Simple regional strain pattern analysis to predict response to cardiac resynchronization therapy: Rationale, initial results, and advantages

doi:10.1016/j.ahj.2012.01.025

American Heart Journal

Volume 163, Issue 4, April 2012, Pages 697-704

https://doi.org/10.1016/j.ahj.2012.01.025 Get rights and content

Background

A classical strain pattern of early contraction in one wall and prestretching of the opposing wall followed by late contraction has previously been associated with left bundle branch block (LBBB) activation and short-term response to cardiac resynchronization therapy (CRT). Aims of this study were to establish the long-term predictive value of an LBBB-related strain pattern and to identify changes in contraction patterns during short-term and long-term CRT.

Methods and Results

Sixty-seven patients with standard CRT criteria were prospectively enrolled between early 2009 and late 2010. Echocardiography including regional strain analysis by 2-dimensional speckle tracking was performed 1 week before implantation, at day 1, and 6 months after. Response was defined as a decrease in left ventricular end-systolic volume ≥15%. The predictive ability of a classical pattern was compared with time-to-peak measurements from velocity and deformation analysis.

Forty-three patients (65%) were classified as responders. The presence of a classical pattern showed 91% specificity and 95% sensitivity for response and performed significantly better than time-to-peak parameters in prediction of response to CRT (P < .001, all). In responders, CRT acutely increased septal longitudinal peak systolic strain (−8.7% ± 3.6% to −11.1% ± 3%, P < .001) but not in nonresponders.

Conclusions

The classical pattern is highly predictive of response to CRT and superior to time-to-peak methods. Patients who obtain long-term reverse remodeling are characterized by short-term reversal of the classical strain pattern. These findings emphasize the value of recognizing potentially reversible strain patterns in selection of CRT candidates.

Section snippets

Study population

A total of 67 consecutive patients with left ventricular (LV) ejection fraction (LVEF) ≤35%, QRS ≥120, LBBB, and New York Heart Association (NYHA) functional class II or III were included between early 2009 and late 2010. All patients received heart failure medication in maximal tolerated dosages, including angiotensin-converting enzyme inhibitors or angiotensin-receptor antagonists (100%), β-blockers (92%), and spironolactone (59%).

Exclusion criteria were significant primary valve disease,

Study population

Baseline characteristics and association with outcome are shown in Table I. CRT-D implantation was successful in all patients. One patient was excluded at 6 months because of suboptimal pace delivery of 82%. Forty-three patients (65%) were responders. Responders compared with nonresponders were more likely to have nonischemic heart disease, longer QRS duration, and a higher degree of LV dyssynchrony by TPS_max. At follow-up, responders showed significant LV reverse remodeling (LVESV decreased

Discussion

The main findings in the current study can be summarized as follows: (1) In all patients, 1 of the 2 patterns could be identified; (2) Identification of LV dyssynchrony by use of the classical pattern was highly predictive of response; (3) Prediction of response by pattern analysis was better than prediction by more common quantitative descriptors; and (4) LV remodeling was dependent on short-term redistribution in the septal and lateral strains, representing the early- and late-activated

Conclusion

The current study presents an easy and highly predictive method for identifying potential responders to CRT based upon previously described factors involved in activation delay–based dyssynchrony. Pattern analysis appears superior to time-to-peak methods of velocity and longitudinal strain based on identifying distinct patterns of contraction that reflect the link between abnormal electrical activation and mechanical dyssynchrony. In addition, our results indicate a key role for the short-term

Disclosures

Sources of funding: None.

Conflicts of interest: None declared.

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Cardiac resynchronization therapy (CRT) is a device-based treatment applied to patients with a specific profile of heart failure. According to current guidelines, indication for CRT is given on the basis of QRS morphology and duration, and traditional transthoracic echocardiography is mainly used to estimate left ventricular (LV) ejection fraction. However, the identification of patients who may benefit from CRT remains challenging, since the application of the above-mentioned guidelines is still associated with a high rate of non-responders. The assessment of various aspects of LV mechanics (including contractile synchrony, coordination and propagation, and myocardial work) performed by conventional and novel ultrasound technologies, first of all speckle tracking echocardiography (STE), may provide additional, useful information for CRT patients' selection, in particular among non-LBBB patients, who generally respond less to CRT. A multiparametric approach, based on the combination of ECG criteria and echocardiographic indices of LV dyssynchrony/discoordination would be desirable to improve the prediction of CRT response.
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Morbidity and mortality increase as Fontan patients age into adulthood. Limited studies have examined cardiac magnetic resonance and echocardiographic parameters to predict death and transplantation in children after the Fontan operation. The aim of this study was to investigate echocardiographic parameters in adolescents and adults after Fontan operation, including myocardial mechanics such as classic-pattern dyssynchrony (CPD), as predictors of transplantation or death.
In a cross-sectional retrospective study, strain analysis was performed on echocardiographic studies performed between 2001 and 2015 on 110 patients with single-ventricle physiology after the Fontan procedure. Strain curves were measured and visually assessed for the presence of CPD. The primary end point was death or transplantation after a follow-up period of 85 ± 35 months after echocardiography.
The median age at the date of echocardiography was 20 years (range, 3-45 years). Of 110 patients, 28 had undergone transplantation. During the study period, three patients died after transplantation and seven patients died without undergoing transplantation. CPD was seen in 16 and protein-losing enteropathy in 21 of 110 patients. On multivariate analysis, CPD (hazard ratio [HR], 9.4; 95% confidence interval [CI], 2.6-34.6), protein-losing enteropathy (HR, 10.6; 95% CI, 3.4-33.2), systolic blood pressure (HR, 0.954; 95% CI, 0.913-0.996), systolic/diastolic duration ratio (HR, 6.83; 95% CI, 1.33-35.0), and E-wave deceleration time (HR, 0.98; 95% CI, 0.97-0.99) were independently associated with the primary end point.
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At least 30% of the patients do not respond to cardiac resynchronization therapy (CRT). We performed a systematic review and meta-analysis of real-world studies trying to identify predictors of response to CRT.
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A total of 24 studies were included. The meta-analysis showed that female gender (p = 0.018), non-ischemic cardiomyopathy (NICM) (p < 0.001), left bundle branch morphology (LBBB) (p = 0.001), longer QRS (p < 0.001) and New York Heart Association (NYHA) class II (p = 0.014) appear to favor response to CRT. After ROC analysis and logistic regression procedures, female gender (kappa = 0.450; p < 0.001), NICM (kappa = 0.636; p < 0.001), LBBB (kappa = 0.935; p < 0.001), and NYHA class II (kappa = 0.647; p < 0.001) were identified as independent predictors of response to CRT, being LBBB the most reliable one (sensitivity = 97.24%; specificity = 98.86%).
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Clinical InvestigationImaging and Diagnostic TestingSimple regional strain pattern analysis to predict response to cardiac resynchronization therapy: Rationale, initial results, and advantages

Background

Methods and Results

Conclusions

Section snippets

Study population

Study population

Discussion

Conclusion

Disclosures

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Soc Echocardiogr

Relationship of echocardiographic dyssynchrony to long-term survival after cardiac resynchronization therapy

Circulation

Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy

Circulation

Clinical Investigation
Imaging and Diagnostic Testing
Simple regional strain pattern analysis to predict response to cardiac resynchronization therapy: Rationale, initial results, and advantages