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Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure

Ole A. Breithardt, MD^*,*, Anil M. Sinha, MD^*, Ehud Schwammenthal, MD, FESC, Nadim Bidaoui, BSc^*, Kai U. Markus, MD^*, Andreas Franke, MD^* and Christoph Stellbrink, MD, FESC^*

^* Department of Cardiology, University Hospital, Aachen, Germany
Heart Institute, Sheba Medical Center, Tel Hashomer, Israel

View larger version (81K): [in a new window]   Figure 1 Continuous wave (CW) Doppler regurgitant jet in a study patient before (left) and after cardiac resynchronization therapy (CRT) (right). Maximal rate of left ventricular systolic pressure rise (LV+dP/dtmax) is estimated by measuring the time interval between 1 m/s and 3 m/s on the downslope of the CW Doppler spectrum (solid lines). Estimated LV+dP/dtmax rises from approximately 510 mm Hg/s (approximately 63 ms) to approximately 720 mm Hg/s (approximately 44 ms), and transmitral pressure gradient peak occurs earlier in systole (arrows). Duration of functional mitral regurgitation (excluding the presystolic component) decreases from 435 ms (OFF) to 382 ms (CRT).

View larger version (18K): [in a new window]   Figure 2 Individual changes in effective regurgitant orifice area (EROA) (mm3) between baseline (OFF) and cardiac resynchronization therapy (CRT); EROA showed a wide range during OFF and decreased with CRT in 23 patients. A small increase in EROA was observed in one patient with mild regurgitation during OFF (dashed line).

View larger version (13K): [in a new window]   Figure 3 The decrease in effective regurgitant orifice area (EROA), displayed as the percent change between OFF and cardiac resynchronization therapy (CRT), was directly correlated to the increase in left ventricular systolic function, as measured by the percent increase in maximal rate of left ventricular systolic pressure rise (LV+dP/dtmax): EROA = –0.7 x LV+dP/dtmax –7.6, r = –0.83, p < 0.0001.

View larger version (42K): [in a new window]   Figure 4 Schematic representation of the relationship between the increase in transmitral pressure gradient (TMP) (the instantaneous difference between left ventricular and left atrial pressure) and the decrease in effective regurgitant orifice area (EROA). During OFF (top panel), left ventricular (LV) contractility is low and results in a slow rise in the LV pressure curve and TMP with a relatively late systolic maximum. Due to the slow LV pressure rise with delayed development of an effective transmitral closing force (approximately TMP), EROA remains large for a relatively long period until it finally reaches its minimal value. In contrast, during cardiac resynchronization therapy (CRT) (bottom panel), LV contractility improves, TMP rises faster and to a higher maximal value, which is also reached earlier. Consequently, the reduction in EROA occurs earlier, EROA reaches lower values and for a prolonged period of time. The shaded area represents the time in systole during which EROA is below 50% of its initial value. Note that, in the chosen example, the reduction in the height of the V-wave after a decrease in the initial mitral regurgitation will contribute to a preserved TMP during the latter half of systole. Solid line = left atrial (LA) and LV pressure; dotted line = EROA. Adapted from Hung et al. (15).