Measurements of electrical and mechanical dyssynchrony are both essential to improve prediction of CRT response☆
Introduction
Cardiac resynchronization therapy (CRT) is a well-established therapy in NYHA ≥ II heart failure (HF) patients with QRS ≥ 120 ms and left ventricular ejection fraction (LVEF) ≤ 35% [1]. CRT is applied in a heterogeneous group of HF patients; ranging from dilated to ischemic cardiomyopathy. Despite demonstrated benefits, in a substantial proportion of the population (up to 50%) the effects of CRT cannot be objectively established [2]. The beneficial effects of CRT are believed to rely to a great extent on the reversal of electrical and mechanical dyssynchrony [3]. In the guidelines, indication for CRT is based on measures of electrical dyssynchrony: QRS width and QRS complex morphology, and no measures of mechanical dyssynchrony proven to be of value are taken into account [1]. Several studies aimed to improve detection of mechanical dyssynchrony but no single criterion has been established yet in multi-center setting that successfully and reliably improves patient selection [2], [4], [5]. Moreover, it remains unclear to what extent mechanical dyssynchrony complements electrical dyssynchrony. This study focused on the additional value of mechanical dyssynchrony; interventricular mechanical delay (IVMD) and systolic rebound stretch of the septum (SRSsept), besides electrical dyssynchrony for prediction of volume response after CRT implantation. Secondly, we hypothesized that due to differences in underlying disease, capacity to predict volume response after CRT implantation might vary for non-ischemic (NICM) and ischemic cardiomyopathy (ICM).
Section snippets
Study cohort and design
For this single-center study we included 227 HF patients of the University Medical Center Utrecht (UMCU) who received a CRT-D device according to guidelines at time of enrolment or inclusion in multi-center clinical trials (e.g. MADIT-CRT) and of which prospectively planned echocardiographic and electrocardiographic data were available. Implantations were performed between August 2005 and December 2011. AV and VV timing delays were optimized invasively (dP/dtmax), echocardiographically, or
Study population
Patient characteristics are summarized in Table 1. Mean age 65.4 ± 10.5 years, 153 (67%) male, 115 (51%) ICM. For NYHA classification the distribution was as follows: NYHA I: n = 1, NYHA II: n = 29, NYHA III: n = 185, NYHA IV: n = 12. Atrial fibrillation (AF) was seen in 42 (19%) patients. In our cohort 127 (56%) had LBBB, 67 (30%) had aspecific interventricular conduction delay (IVCD), and 32 (14%) had right ventricular (RV) pacing.
Echocardiographic response was seen in 115 (51%) patients. Responders
Discussion
The main finding of this study is that the combination of electrical and mechanical measurements of dyssynchrony (BLISS model) significantly improves response prediction after CRT implantation. The BLISS model contains easy available measurements, and BNP, LBBB, and IVMD are well-known and widespread used parameters which are easy to perform. SRSsept is a relatively new parameter, however previously our center proved this to be a very valuable measurement concerning prediction of reverse
Conclusion
Both electrical dyssynchrony and mechanical dyssynchrony are important concerning prediction of CRT response. However, response prediction in ischemic subjects remains challenging and new predictors for this subgroup should be identified.
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