ECHOCARDIOGRAPHY AND RESYNCHRONIZATION
A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy
Insights from mechanical activation strain mapping
Hideaki Kanzaki, MD,
Raveen Bazaz, MD,
David Schwartzman, MD, FACC,
Kaoru Dohi, MD,
L. Elif Sade, MD and
John Gorcsan, III, MD, FACC*
University of Pittsburgh, Pittsburgh, Pennsylvania
Manuscript received May 10, 2004;
revised manuscript received July 14, 2004,
accepted July 19, 2004.
* Reprint requests and correspondence: Dr. John Gorcsan III, University of Pittsburgh, Scaife S564, 200 Lothrop Street, Pittsburgh, Pennsylvania 15213-2582 (Email: gorcsanj{at}msx.upmc.edu).
OBJECTIVES: We tested the hypothesis that an immediate reduction in mitral regurgitation (MR) after cardiac resynchronization therapy (CRT) results from improved coordinated timing of the papillary muscle insertion sites, using the novel approach of mechanical activation strain mapping.
BACKGROUND: Heart failure patients with left bundle branch block often benefit acutely from CRT; however, the role and mechanism of reduction of MR are unclear.
METHODS: Twenty-six consecutive patients undergoing CRT with at least mild MR were studied (ejection fraction 24 ± 6%; QRS duration 168 ± 30 ms). Echocardiographic Doppler and strain imaging was performed immediately before and the day after CRT, as well as in 10 normal control subjects. Mechanical activation sequence maps were constructed using longitudinal strain from 12 basal and mid-LV sites, with color codingof time-to-peak strain.
RESULTS: Mitral regurgitation by the volumetric method consistently decreased after CRT: regurgitant volume from 40 ± 20 ml to 24 ± 17 ml and regurgitant fraction from 40 ± 12% to 25 ± 14% (both: p < 0.001 vs. baseline). Normal controls had uniform segmental time-to-peak strain, with a difference of only 12 ± 8 ms between all segments. In contrast, CRT patients at baseline had a 106 ± 74 ms time delay between papillary muscle insertion sites (p < 0.001 vs. normal). This interpapillary muscle time delay shortened after CRT to 39 ± 43 ms (p < 0.001 vs. baseline) and was significantly correlated with reductions in mitral regurgitant fraction (r = 0.77, p < 0.001).
CONCLUSIONS: Cardiac resynchronization therapy significantly and immediately reduced MR. Improved coordinated timing of mechanical activation of papillary muscle insertion sites appears to be a mechanistic contributor to immediate MR reduction by CRT.
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Abbreviations and Acronyms
| | AV = atrioventricular | | CRT = cardiac resynchronization therapy | | HF = heart failure | | LBBB = left bundle branch block | | LV = left ventricular | | MR = mitral regurgitation |
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|
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|
|
|
|
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T Z Naqvi, A M Rafique, C Swerdlow, S Verma, R J Siegel, K Tolstrup, W Kerwin, J Goodman, D Gallik, E Gang, et al.
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94(12):
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|
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|
|
|
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|
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|
|
|
|
|
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|
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|
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|
|
|
|
|
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J. Am. Coll. Cardiol.,
May 27, 2008;
51(21):
e1 - e62.
[Full Text]
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|
|
|
|
|
|
|
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May 27, 2008;
117(21):
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|
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April 29, 2008;
51(17):
1702 - 1703.
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|
|
|
|
|
|
|
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March 2, 2008;
29(6):
757 - 765.
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[PDF]
|
|
|
|
|
|
|
E. Agricola, M. Oppizzi, M. Pisani, A. Meris, F. Maisano, and A. Margonato
Ischemic mitral regurgitation: mechanisms and echocardiographic classification
Eur J Echocardiogr,
March 1, 2008;
9(2):
207 - 221.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Lancellotti, E. Donal, B. Cosyns, G. Van Camp, J.-L. Monin, E. Brochet, A. Berrebi, P. Pibarot, C. Chauvel, C. Hassager, et al.
Effects of surgery on ischaemic mitral regurgitation: a prospective multicentre registry (SIMRAM registry)
Eur J Echocardiogr,
January 1, 2008;
9(1):
26 - 30.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Ypenburg, P. Lancellotti, L. F. Tops, G. B. Bleeker, E. R. Holman, L. A. Pierard, M. J. Schalij, and J. J. Bax
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J. Am. Coll. Cardiol.,
November 20, 2007;
50(21):
2071 - 2077.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Yoshida, Y. Seo, H. Yamasaki, K. Tanoue, N. Murakoshi, T. Ishizu, Y. Sekiguchi, S. Kawano, S. Otsuka, S. Watanabe, et al.
