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European Journal of Echocardiography 2005 6(5):382-384; doi:10.1016/j.euje.2004.12.002
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Copyright © 2004, The European Society of Cardiology

Tissue Doppler imaging to assess left ventricular dyssynchrony and resynchronization therapy*

Gabe B. Bleekera,b, Jeroen J. Baxa,*, Martin J. Schalija and Ernst E. van der Walla

aDepartment of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
bInteruniversity Cardiology Institute of the Netherlands (ICIN), Utrecht, The Netherlands

Received 28 September 2004; .

jbax{at}knoware.nl

* Corresponding author. Tel.: +31 71 5262020; fax: +31 71 5266809.


   Abstract
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 Abstract
Case report
 Notes
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We describe the use of tissue Doppler imaging to assess left ventricular dyssynchrony and subsequent resynchronization in a patient with end-stage heart failure undergoing cardiac resynchronization therapy.

Keywords: Heart failure; Cardiac resynchronization therapy; Tissue Doppler imaging


   Case report
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A 62-year-old male experienced a gradual decline in exercise capacity over the last 2 years, and presented with heart failure NYHA class III, and a 6-min walking distance of 220m. The patient had a history of an antero-septal and inferior infarction, 11 and 12 years before the current presentation. The ECG showed a wide QRS complex (238ms) with left bundle branch block configuration (Fig. 1).


Figure 1
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  		Figure 1 QRS complex (lead V1) before (A) and after (B) cardiac resynchronization therapy. A reduction in QRS duration from 238ms to 184ms was observed.

 
Transthoracic echocardiography showed a severely dilated left ventricle (LVESV 372ml, LVEDV 427ml) with a severely reduced left ventricular ejection fraction (12%). Recently, it has been emphasized that the presence of significant left ventricular dyssynchrony may predict benefit from cardiac resynchronization therapy.1,2 The delay between the peak systolic velocities of the septum and lateral wall is an indicator of the extent of dyssynchrony (Fig. 2).


Figure 2
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  		Figure 2 Panel A: Tracing derived from color tissue Doppler image of a normal individual with the sample placed in the basal part of the septum, demonstrating peak systolic velocity (PSV), and diastolic parameters (E' and A'). Panel B: Color tissue Doppler image of a normal individual. The tissue Doppler tracings are obtained from samples placed in the basal part of the septum (yellow curve) and the lateral wall (green curve), illustrating perfect synchrony of these 2 walls.

 
Accordingly, echocardiography using tissue Doppler imaging (TDI) was performed to assess left ventricular dyssynchrony. TDI showed a delay in peak systolic velocities between the septum and the lateral wall (referred to as septal-to-lateral delay) of 250ms (Fig. 3A). Based on the presence of systolic heart failure combined with extensive left ventricular dyssynchrony, the patient was referred for biventricular pacemaker therapy.


Figure 3
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  		Figure 3 Panel A: Color tissue Doppler image of the patient with severe heart failure and dilated cardiomyopathy. The sample volumes are placed in the basal part of the septum and lateral wall, and tracings are derived (yellow curve=septum, green curve=lateral wall, arrows indicate peak systolic velocity). The septal-to-lateral delay is 250ms, indicating severe left ventricular dyssynchrony. Panel B: Color tissue Doppler image illustrating resynchronization 2 days after cardiac resynchronization therapy; the septal-to-lateral delay is reduced to 10ms.

 
Immediately after the implantation, the ECG revealed a shortening of the QRS complex to 184ms. TDI, performed 2 days after pacemaker implantation, showed a dramatic reduction in the left ventricular dyssynchrony, evidenced by a septal-to-lateral delay of 10ms (Fig. 3B).

Six months after implantation the patient was in NYHA class I, and the 6-min walking distance had increased to 360m, associated with a significant reverse remodeling of the left ventricle (LVESV 309ml, LVEDV 389ml).


   Notes
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* Dr. G.B. Bleeker is supported by the Dutch Heart Foundation, Grant nr. 2002B109. Back


   References
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  1. Bax J.J., Marwick T.H., Molhoek S.G., Bleeker G.B., van Erven L., Boersma E., et al. Left ventricular dyssynchrony predicts benefit of cardiac resynchronization therapy in patients with end-stage heart failure before pacemaker implantation. Am J Cardiol (2003) 92:1238–1240.[CrossRef][Web of Science][Medline]
  2. Yu C.M., Chau E., Sanderson J.E., Fan K., Tang M.O., Fung W.H., et al. Tissue Doppler echocardiographic evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure. Circulation (2002) 105:438–445.[Abstract/Free Full Text]

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