LETTER TO THE EDITOR
Prognostic value of left ventricular dyssynchrony in patients with heart failure
Jeroen J. Bax, MD
Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
Ernst E. van der Wall, MD and
Martin J. Schalij, MD
(Email: jbax{at}knoware.nl).
Bader et al. (1) in a recent issue of the Journal reported on the value of left ventricular (LV) dyssynchrony for the prognostification of patients with severe heart failure (HF). A large group of HF patients (n = 104) with depressed left ventricular ejection fraction (LVEF) (<45%) was followed up for one year. During this one-year period, 83% of the patients were hospitalized for decompensated HF. Based on multivariate Cox regression analysis, three variables predicted HF hospitalization: QRS width >140 ms, LVEF <25%, and LV dyssynchrony (the mean LV dyssynchrony was 68 ± 44 ms). The patients included in the study by Bader et al. (1) represent typical patients who may benefit from cardiac resynchronization therapy (CRT). Recent studies on CRT have shown improvement in symptoms, quality-of-life score, exercise capacity, and LV systolic function after CRT (2). Current selection criteria for CRT include: severe HF (New York Heart Association functional class III or IV), depressed LVEF (<35%), and wide QRS complex (>120 ms). Careful analysis of the large clinical trials, however, has revealed that 20% to 30% of patients do not respond to CRT. Based on these observations, emphasis has shifted toward a better selection of patients who may benefit from CRT (3). Various studies have demonstrated that LV dyssynchrony may predict response to CRT and, therefore, the findings of Bader et al. (1) are of great importance. Eventually, the identification of patients with dyssynchrony may not only allow for optimal selection for CRT but also may favorably affect the prognosis of these patients. On the basis of their findings, do the authors feel that the presence of dyssynchrony should be used to identify patients who may benefit from CRT? And, if so, should the region of latest activation before CRT be the preferred location for the LV lead? This is of interest because substantial percentage of patients in the study by Bader et al. (1) exhibited other regions than the lateral wall as the latest activation. This may then in turn raise the question whether a surgical approach may sometimes be preferred rather than transvenous implantation of the LV lead.
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References
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- Bader H, Garrigue S, Lafitte S, et al. Intra-left ventricular electromechanical asynchronyA new independent predictor of severe cardiac events in heart failure patients J Am Coll Cardiol 2004;43:248-256.[Abstract/Free Full Text]
- Leclercq C, Hare JM. Ventricular resynchronization Circulation 2004;109:296-299.[Free Full Text]
- Kass DA. Ventricular resynchronization: pathophysiology and identification of responders Rev Cardiovasc Med 2003;4(Suppl 2):S3-13.
Related Article
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Prognostic value of left ventricular dyssynchrony in patients with heart failure: Reply
- Stephane Garrigue and Hugues Bader
J. Am. Coll. Cardiol. 2004 44: 937-938.
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