Real-time three-dimensional echocardiography as a novel approach to assess left ventricular and left atrium reverse remodeling and to predict response to cardiac resynchronization therapy

doi:10.1016/j.hrthm.2008.05.021

Heart Rhythm

Volume 5, Issue 9, September 2008, Pages 1257-1264

https://doi.org/10.1016/j.hrthm.2008.05.021 Get rights and content

Background

Real-time 3-dimensional echocardiography (RT3DE) is a novel promising technique for the assessment of left ventricular (LV) dyssynchrony.

Objective

This study sought to explore the value of RT3DE to assess LV and left atrium (LA) reverse remodeling and to predict response to cardiac resynchronization therapy (CRT).

Methods

A total of 57 consecutive heart failure patients scheduled for CRT were included, and RT3DE was performed before and 6 months after implantation. LV dyssynchrony was defined as the standard deviation of the time to reach the minimum systolic volume for 16 LV segments, expressed in percentage of cardiac cycle (systolic dyssynchrony index, SDI). Patients were divided into responders or nonresponders, based on a reduction ≥15% in LV end-systolic volume after CRT.

Results

Six patients (10%) were excluded from further analysis because of suboptimal images. Of the remaining 51 patients, 34 (67%) were classified as responders. Baseline characteristics were similar between responders and nonresponders, except for the SDI, which was larger in responders (9.7% ± 3.6% versus 5.1% ± 1.8%, P <.0001). ROC curve analysis revealed that a cutoff value for SDI of 6.4% yielded a sensitivity of 88% with a specificity of 85% to predict response to CRT. In responders, RT3DE also showed beneficial effects of CRT on LA: (1) significant LA reverse remodeling; (2) significant improvement in LA total emptying fraction and in LA conduit and reservoir function.

Conclusion

RT3DE allows assessment of changes in LV and LA volumes and function after CRT, and it is highly predictive for response to CRT.

Introduction

Cardiac resynchronization therapy (CRT) is considered an additional therapeutic option in heart failure patients who remain highly symptomatic despite optimized medical treatment.¹ Large studies have shown a significant improvement in clinical and echocardiographic endpoints.² However, up to 30% of the patients do not respond to CRT when selection is based on the traditional clinical and electrocardiographic criteria.³ In the search for better selection criteria for CRT, it has been shown that a direct echocardiographic assessment of left ventricular (LV) dyssynchrony is highly predictive for response to CRT.⁴ A novel echocardiographic technique has emerged for the assessment of LV dyssynchrony based on the analysis of regional volumetric changes: real-time 3-dimensional echocardiography (RT3DE). Promising results for the assessment of LV dyssynchrony have been shown when RT3DE was applied in patients with varying degrees of LV dysfunction and in normal subjects.⁵ Furthermore, we have recently shown the value of RT3DE to predict acute echocardiographic response to CRT.⁶ Clinically more important however, is the response at long-term follow-up. In the current study, the value of RT3DE both to assess LV reverse remodeling and to predict echocardiographic response to CRT was evaluated at 6-month follow-up.

In addition, it has been shown recently that RT3DE provides a highly accurate evaluation of left atrium (LA) size and function7, 8 that are established markers of adverse cardiovascular outcomes.9, 10, 11 Few data are available about the effect of CRT on LA remodeling and function.¹² In the current study, it was hypothesized that a favorable response to CRT would also lead to an improvement in LA size and function.

Section snippets

Study population and protocol

The study population consisted of 57 consecutive patients with heart failure scheduled for CRT implantation. Traditional selection criteria for CRT were applied: New York Heart Association (NYHA) functional class III to IV, LV ejection fraction (EF) ≤35%, and QRS duration >120 ms. Patients with atrial fibrillation were excluded to allow a complete evaluation of LA function. Of note, acute results after CRT in 42 of these patients have been reported recently.⁶ Before CRT implantation and at

Pacemaker implantation

The LV pacing lead was inserted transvenously via the subclavian route and positioned as far as possible in a lateral or posterolateral vein. The right atrial and ventricular leads were positioned in the right atrial appendage (or on the right atrium lateral wall) and in the right ventricular apex, respectively. All patients received a combined device (CRT-D; Contak Renewal, Boston Scientific, St Paul, MN.; Insync III-CD or Insync Sentry, Medtronic Inc. Minneapolis, MN) without major