Effect of triangle ventricular pacing on haemodynamics and dyssynchrony in patients with advanced heart failure: a comparison study with conventional bi-ventricular pacing therapy
Eur. Heart J.,
November 1, 2007;
28(21):
2610 - 2619.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. B Bleeker, C.-M. Yu, P. Nihoyannopoulos, J. de Sutter, N. Van de Veire, E. R Holman, M. J Schalij, E. E van der Wall, and J. J Bax
Optimal use of echocardiography in cardiac resynchronisation therapy
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November 1, 2007;
93(11):
1339 - 1350.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Vitarelli, P. Franciosa, and S. Rosanio
Tissue Doppler Imaging in the assessment of selection and response from cardiac resynchronization therapy
Eur J Echocardiogr,
October 1, 2007;
8(5):
309 - 316.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. O. Sweeney, A. J. Bank, E. Nsah, M. Koullick, Q. C. Zeng, D. Hettrick, T. Sheldon, G. A. Lamas, and the Search AV Extension and Managed Ventricular Pa
Minimizing Ventricular Pacing to Reduce Atrial Fibrillation in Sinus-Node Disease
N. Engl. J. Med.,
September 6, 2007;
357(10):
1000 - 1008.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Madaric, M. Vanderheyden, C. Van Laethem, K. Verhamme, A. Feys, M. Goethals, S. Verstreken, P. Geelen, M. Penicka, B. De Bruyne, et al.
Early and late effects of cardiac resynchronization therapy on exercise-induced mitral regurgitation: relationship with left ventricular dyssynchrony, remodelling and cardiopulmonary performance
Eur. Heart J.,
September 1, 2007;
28(17):
2134 - 2141.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Pierard and P. Lancellotti
When and how does cardiac resynchronization therapy reduce dynamic mitral regurgitation?
Eur. Heart J.,
September 1, 2007;
28(17):
2055 - 2056.
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. Cabrera-Bueno, J. M. Garcia-Pinilla, J. Pena-Hernandez, M. Jimenez-Navarro, J. J. Gomez-Doblas, A. Barrera-Cordero, J. Alzueta-Rodriguez, and E. de Teresa-Galvan
Repercussion of functional mitral regurgitation on reverse remodelling in cardiac resynchronization therapy
Europace,
September 1, 2007;
9(9):
757 - 761.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C.-M. Yu, F. Fang, Q. Zhang, G. W.K. Yip, C. M. Li, J. Y.-S. Chan, L. Wu, and J. W.-H. Fung
Improvement of Atrial Function and Atrial Reverse Remodeling After Cardiac Resynchronization Therapy for Heart Failure
J. Am. Coll. Cardiol.,
August 21, 2007;
50(8):
778 - 785.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. Arita, G. P. Sorescu, B. T. Schuler, L. S. Schmarkey, J. D. Merlino, J. Vinten-Johansen, A. R. Leon, R. P. Martin, and D. Sorescu
Speckle-tracking strain echocardiography for detecting cardiac dyssynchrony in a canine model of dyssynchrony and heart failure
Am J Physiol Heart Circ Physiol,
July 1, 2007;
293(1):
H735 - H742.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. B. Tournoux, C. Alabiad, D. Fan, A. A. Chen, M. Chaput, E. K. Heist, T. Mela, M. Mansour, V. Reddy, J. N. Ruskin, et al.
Echocardiographic measures of acute haemodynamic response after cardiac resynchronization therapy predict long-term clinical outcome
Eur. Heart J.,
May 1, 2007;
28(9):
1143 - 1148.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Pierard
Left ventricular dyssynchrony and functional mitral regurgitation: two dynamic conditions
Eur. Heart J.,
April 12, 2007;
(2007)
ehm079v1.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. D'Andrea, P. Caso, S. Cuomo, R. Scarafile, G. Salerno, G. Limongelli, G. Di Salvo, S. Severino, L. Ascione, P. Calabro, et al.
Effect of dynamic myocardial dyssynchrony on mitral regurgitation during supine bicycle exercise stress echocardiography in patients with idiopathic dilated cardiomyopathy and 'narrow' QRS
Eur. Heart J.,
April 2, 2007;
28(8):
1004 - 1011.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M S. J. Sutton and M G Keane
Reverse remodelling in heart failure with cardiac resynchronisation therapy
Heart,
February 1, 2007;
93(2):
167 - 171.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Cannesson, B. Gostoli, P. Rosamel, C. Flamens, G. Derumeaux, P. Chevallier, J.-F. Obadia, O. Bastien, and J.-J. Lehot
Successful Cardiac Resynchronization Therapy After Cardiac Surgery
Anesth. Analg.,
January 1, 2007;
104(1):
71 - 74.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E Agricola, M Oppizzi, M Galderisi, M Pisani, A Meris, C Pappone, and A Margonato
Role of regional mechanical dyssynchrony as a determinant of functional mitral regurgitation in patients with left ventricular systolic dysfunction
Heart,
October 1, 2006;
92(10):
1390 - 1395.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J J Bax and D Poldermans
Mitral regurgitation and left ventricular dyssynchrony: implications for treatment
Heart,
October 1, 2006;
92(10):
1363 - 1364.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. O. Sweeney and A. S. Hellkamp
Heart Failure During Cardiac Pacing
Circulation,
May 2, 2006;
113(17):
2082 - 2088.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Mele, G. Pasanisi, F. Capasso, A. De Simone, M.-A. Morales, D. Poggio, A. Capucci, G. Tabacchi, L. Sallusti, and R. Ferrari
Left intraventricular myocardial deformation dyssynchrony identifies responders to cardiac resynchronization therapy in patients with heart failure
Eur. Heart J.,
May 1, 2006;
27(9):
1070 - 1078.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. V. Ennezat, S. Marechaux, T. Le Tourneau, N. Lamblin, C. Bauters, E. Van Belle, B. Gal, S. Kacet, P. Asseman, G. Deklunder, et al.
