The Impact of Myocardial Viability on the Clinical Outcome of Cardiac Resynchronization Therapy

Riedlbauchová, Lucie; Brunken, Richard C.; Jaber, Wael A.; Popova, Lucie; Patel, Dimpi; Lánská, Věra; Civello, Kenneth C.; Cummings, Jennifer E.; Burkhardt, J. David; Saliba, Walid; Martin, David O.; Schweikert, Robert A.; Wilkoff, Bruce L.; Grimm, Richard A.; Natale, Andrea

doi:10.1111/j.1540-8167.2008.01294.x

Cited by 41 publications

(24 citation statements)

References 20 publications

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“…The anatomic lead locations in the 17-segment model were assessed by review of fluoroscopic cinegrams in right and left anterior oblique views in available patients (22). The left ventricle was divided into 3 levels (basal, mid, and apical).…”

Section: Methodsmentioning

confidence: 99%

Impact of Myocardial Scarring on Outcomes of Cardiac Resynchronization Therapy: Extent or Location?

Mei²,

Feng³

et al. 2011

J Nucl Med

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Refining the criteria for patient selection for cardiac resynchronization therapy (CRT) may improve its outcomes. The study objective was to determine the effect of scar location, scar burden, and left ventricular (LV) lead position on CRT outcomes. Methods: The study included 213 consecutive CRT recipients with radionuclide myocardial perfusion imaging before CRT between January 2002 and December 2008. Scar localization and myocardial viability were analyzed using a 17-segment model and a 5-point semiquantitative scale. New York Heart Association (NYHA) class and echocardiography were assessed before and after CRT. The anatomic LV lead location in the 17-segment model was assessed by review of fluoroscopic cinegrams in right and left anterior oblique views. As in published studies, clinical response was defined as an absolute improvement in LV ejection fraction of $5 percentage points after CRT. Results: A total of 651 scar segments was identified in 213 patients. Eighty-three percent of scar segments were located in the LV anterior, posterior, septal, and apical regions, whereas 84% of LV leads were in the lateral wall. Only 11% of LV leads were positioned in scar segments. The extent of scarring was significantly higher in nonresponders than in responders (18.0% vs. 6%, P 5 0.001). Compared with patients with scarring .22%, patients #70 y with scarring #22% of the left ventricle had a greater increase in LV ejection fraction (10.1% 6 10.5% vs. 0.8% 6 6.1%; P , 0.001) and improvement in NYHA class (-0.9 6 0.7 vs. -0.5 6 0.8; P 5 0.02). Conclusion: LV leads were often located in viable myocardial regions. Less scar burden was associated with a greater improvement in heart failure but only in relatively younger CRT recipients.Key Words: cardiac resynchronization therapy; heart failure; myocardial scarring; viability; imaging Heart failure (HF) prevalence is estimated to be 1%-2% in Western countries, with an incidence of approximately 5-10 per 1,000 persons per year. HF negatively affects quality of life and survival and accounts for 1%-2% of all health-care expenditure in developed countries. Left ventricular (LV) systolic function underlies the traditional HF paradigm and, despite significant advances in treatment, 5-y mortality still approaches 50% (1). Cardiac resynchronization therapy (CRT) is a treatment option for advanced HF despite optimal medical therapy, reduced LV ejection fraction (EF), and wide QRS complex. Randomized studies have demonstrated that CRT can improve cardiac function, clinical symptoms, quality of life, and even survival for patients with advanced HF (2-5). However, about one third of HF patients with reduced LVEF and wide QRS do not clinically respond after CRT. The reasons are multifactorial, and predicting who will respond to CRT remains a challenge (2,6). The suboptimal selection of CRT candidates has been considered an important contributor to the less optimal response rate. Diverse strategies to identify cardiac mechanical dyssynchrony and other predictors of benefit from CRT ha...

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Section: Methodsmentioning

confidence: 99%

Impact of Myocardial Scarring on Outcomes of Cardiac Resynchronization Therapy: Extent or Location?