Statistical analysis

Continuous data are presented as mean ± standard deviation. Categorical data are presented as absolute numbers or percentages. The t test and chi-square test were used for appropriate comparisons. Changes in NYHA class, LV filling pattern, and mitral regurgitation before and after CRT have been evaluated with a Wilcoxon ranks test. To determine the relationship between baseline variables and echocardiographic response to CRT, logistic regression analysis was applied. First, univariate analysis

Study population

Six patients (10.5%) were excluded from further analysis because of suboptimal images; baseline characteristics of the remaining 51 patients are summarized in Table 1. RT3DE revealed severe LV dilatation (mean LV end-diastolic volume 200 ± 47 ml), with depressed LV function (mean LV EF 28% ± 6%). Furthermore, a moderate to severe LA dilatation (LAmax 40 ± 18 ml/m²) and dysfunction (LA EF 36% ± 14%) was observed.19, 20

Mean LV dyssynchrony (SDI) was 8.4% ± 3.9%, and the latest activated LV wall

Discussion

In the current study, RT3DE showed a significant improvement in LV remodeling and function at 6 months after CRT associated with a significant improvement in LA volumes and function. In addition, LV dyssynchrony (as measured with SDI) was the only predictor of echocardiographic response to CRT with high sensitivity and specificity.

Study limitations

The patient cohort was relatively small, and the predictive value of RT3DE needs to be assessed for clinical endpoints and confirmed in larger prospective studies. Data on scar tissue and the exact LV lead position were not systematically available, which have been shown to affect response to CRT.27, 28 Also, the contribution of reduction in mitral regurgitation on LA size and function after CRT should be explored in a larger group of patients.

Conclusion

RT3DE allows assessment of the effects of CRT on LV and LA volumes and function. Baseline LV dyssynchrony (as measured with SDI) is predictive for echocardiographic response to CRT.

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Real-time three-dimensional echocardiography permits quantification of left ventricular mechanical dyssynchrony and predicts acute response to cardiac resynchronization therapy