Myocardial asynchronism is a determinant of changes in functional mitral regurgitation severity during dynamic exercise in patients with chronic heart failure due to severe left ventricular systolic dysfunction
Eur. Heart J.,
March 2, 2006;
27(6):
679 - 683.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Pierard and P. Lancellotti
Left ventricular dyssynchrony and dynamic functional mitral regurgitation: relationship or association?
Eur. Heart J.,
March 2, 2006;
27(6):
638 - 640.
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. (Cindy) Le and D. M. Thys
Ischemic Mitral Regurgitation
Seminars in Cardiothoracic and Vascular Anesthesia,
March 1, 2006;
10(1):
73 - 77.
[Abstract]
[PDF]
|
|
|
|
|
|
|
S. Z. Campwala, R. C. Bansal, N. Wang, A. Razzouk, and R. G. Pai
Mitral regurgitation progression following isolated coronary artery bypass surgery: frequency, risk factors, and potential prevention strategies
Eur. J. Cardiothorac. Surg.,
March 1, 2006;
29(3):
348 - 353.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. S. Suffoletto, K. Dohi, M. Cannesson, S. Saba, and J. Gorcsan III
Novel Speckle-Tracking Radial Strain From Routine Black-and-White Echocardiographic Images to Quantify Dyssynchrony and Predict Response to Cardiac Resynchronization Therapy
Circulation,
February 21, 2006;
113(7):
960 - 968.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. R. Brandt, C. Reiner, R. Arnold, J. Sperzel, H. F. Pitschner, and C. W. Hamm
Contractile response and mitral regurgitation after temporary interruption of long-term cardiac resynchronization therapy
Eur. Heart J.,
January 2, 2006;
27(2):
187 - 192.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. J. Bax, T. Abraham, S. S. Barold, O. A. Breithardt, J. W.H. Fung, S. Garrigue, J. Gorcsan III, D. L. Hayes, D. A. Kass, J. Knuuti, et al.
Cardiac Resynchronization Therapy: Part 2--Issues During and After Device Implantation and Unresolved Questions
J. Am. Coll. Cardiol.,
December 20, 2005;
46(12):
2168 - 2182.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Fukuda, R. Grimm, J.-M. Song, T. Kihara, M. Daimon, D. A. Agler, B. L. Wilkoff, A. Natale, J. D. Thomas, and T. Shiota
Electrical Conduction Disturbance Effects on Dynamic Changes of Functional Mitral Regurgitation
J. Am. Coll. Cardiol.,
December 20, 2005;
46(12):
2270 - 2276.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Dohi, M. Suffoletto, S. Murali, R. Bazaz, and J. Gorcsan
Benefit of cardiac resynchronization therapy to a patient with a narrow QRS complex and ventricular dyssynchrony identified by tissue synchronization imaging
Eur J Echocardiogr,
December 1, 2005;
6(6):
455 - 460.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. A. Levine and E. Schwammenthal
Ischemic Mitral Regurgitation on the Threshold of a Solution: From Paradoxes to Unifying Concepts
Circulation,
August 2, 2005;
112(5):
745 - 758.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. Kadish and M. Mehra
Heart Failure Devices: Implantable Cardioverter-Defibrillators and Biventricular Pacing Therapy
Circulation,
June 21, 2005;
111(24):
3327 - 3335.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. E. Weyman
The year in echocardiography
J. Am. Coll. Cardiol.,
February 1, 2005;
45(3):
448 - 455.
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. V. Salukhe, M. Y. Henein, and R. Sutton
Ischemic Mitral Regurgitation and Its Related Risk After Myocardial Infarction
Circulation,
January 25, 2005;
111(3):
254 - 256.
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. N. DeMaria, O. Ben-Yehuda, D. Berman, G. K. Feld, B. H. Greenberg, J. D. Knoke, K. U. Knowlton, W. Y.W. Lew, J. Narula, D. Sahn, et al.
Highlights of the year in JACC 2004
J. Am. Coll. Cardiol.,
January 4, 2005;
45(1):
137 - 153.
[Full Text]
[PDF]
|
|
|
|
