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CLINICAL RESEARCH: CARDIAC RESYNCHRONIZATION THERAPY

Intraventricular Dyssynchrony Predicts Mortality and Morbidity After Cardiac Resynchronization Therapy

A Study Using Cardiovascular Magnetic Resonance Tissue Synchronization Imaging

Shajil Chalil, MRCP^_*,1, Berthold Stegemann, PhD^,2, Sarkaw Muhyaldeen, MRCP^_*,1, Kayvan Khadjooi, MRCP^_*, Russell E.A. Smith, MD, FRCP^_*,3, Paul J. Jordan, FRCP^_*,3 and Francisco Leyva, MD, FRCP^_*,3,4,_*

^_* Department of Cardiology, Good Hope Hospital, Sutton Coldfield/Birmingham, West Midlands, England
Medtronic Inc., Bakken Research Center, Maastricht, the Netherlands.

Manuscript received November 20, 2006; revised manuscript received March 9, 2007, accepted March 13, 2007.

^_* Reprint requests and correspondence: Dr. Francisco Leyva, Department of Cardiology, Good Hope Hospital, Rectory Road, Sutton Coldfield/Birmingham, West Midlands B75 7RR, United Kingdom. (Email: francisco.leyva{at}heartofengland.nhs.uk).

Objectives: We aimed to assess a novel measure of left ventricular (LV) dyssynchrony, a cardiovascular magnetic resonance-tissue synchronization index (CMR-TSI), in patients with heart failure (HF). A further aim was to determine whether CMR-TSI predicts mortality and major cardiovascular events (MCE) after cardiac resynchronization therapy (CRT).

Background: Cardiac dyssynchrony is a predictor of mortality in patients with HF. The unparalleled spatial resolution of CMR may render CMR-TSI a predictor of clinical benefit after CRT.

Methods: In substudy A, CMR-TSI was assessed in 66 patients with HF (age 60.8 ± 10.8 years, LV ejection fraction 23.9 ± 12.1% [mean ± SD]) and 20 age-matched control subjects. In substudy B, CMR-TSI was assessed in relation to clinical events in 77 patients with HF and with a QRS 120 ms undergoing CRT.

Results: In analysis A, CMR-TSI was higher in patients with HF and a QRS <120 ms (79.5 ± 31.2 ms, p = 0.0003) and in those with a QRS 120 ms (105.9 ± 55.8 ms, p < 0.0001) than in control subjects (21.2 ± 8.1 ms). In analysis B, a CMR-TSI 110 ms emerged as an independent predictor of the composite end points of death or unplanned hospitalization for MCE (hazard ratio [HR] 2.45; 95% confidence interval [CI] 1.51 to 4.34, p = 0.0002) or death from any cause or unplanned hospitalization for HF (HR 2.15; 95% CI 1.23 to 4.14, p = 0.0060) as well as death from any cause (HR: 2.6; 95% CI 1.29 to 6.73, p = 0.0061) and cardiovascular death (HR 3.82; 95% CI 1.63 to 16.5, p = 0.0007) over a mean follow-up of 764 days.

Conclusions: Myocardial dyssynchrony assessed by CMR-TSI is a powerful independent predictor of mortality and morbidity after CRT.

Abbreviations and Acronyms   CMR-TSI = cardiovascular magnetic resonance-tissue synchronization index   CRT = cardiac resynchronization therapy   HF = heart failure   LV = left ventricle/ventricular   LVEDV = left ventricular end-diastolic volume   LVEF = left ventricular ejection fraction   LVESV = left ventricular end-systolic volume   MCE = major cardiovascular events   NYHA = New York Heart Association   ROC = receiver-operating characteristic

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