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Left atrial strain provides incremental value for embolism risk stratification over CHA<inf>2</inf>DS<inf>2</inf>-VASc score and indicates prognostic impact in patients with atrial fibrillation
2014, Journal of the American Society of Echocardiography
The aim of this study was to investigate whether left atrial (LA) strain has incremental value over the CHA₂DS₂-VASc score for stratifying the risk for embolism in patients with atrial fibrillation (AF) and whether LA strain predicts poststroke mortality.
Consecutive patients with paroxysmal or persistent AF with acute embolism (82 patients) or without (204 controls) were prospectively enrolled. Global peak LA longitudinal strain during ventricular systole (LA_S) was assessed during AF rhythm. Global LA_S was compared between the groups in the first cross-sectional study. Then, the 82 patients with acute embolism were prospectively followed during the second prospective cohort study.
Global LA_S was lower in patients with acute embolism than in controls (P < .001). Global LA_S < 15.4% differentiated patients with acute embolism from controls, with an area under the curve of 0.83 (P < .0001). In multivariate analysis, global LA_S was independently associated with acute embolism (odds ratio, 0.74; 95% confidence interval, 0.67–0.82; P < .001) and had an incremental value over the CHA₂DS₂-VASc score (P < .0001). Furthermore, 26 patients with acute embolisms died during a median follow-up period of 425 days. Global LA_S independently predicted mortality after embolism.
In this observational study, LA strain provided incremental diagnostic information over that provided by the CHA₂DS₂-VASc score, suggesting that LA strain analysis could improve the current risk stratification of embolism in patients with AF. LA strain can also predict poststroke mortality.
Association between multilayer left ventricular rotational mechanics and the development of left ventricular remodeling after acute myocardial infarction
2014, Journal of the American Society of Echocardiography
The identification of patients at risk for developing left ventricular (LV) remodeling after acute myocardial infarction (AMI) has crucial prognostic implications. The aims of this study were (1) to investigate the relationship between peak subepicardial and subendocardial twist and infarct transmurality, as assessed using contrast-enhanced magnetic resonance imaging, and (2) to evaluate the association between peak subepicardial and subendocardial twist and LV remodeling 6 months after AMI.
A total of 213 patients with ST-segment elevation AMIs who underwent three-dimensional echocardiography for LV volumes and functional assessment and two-dimensional speckle-tracking analysis for the evaluation of LV twist (subendocardial vs subepicardial) were retrospectively included. A subgroup of 40 patients underwent magnetic resonance imaging within 2 months for infarct size quantification.
Peak subepicardial twist was strongly related to infarct size (number of segments with transmural scar: r² = 0.526, P < .001; total scar score: r² = 0.515, P < .001) compared with peak subendocardial twist (number of segments with transmural scar: r² = 0.379, P < .001; total scar score: r² = 0.331, P < .001). In the overall population, 44 patients (21%) developed significant LV remodeling at 6-month follow-up (LV end-systolic volume increase ≥ 15%). These patients showed significantly more impaired peak subepicardial and subendocardial twist at baseline compared with patients without LV remodeling (4.5 ± 1.3° vs 9.4 ± 3.5°, P < .001; 7.0 ± 3.2° vs 12.9 ± 5.8°, P < .001, respectively). Importantly, peak subepicardial twist (odds ratio, 0.241; 95% confidence interval, 0.134–0.431; P < .001) and peak troponin T (odds ratio, 1.152; 95% confidence interval, 1.006–1.320; P = .041) were independently associated with the development of LV remodeling.
Peak subepicardial twist strongly reflects infarct transmurality as assessed with magnetic resonance imaging and is independently associated with LV remodeling after AMI.
Usefulness of overlapping of the e and A waves of the transmitral flow as a predictor of responders to cardiac resynchronization therapy
2013, American Journal of Cardiology
Citation Excerpt :
However, no single echocardiographic measurement of dyssynchrony appears to have had a clinically relevant impact in large clinical trials.2,3 Two-dimensional speckle-tracking imaging and real-time 3-dimensional echocardiography are promising methods to decrease nonresponse.12–17 However, the reproducibility of these echocardiographic parameters remains controversial.
Atrioventricular (AV) dyssynchrony as well as ventricular-ventricular dyssynchrony plays an important role in the selection of candidates for cardiac resynchronization therapy (CRT), but no method for assessing the AV dyssynchrony has been established. The aim of this study was to investigate whether the degree of overlap of the E and A waves can predict response to CRT. The study subjects were 48 consecutive patients maintaining sinus rhythm and intrinsic AV conduction who underwent de novo dual-chamber CRT device implantation. CRT responders were defined as those with reductions in left ventricular end-systolic volume >15% at 6 months after CRT device implantations. Twenty-three patients (48%) were CRT responders. In a multivariate analysis, the overlap ratio of the E and A waves was the only independent predictor of response to CRT (odds ratio 1.03, 95% confidence interval 1.01 to 1.06, p = 0.01). Using a cut-off value of 33%, patients with overlap ratios of the E and A waves ≥33% had a significantly higher rate of response to CRT than those with ratios <33% (73% vs 27%, p = 0.002). In conclusion, the overlap ratio of the E and A waves before CRT device implantation may predict CRT response. This simple method may be helpful in evaluating dyssynchrony in patients, particularly with severe reduced left ventricular wall motion, because this method does not require any wall motion analysis.
Cardiac resynchronization considerations in left bundle branch block
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Left atrial volume index predicts response to cardiac resynchronisation therapy: a systematic review and meta-analysis
2022, Archives of Medical Science
Improved left atrial function in CRT responders: A systematic review and meta-analysis
2020, Journal of Clinical Medicine

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: Dr. Marsan is financially supported by the Research Fellowship of the European Society of Cardiology. Dr. Bax has received research grants from Medtronic, Boston Scientific, BMS medical imaging, St. Jude Medical, GE Healthcare. Dr. Schalij has received research grants from Biotronik, Medtronic, and Boston Scientific.

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Original-clinicalReal-time three-dimensional echocardiography as a novel approach to assess left ventricular and left atrium reverse remodeling and to predict response to cardiac resynchronization therapy

Background

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Study population and protocol

Pacemaker implantation

Statistical analysis

Study population

Discussion

Study limitations

Conclusion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Cardiac resynchronisation for patients with heart failure due to left ventricular systolic dysfunction—a systematic review and meta-analysis

Eur J Heart Fail

The effect of cardiac resynchronization on morbidity and mortality in heart failure

N Engl J Med

Real-time three-dimensional echocardiography: a novel technique to quantify global left ventricular mechanical dyssynchrony

Circulation

Real-time three-dimensional echocardiography permits quantification of left ventricular mechanical dyssynchrony and predicts acute response to cardiac resynchronization therapy

J Cardiovasc Electrophysiol

Original-clinical
Real-time three-dimensional echocardiography as a novel approach to assess left ventricular and left atrium reverse remodeling and to predict response to cardiac resynchronization therapy