Mei²,

Feng³

et al. 2011

J Nucl Med

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“…EF response to CRT was defined as an absolute increase of LVEF ≥5% (EF units). [15][16][17] The principal outcome variable was the combined end point of death, heart transplantation, or LV assist device (LVAD) implantation. This combined end point was predetermined because only patients with HF who are clinically considered end stage undergo transplantation or LVAD implantation at our institution.…”

Section: Follow-up Echocardiography and Long-term Outcome Assessmentmentioning

confidence: 99%

Mechanistic Features Associated With Improvement in Mitral Regurgitation After Cardiac Resynchronization Therapy and Their Relation to Long-Term Patient Outcome

Onishi

Marek

et al. 2013

Circ: Heart Failure

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Background-Mechanisms of mitral regurgitation (MR) reduction with cardiac resynchronization therapy (CRT) are complex, and their association with long-term outcome is unclear. We sought to elucidate mechanistic features of reduction in MR with CRT, which impact long-term patient survival. Methods and Results-A prospective longitudinal study of 277 patients with heart failure with QRS width ≥120 ms and ejection fraction ≤35% for CRT was performed. Quantitative echocardiography, including dyssynchrony analysis, was performed at baseline. MR was quantified by color Doppler before and 6 months after CRT. Predefined end points of death, transplant, or left ventricular assist device were tracked during 4 years. There were 114 (48%) patients with CRT with significant MR (≥moderate) at baseline; of whom 48 (42%) patients had MR improvement, and 24 (19%) patients had MR worsening after CRT. The 66 events (47 deaths, 10 transplantations, and 9 left ventricular assist devices) were strongly associated with significant MR after CRT (hazard ratio, 3.58; 95% confidence interval, 2.18-5.87; P<0.0001). Three echocardiographic features were independently associated with amelioration of significant MR after CRT by multivariable analysis: anteroseptal to posterior wall radial strain dyssynchrony >200 ms, lack of severe left ventricular dilatation (end-systolic dimension index <29 mm/m 2 ), and lack of echocardiographic scar at papillary muscle insertion sites (all P<0.05) and, when combined, were additively associated with long-term survival (P=0.0001). Conclusions-Significant MR after CRT was strongly associated with less favorable long-term survival. Echocardiographic mechanistic features were identified that were associated with improvement in MR after CRT and favorable long-term survival. to body surface area. 8 Assessment for myocardial scar focused on the papillary muscle insertion sites using a wall motion score index where akinesis or dyskinesis and a reduction in end-diastolic wall thickness ≤0.6 cm were consistent with scar as suggested by the American Society of Echocardiography and European Association of Echocardiography. 8,9 Specifically, the wall motion score index at the level of the papillary muscle attachment site was determined from the corresponding 8 LV segments as previously reported. 10,11 Figure 1. Study patient flowchart. A flowchart of consecutive patients referred for cardiac resynchronization therapy (CRT) who were included in this study. The prevalence of significant mitral regurgitation (MR) before and after CRT is shown. Quantification of MR SeverityColor Doppler quantification of MR was based on the guidelines of the American Society of Echocardiography and European Society of Cardiology 11,12 using a multiparametric approach. A Nyquist limit of 40 to 60 cm/s and a color gain were used to optimize color Doppler jet visualization. Vena contracta width was measured as the narrowest portion of the MR color Doppler jet from zoomed optimized views. The ratio of the jet area to the left atrium area was m...

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“…Different results were reported by Riedlbauchova et al [14]. They assessed myocardial viability in CRT recipients with ischemic HF using a method of positron emission tomography.…”

Section: Discussionmentioning

confidence: 92%

Regional myocardial contractile reserve assessed by strain echocardiography and the response to cardiac resynchronization therapy

et al. 2014

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non-responders (2.14 ± 2.9 vs. -0.94 ± 1.74, p = 0.042). Patients with increased deformation in the LV lead area during dobutamine stimulation were more likely to be responders to CRT compared to patients without increased deformation in this area (81% vs. 20%, p = 0.0002). They exhibited significant increase in LVEF (8.8% ± 10.3% vs. 0.3% ± 6.4%, p = 0.01). LV electrode localization in viable myocardium was a good predictor of response to CRT (AUC 0.852, p < 0.0001). Conclusions: Regional contractile reserve assessed by strain rate echocardiography during dobutamine infusion predicts the response to CRT. (Cardiol J 2014; 21, 5: 524-531)

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The Impact of Myocardial Viability on the Clinical Outcome of Cardiac Resynchronization Therapy

Abstract: At follow-up, response to CRT is observed regardless of the presence of extensive scarring. Left ventricular (LV) pacing at sites with ischemia, hibernation, or nontransmural scar does not appear to modify the effect of CRT as compared to viable tissue.

Cited by 41 publications

References 20 publications

Impact of Myocardial Scarring on Outcomes of Cardiac Resynchronization Therapy: Extent or Location?

Impact of Myocardial Scarring on Outcomes of Cardiac Resynchronization Therapy: Extent or Location?

Mechanistic Features Associated With Improvement in Mitral Regurgitation After Cardiac Resynchronization Therapy and Their Relation to Long-Term Patient Outcome

Regional myocardial contractile reserve assessed by strain echocardiography and the response to cardiac resynchronization therapy

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