with HF (60 ± 12 years of age, 73% men) who received CRT-D and had (1) New York Heart Association functional class ≥III despite optimal drug therapy, (2) impaired LV ejection fraction (<35%), and (3) wide QRS complex >120 ms. Patients with atrial fibrillation, acute coronary syndrome, or coronary revascularization within 6 months before CRT were excluded. Informed consent was obtained from all patients and the institutional review board approved the

Baseline data

Out of the originally enrolled 100 patients, 6 patients (6%) were excluded due to poor RT3DE image quality and 4 patients had died during the first year after CRT. The final study cohort included 90 patients (mean age 60 ± 12 years, 73% men). Forty-six patients (51%) had ischemic HF and 44 patients (49%) had nonischemic HF. Eighty-seven patients (97%) were in New York Heart Association class III, and 3 patients were in New York Heart Association class IV. Baseline clinical characteristics of

Discussion

The main findings of this prospective study are that (1) RT3DE showed reverse volumetric LV remodeling in 76% of patients with HF treated by CRT-D after 12-month follow-up and (2) the SDI predicted reverse LV remodeling after CRT with a high positive likelihood ratio and a minimal negative likelihood ratio. In most CRT studies 2-dimensional echocardiography has been used for assessment of LV size and function before and after CRT. However, the accuracy of serial measurements of LV volume from

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