Ruolo dell`imaging cardiaco per una corretta selezione dei pazienti

Ruolo dell'imaging cardiaco per una corretta
selezione dei pazienti candidati alla CRT
Donato Mele
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
LV dilatation no longer required compared to the 2007 ESC Guidelines.
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
CRT FOR NYHA CLASS II-IV PATIENTS
• The number of non-responders is high (about 30-50%
depending on response definition and HF etiology).
• CRT is not without complications (11% periprocedural, 4%
device-related according to the 2009 European CRT Survey).
• Economic resources are limited and a wise use of them is
expected.
Therefore, today identification of CRT non-responders is a needed
health care strategy.
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
CRT FOR NYHA CLASS II-IV PATIENTS
Can mechanical dyssynchrony help to
identify CRT non-responders?
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
CRT FOR NYHA CLASS II-IV PATIENTS
After initial enthusiasm…
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Atrio-ventricular
Intra-LV
Inter-ventricular
Global
Global
Δ time RV vs. LV pre-ejection; Doppler flow
LV filling time ÷ total cycle
time; Doppler flow
Segmental
Global
Δ time velocity onset, RV vs. LV; Pulsed TD
QRS to aortic valve opening; Doppler flow
Segmental
Δ time
Time variability
2 segments
- Max deflection; M-mode
- Peak velocity; Color TD
- Radial strain; Color TD
12 segment std. dev. of
time to peak velocity;
Color TD
6 segment std dev of
strain ÷ mean
strain;
Color
TD
Time to
peak strain
3 segments
- Velocity onset; Pulsed TD
4 segments
- Velocity onset; Pulsed TD
- Peak velocity; Color TD
- Peak strain/strain rate; Color TD
Absolute time
QRS to peak lateral wall
deflection; M-mode
QRS to end of lateral wall
contraction; Pulsed TD
QRS to peak velocity;
Color coded, Color TD
coefficient of variation;
custom application
6 segments
- Peak velocity; Color TD
- Displacement peak; Color TD
8 segments: Peak velocity; Color TD
Δ time hit the highest point velocity, RV vs. LV;
Color TD
Relative time
Qualitative
% basal segments with
negative strain rate
post aortic valve
closure; Color TD
Lateral wall
contraction post aortic
valve closure; Pulsed
TD
5 basal segment;
Pulsed TD
Abbreviations:
LV = left ventricular
RV = right ventricular
TD = tissue Doppler
12 segments: Peak velocity; Color TD
16 segments: Ejection; 3D
Averaged peak displacement normalized to
cardiac cycle length; custom application
Azienda Ospedaliera
Universitaria - Ferrara
The Babel (Dyssynchrony) Tower
Napoli 2011
Results of the Predictors of Response
to CRT (PROSPECT) Trial
Conv
echo
DTI
Azienda Ospedaliera
Universitaria - Ferrara
Chung ES et al; Circulation 2008.
“Given the modest sensitivity and
specificity in this multicenter setting
despite training and central analysis, no
single echocardiographic measure of
dyssynchrony may be recommended
to improve patient selection for CRT
beyond current guidelines.”
Napoli 2011
CRT FOR NYHA CLASS II-IV PATIENTS
Does mechanical dyssynchrony evaluation
still have a sense
after the PROSPECT study?
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
SPECKLE-TRACKING ECHOCARDIOGRAPHY:
Comprehensive assessment of myocardial deformation
Longitudinal deformation
Base
LONGITUDINAL
Circumferential
deformation
Radial
deformation
Radial
deformation
• Torsion
TORSION
Azienda Ospedaliera
Universitaria - Ferrara
CIRCUMFERENTIAL
Apex
Torsional deformation
RADIAL
Napoli 2011
RADIAL STRAIN DYSSYNCHRONY
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
PREDICTIVE VALUE OF RADIAL STRAIN DYSSYNCHRONY
Novel Speckle-Tracking Radial Strain From
Routine Black-and-White Echo Images to
Quantify Dyssynchrony and Predict Response to
CRT
Suffoletto et al, Circulation 2006;113:960-968
6 mid-ventricle myocardial segments
normal
dyssynchrony
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
PREDICTIVE VALUE OF RADIAL STRAIN DYSSYNCHRONY
Assessment of Left Ventricular Dyssynchrony by Speckle
Tracking Strain Imaging
Comparison Between Longitudinal, Circumferential, and Radial Strain in CRT
Delgado V, JACC 2008
Radial
Radial
Longitudinal
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Multicenter prospective study
on 132 patients
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Usefulness of Echo Dyssynchrony in Pts with Borderline
QRS duration to Assist With Selection for CRT
Oyenuga et al, JACC Imaging 2010; 2:132-140
Cut-off≥130 ms
strain
Borderline QRS=100-130 ms
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
SPECKLE TRACKING ECHO FOR CARDIAC
DYSSYNCHRONY
ADVANTAGES OF THE SPECKLE TRACKING TECHNIQUE:
• Pathophysiologic sound (it assesses myocardial
deformation, not motion or displacement)
• Correlates with MRI
• More accessible than MRI
ADVANTAGES OF THE RADIAL DYSSYNCHRONY INDEX:
•
•
•
•
Easy to apply
Rapid
Highly reproducible
More predictive data compared with MRI
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
NORMALE
ECOCARDIOGRAFIA 3D
systolic dyssynchrony index 0,62%
Azienda Ospedaliera
Universitaria - Ferrara
DISSINCRONO
systolic dyssynchrony index 11,22%
Napoli 2011
Real-Time 3D Echo in Patient Selection for Cardiac
Resynchronization Therapy
Kapetanakis et al, JACC imaging 2011
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
CRT FOR NYHA CLASS III-IV PATIENTS
The issue of LV scar burden
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Effect of Posterolateral Scar Tissue on Clinical and
Echocardiographic Improvement After CRT
Bleeker et al - Circulation 2006;113:969-976
40 ischemic HF pts, NYHA class III-IV, LV-EF35%, QRS>120 msec, LBBB
Transmural scar: hyperenhancement 51-100% of LV wall thickness
Combined assessment of scar tissue and LV dyssynchrony
is needed for best prediction of CRT response.
