Cardiac Resynchronization Therapy
Part 1—Issues Before Device Implantation
Jeroen J. Bax, MD*,*,
Theodore Abraham, MD, FACC
,
S. Serge Barold, MD, FACC
,
Ole A. Breithardt, MD
,
Jeffrey W.H. Fung, MD||,
Stephane Garrigue, MD, PhD¶,
John Gorcsan, III, MD, FACC#,
David L. Hayes, MD, FACC**,
David A. Kass, MD,
Juhani Knuuti, MD, PhD,
Christophe Leclercq, MD, PhD,
Cecilia Linde, MD, PhD,
Daniel B. Mark, MD, PhD, FACC||||,
Mark J. Monaghan, PhD¶¶,
Petros Nihoyannopoulos, MD, FRCP, FACC, FESC***,
Martin J. Schalij, MD*,
Christophe Stellbrink, MD and
Cheuk-Man Yu, MD||
* Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
Johns Hopkins University, Baltimore, Maryland
University of South Florida, Tampa, Florida
University of Klinikum Mannheim, Mannheim, Germany
|| The Chinese University of Hong Kong, Hong Kong, China
¶ Hopital Cardiologique du Haut-Leveque, Pessac, France
# University of Pittsburgh, Pittsburgh, Pennsylvania
** Mayo Clinic, Rochester, Minnesota
Turku PET Center, University of Turku, Turku, Finland
Hopital Pontchaillou, Rennes, France
Karolinska University Hospital, Stockholm, Sweden
|||| Duke Clinical Research Institute, Durham, North Carolina
¶¶ King’s College Hospital, London, United Kingdom
*** Hammersmith Hospital, London, United Kingdom
Stadtische Kliniken Bielefeld, Bielefeld, Germany
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Figure 1 Receiver operating characteristic curve analysis on the change in QRS duration after six months of cardiac resynchronization therapy (CRT) demonstrated an optimal sensitivity of 58% and 56% (using a cutoff value of 30 ms) to predict response to CRT. Adapted from Molhoek et al. (15).
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Figure 2 The QRS duration does not relate with the extent of left ventricular (LV) dyssynchrony as assessed with tissue Doppler imaging. Adapted from Bleeker et al. (17).
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Figure 3 Color-coded four-chamber tissue Doppler image (upper left). Post-processing yields velocity tracings (right); severe left ventricular dyssynchrony is present as indicated by the delay in the peak systolic velocity of the septum (yellow curve) as compared to the lateral wall (green curve).
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Figure 4 Tissue synchronization imaging, four-chamber view. (Left) The color represents timing: green = normal timing; red = severe delay. Color-guided visual identification of the site of latest activation facilitates sample-placement to derive the tissue Doppler imaging (TDI) velocity tracings. In this patient, the earliest activation (green) is in the lateral wall, and the latest activation is in the lateral wall (red); the TDI velocity tracings (right) confirm the delay between the septum and lateral wall.
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Figure 5 Four-dimensional tissue synchronization imaging (TSI) of a normal individual. From the different views (left), a three-dimensional impression of the left ventricle is reconstructed (middle). The entire three-dimensional image of the left ventricle is green indicating no dyssynchrony. Post- processing allows the display of the different segments in a polar map format (right) to further facilitate identification of the site of latest activation.
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Figure 6 Four-dimensional tissue synchronization imaging (TSI) of a patient with left ventricular dyssynchrony. From the different views (left), a three-dimensional impression of the left ventricle is reconstructed (middle). The region of latest activation is indicated in red. Post-processing yields the polar-map format (upper right) indicating in red the site of latest activation (anteroseptal), and further calculations can be performed (lower right) to further quantify the extent of left ventricular dyssynchrony using different parameters.
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Figure 7 Real-time three-dimensional full volume analysis of regional left ventricular function showing (top left) the reconstructed left ventricular cast and the bulls-eye display (bottom left) of the 16 segments. Changes in regional volume (color-matched) for each of the 16 segments is displayed in the upper right. The anteroseptal and septal segments (light blue and green) show poor function and significant delay in achieving a minimum volume compared to other segments. A first derivative display of the regional volume curves is shown in the lower right panel and also demonstrates significant dispersion in the timing of minimal regional volume (indicated by the zero crossing points).
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Figure 8 Parametric polar-map displays (lower left and lower right panels) of left ventricular dyssynchrony of the real-time three-dimensional images; blue indicates early activation, red indicates late activation. Left ventricular dyssynchrony is present before cardiac resynchronization therapy (CRT) in the anteroseptal region (red, lower left panel); almost complete resynchronization has occurred after CRT, with disappearance of "red" regions (lower right).
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Figure 9 Noninvasive multislice computed tomography of the venous anatomy. (Left) Three-dimensional volume rendered reconstruction. (Right) Multiplanar curved reconstruction (MPR) of the coronary sinus (CS). Indicated on the three-dimensional reconstruction (left) are the CS, the posterior interventricular vein (PIV), the posterior vein of the left ventricle (PVLV), and the great cardiac vein (GCV). LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.
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Figure 10 Resting single-photon emission computed tomography images (using technetium-99m tetrofosmin) of a patient with a previous inferoposterolateral infarction. A severe defect in tracer uptake is visible on the mid-ventricular short-axis slice (SA) (left) in the inferior and posterolateral regions, which is confirmed on the horizontal long-axis (HLA) (middle) and vertical long-axis (VLA) (right) projections.
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Figure 11 Contrast-enhanced cardiovascular magnetic resonance short-axis slices illustrating the presence and transmural extent of scar tissue. (Left) Non-transmural scar tissue in the posterolateral wall as indicated by the hyperenhanced (white) region. (Right) Transmural scar formation in the posterolateral region.
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Copyright © 2005 by the American College of Cardiology Foundation.
