Echocardiography and Noninvasive Imaging in Cardiac Resynchronization TherapyResults of the PROSPECT (Predictors of Response to Cardiac Resynchronization Therapy) Study in Perspective
Jeroen J. Bax, MD, PhD*,* and
John Gorcsan, III, MD
* Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
Cardiovascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
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Figure 1 Incidence of Response/Nonresponse According to QRS Width in 242 Patients Undergoing CRT
The percentage of nonresponders is virtually the same in the different groups (43). CRT = cardiac resynchronization therapy.
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Figure 3 Patient Example of 2D Speckle Tracking Strain Assessment
(Left) The 2-dimensional (2D) strain images and segmental curves in a patient before cardiac resynchronization therapy. The segmental time-strain curves (color-coded) represent the 6 myocardial segments (light blue = septal; yellow = anteroseptal [AS]; red = anterior; green = lateral; purple = posterior [P]; and dark blue = inferior). From these curves, the maximum time difference in peak systolic strain between 2 segments can be determined (in this patient, 228 ms). Resynchronization after 6 months of cardiac resynchronization therapy is shown in the right panel.
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Figure 4 Tri-Plane Tissue Synchronization Imaging in a Patient With Dilated Cardiomyopathy Showing Severe LV Dyssynchrony
Using a tri-plane probe, the 2-, 3-, and 4-chamber views are simultaneously acquired. This 3-dimensional assessment of dyssynchrony displays mechanical activation times in colors. The orange-yellow color indicates late activation of the inferior and posterior regions as compared with the remainder of the myocardium (green). The polar map shows the timing from QRS to peak systolic velocity in each of 12 segments that are analyzed (bottom right); the inferior and posterior segments (yellow) show the latest mechanical activation. LV = left ventricular.
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Figure 5 Parametric Polar Maps Derived From Real-Time 3-Dimensional Echocardiography
Color-coding (blue indicating early activation and orange-red late activation) represents the time needed to reach the minimum systolic volume, showing that the inferior and posterior left ventricular regions are the latest activated before cardiac resynchronization therapy (A). Six months after cardiac resynchronization therapy (B), the overall green color indicates absence of regions with delayed activation.
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Figure 6 Phase Analysis on Gated Myocardial Perfusion SPECT Permits Assessment of LV Dyssynchrony
(A) Shows data from a patient without left ventricular (LV) dyssynchrony. The homogeneous phase angle distribution (non-normalized) is illustrated by a homogeneous color-coding scale (polar map format, left) and a narrow and highly peaked histogram (right). Phase angle reflects timing of conduction within the cardiac cycle (0° to 360°). (B) Shows data from a patient with extensive LV dyssynchrony. The heterogeneous phase angle distribution (non-normalized) is reflected by a heterogeneous color-coding scale (polar map format, left) and a broad and moderate peaked histogram (right). SPECT = single-photon emission computed tomography. Reproduced, with permission, from Henneman et al. (60).
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Figure 7 The Total Scar Burden Versus the Change in LVESV After 6 Months of CRT
A clear relation between the 2 parameters existed. Patients with extensive scar tissue showed virtually no improvement in left ventricular end-systolic volume (LVESV) after cardiac resynchronization therapy (CRT). LV = left ventricle. Reproduced, with permission from Ypenburg et al. (63).
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Figure 8 Location and Quantification of Scar Tissue With Contrast-Enhanced MRI
Contrast-enhanced magnetic resonance imaging (MRI) has excellent spatial resolution and may be the preferred technique for assessment of scar tissue. (A) A patient with transmural infarction in (part of) the lateral wall, the inferior wall, and the septum (the white tissue, arrow). (B) Subendocardial scar formation in a patient with a previous inferior infarction (arrow indicates scar formation).
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Figure 9 Noninvasive Visualization of the Venous Anatomy Is Possible With Multislice CT
(A) An example of 64-slice computed tomography (CT) in a patient without coronary artery disease and a large variety of cardiac veins. (B) 64-slice CT in a patient with previous infarction (the scar tissue is visible) and minimal cardiac veins. CS = coronary sinus; GCV = great cardiac vein; LMV = left marginal vein; PIV = posterior interventricular vein; PVLV = posterior vein of the left ventricle.
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Figure 10 Integrated Information on Dyssynchrony, Scar, and Region of Latest Mechanical Activation May Improve Response to CRT
Various factors for prediction of response to cardiac resynchronization therapy (CRT) are important, including left ventricular (LV) dyssynchrony, scar tissue in the region where the LV pacing lead is positioned, the total extent of scar in the LV, and whether the LV lead is positioned in the site of latest mechanical activation. Based on these factors, one can distinguish patients with a low and high likelihood of response to CRT. LVEF = left ventricular ejection fraction; NYHA = New York Heart Association.
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