Percentages of responders to CRT for 4 different patient
categories based on the presence or absence of transmural
posterolateral scar tissue (Scar+/Scar-) in combination with
the presence or absence of baseline LV dyssynchrony ≥65
ms (Dys+/Dys-).
Azienda Ospedaliera
Universitaria - Ferrara
Contrast-enhanced MRI of a patient with
transmural scar tissue in the posterolateral wall.
Napoli 2011
Development and validation of a clinical index to
predict survival after CRT
Leyva et al – Heart 2009;95:1619-1625
148 HF pts, NYHA class III-IV, LV-EF<35%, QRS≥120 msec
DSC Index: Dyssynchrony, Scar (posterolateral location), Creatinine
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Effects of global longitudinal strain and total scar burden on response to CRT in
patients with ischaemic dilated cardiomyopathy
D’Andrea A et al. Eur J Heart F 2009; 11: 58-67
Average Global longitudinal strain (GLS) correlates
closely with MRI total scar burden (r=0.64,
P<0.001).
GLS and radial intraventricular dyssynchrony
were powerful independent determinants of
response to CRT.
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
CRT FOR NYHA CLASS III-IV PATIENTS
The issue of LV pacing site
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
Pacing a segment with peak radial strain amplitude <10% is associated with poor outcomes of CRT
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
LV PACING SITE RELATIVE TO SCAR LOCATION
BY ECHOCARDIOGRAPHY
Mele D et al, submitted
Non responders
Responders
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
CRT FOR NYHA CLASS III-IV PATIENTS
The issue of LV contractile
reserve
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
VALUTAZIONE DELLA RISERVA CONTRATTILE DEL
VENTRICOLO SINISTRO
Eco-stress con dobutamina a bassa dose
Autore
Parametro
Cut-off
End-point
Da Costa A et al, Heart Rhythm 2006
LV-EF
>25%
Riduzione eventi di
scompenso cardiaco a
12,18,7 mesi
Ypenburg C et al, Am Heart J 2007
LV-EF
>7.5%
ESV ≥15% a 6 mesi
Tuccillo B et al , J Interv Card Electrophysiol 2008
LV-EF
>25%
ESV ≥15% a 6 mesi
Ciampi Q et al, Eur J Heart Fail 2009
WMSI
≥0.20
ESV ≥15% a dopo 11 mesi
(mediana)
Azienda Ospedaliera
Universitaria - Ferrara
Viareggio
2011
Roma 2010
CONCLUSIONS
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
•
The response of the “average” patient to a therapy is not
necessarily the response of the individual patient standing
before the clinician (C Bernard, 1865).
•
Identification of patients with highest probability of CRT
response could allow allocate resources to those patients who
can really benefit from the treatment.
•
Cause of nonresponse to CRT is probably multifactorial: beyond
dyssynchrony, factors related to the myocardial substrate play
an important role (global scar burden, scar at pacing site and
contractile reserve).
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
APPROCCIO A STEP PER LO STUDIO DEI CANDIDATI ALLA CRT
STEP I - VALUTARE LE INDICAZIONI ALL’ IMPIANTO (Classe IA)
•
•
•
•
•
Classe NYHA II-IV
Terapia medica ottimizzata
FE ventricolare sinistra ≤35%
QRS>120 ms (classe NYHA III-IV) o >150 msec (classe NYHA II)
Ritmo sinusale
STEP II - VALUTARE LA PROBABILITA’ DI RISPOSTA A LUNGO TERMINE
ALTA PROBABILITA’ DI RISPOSTA POSITIVA IN CLASSE NYHA III-IV
•
•
•
•
•
•
Eziologia non ischemica
QRS>150 ms
Blocco di branca sinistra
Scarso scar burden totale (soprattutto nelle forme ischemiche)
Conservata riserva contrattile globale (soprattutto nelle forme non ischemiche)
Normale funzione renale
Utile aggiungere la quantificazione della dissincronia meccanica se:
• QRS “intermedio” (120-150 msec)
• Blocco di branca destra
• Blocco di branca sinistra senza evidenza di “bounce” settale
• Indicazioni “off-label” (QRS “stretto” <120 msec, FE>35%)
STEP III - IDENTIFICARE IL SITO DI PACING OTTIMALE
• Zona più ritardata e vitale (senza cicatrice transmurale)
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011
3D Speckle Tracking Echo: ONE STOP-SHOP APPROACH
•LV function
•Dyssynchrony (with torsion)
•Global scar burden
•Target zone characterization
•Contractile reserve
Azienda Ospedaliera
Universitaria - Ferrara
Napoli 2011