Assessment of right ventriclular systolic function prior to cardiac resynchronization therapy: Does it make any difference?

Abstract

BackgroundCardiac resynchronization therapy (CRT) is an effective treatment for patients with advanced heart failure (HF). Nearly 30% of candidates are inadequate responders. The benefit of patients with right sided heart failure from CRT is still a matter of debate. We examined the effect of CRT on right ventricular (RV) dimensions and overall systolic function and whether RV function prior to CRT could have an impact on CRT response.Methods94 patients with a mean age of 53.7 ± 14.6 years including 19 (20%) females, with advanced HF (EF < 35%, LBBB > 120 ms, or non-LBBB > 150 ms, with NYHA –III or ambulatory class IV) were enrolled and underwent CRT implantation. Standard two dimensional (2D) echocardiography, tissue Doppler imaging, for assessment of Left ventricular (LV) end-diastolic (LVEDV), and end-systolic volumes (LVESV), ejection fraction, RV maximum basal (RVD basal), maximum mid (RVD mid) transverse, maximum longitudinal (RVD long) diameters, TAPSE, fractional area change (FAC), and tricuspid lateral annular systolic velocity (S′), in addition to RV global longitudinal strain (RVGLS) measured by speckle tracking echocardiography, were done before CRT implantation and at the end of the follow up period (5.9 ± 1.2 months). Patients presenting with reductions of LVESV of >15% were termed volumetric responders for further statistical analysis.Results63 (67%) cases were volumetric responders. Both groups were matched regarding demographic, clinical, ECG, and echocardiographic criteria apart from the RV significantly smaller transverse diameters and significantly better systolic function parameters in the responders group prior to CRT compared to non-responders (NR) group. At the end of the follow up, only the responders group had further significant reduction in RV basal, mid and longitudinal diameters (33.6 ± 7.1 vs 40.7 ± 8.6, 21.4 ± 4.9 vs 27 ± 6.1, 68.3 ± 10.8 vs 81.2 ± 15, respectively), p < 0.01, together with significant improvement in RV systolic performance: FAC (47.7 ± 7.3 vs 40.9 ± 6.4), TAPSE (25.2 ± 4.6 vs 22.1 ± 4.9), S′ (15.3 ± 2.3 vs 12.8 ± 2.3), and GLS (26.1 ± 2.1 vs 18.5 ± 1.6), P < 0.01, compared to baseline readings. S' and GLS were the only independent predictors of CRT response by multivariate analysis. S′ >9 cm/s, and GLS >12.45% had 100% sensitivity and 70%, 99.7% specificity, respectively for prediction of response to CRT.ConclusionsCRT induces RV reverse remodeling and improves RV systolic function particularly in cardiac volumetric responders. RV systolic dysfunction before CRT implantation could identify patients that might not benefit from CRT thus helping proper patient selection and optimizing CRT response.

Right ventricular‐arterial coupling – A new perspective for right ventricle evaluation in heart failure patients undergoing cardiac resynchronization therapy

“…In the CARE‐HF trial, RV dysfunction, estimated by TAPSE was a powerful determinant of poor prognosis regardless of treatment assigned 17 . Several other studies confirmed the prognostic value of TAPSE in patients with HFrEF and CRT 18,19 . Pulmonary hypertension was also associated with adverse outcome in patients with LV systolic dysfunction who received CRT 20 …”

Ratio between Right Ventricular Longitudinal Strain and Pulmonary Arterial Systolic Pressure: Novel Prognostic Parameter in Patients Undergoing Cardiac Resynchronization Therapy

“…This may be explained mostly by the lack of significant decrease in PASP one year after CRT ( Table 2 ). The contradictory results of the effect of CRT upon RV function [ 19 , 20 ] may be due to the fact that the RV workload seems to be increased by CRT [ 17 ], and therefore the RV evolution in time may differ among CRT patients depending on the RV function at baseline.…”

Prognostication of Poor Survival After Cardiac Resynchronization Therapy

“…Trials demonstrate different TAPSE cut-off values associated with CRT outcome (15 mm [35], 17 mm [36]) but their diagnostic accuracy is only modest. In single studies there have also appeared other parameters, such as tricuspid lateral annular systolic velocity >9 cm/s and RV global longitudinal strain >12.45%, with very high sensitivity and specificity in predicting LV reverse remodeling [37] or even decreased survival (RV global longitudinal strain <10.04%) [38]), but meta-analysis by Sharma concluded that TAPSE, RV ejection fraction, RV basal strain, and RV fractional area change were not able to predict CRT response as assessed by change in LVEF [39]. In summary, due to the different definitions of CRT outcomes and the small number of appropriate trials, any practical recommendations can be admitted.…”