Skip Navigation

European Journal of Echocardiography 2005 6(6):455-460; doi:10.1016/j.euje.2005.02.001
This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Dohi, K.
Right arrow Articles by Gorcsan, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dohi, K.
Right arrow Articles by Gorcsan, J.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

Copyright © 2005, The European Society of Cardiology

Benefit of cardiac resynchronization therapy to a patient with a narrow QRS complex and ventricular dyssynchrony identified by tissue synchronization imaging*

Kaoru Dohi, Matthew Suffoletto, Srinivas Murali, Raveen Bazaz and John Gorcsan*

University of Pittsburgh, Scaife 564, 200 Lothrop Street, Pittsburgh, PA 15213-2582, USA

Received 14 December 2004; accepted after revision 6 February 2005.

gorcsanj{at}msx.upmc.edu

gorcsanj{at}upmc.edu

* Corresponding author. Tel.: +1 412 647 6570; fax: +1 412 647 0568.


   Abstract
Top
 Abstract
Case report
 Discussion
 Conclusion
 Notes
 References
 
This report described an 81-year-old woman with severe symptomatic heart failure, reduced ejection fraction, mitral regurgitation, and an electrocardiographic QRS width of 118ms who had ventricular dyssynchrony identified by echocardiographic tissue synchronization imaging. Because of her severe heart failure symptoms on maximal medical therapy, referral to implant a defibrillator, and mechanical dyssynchrony, she underwent cardiac resynchronization-defibrillator therapy with lateral left ventricular lead placement. This resulted in an immediate 30% increase in stroke volume and 35% decrease in mitral regurgitation. Echocardiographic tissue synchronization imaging may play a role in identifying mechanical dyssynchrony in patients with narrow QRS duration who may potentially benefit from cardiac resynchronization therapy.

Keywords: Heart failure; Narrow QRS; Mechanical dyssynchrony; Tissue synchronization imaging; Cardiac resynchronization therapy; Mitral regurgitation; Echocardiography; Pacing therapy; Doppler ultrasound

Clinical criteria for cardiac resynchronization therapy (CRT) currently include an electrocardiographic duration of at least 120–130ms, severe symptomatic heart failure, and reduced ejection fraction.1–4 This report described an 81-year-old woman with non-ischemic cardiomyopathy, mitral regurgitation, and a QRS width of 118ms who had ventricular dyssynchrony identified by echocardiographic tissue synchronization imaging.5 An average significant septal to posterior-lateral delay of 165ms was demonstrated by time–velocity plot analysis. Because of continued severe symptoms on maximal medical therapy and referral to implant a defibrillator, coupled with echocardiographic dyssynchrony, she underwent CRT-defibrillator therapy with lateral left ventricular lead placement. CRT resulted in an immediate 30% increase in stroke volume and a 35% decrease in mitral regurgitation. Although long-term follow-up data were not available, this illustrates how tissue synchronization imaging may play a role in identifying mechanical dyssynchrony in patients with narrow QRS duration who may benefit from CRT.


   Case report
Top
 Abstract
 Case report
Discussion
 Conclusion
 Notes
 References
 
An 81-year-old woman with non-ischemic cardiomyopathy (nonobstructive coronary disease by angiography) and New York Heart Association Functional Class IV heart failure was being considered for an implantable defibrillator because of depressed ejection fraction of 29% and ventricular tachycardia. She also had severe mitral regurgitation by quantitative two-dimensional and Doppler echocardiography.6–8 Her electrocardiogram demonstrated a QRS complex of 118ms (Fig. 1). Her medications included digoxin, furosemide, enalapril, and carvedilol. Because of continued severe heart failure symptoms on maximal medical therapy and because she was at high risk for mitral valve surgery due to advanced age, she was referred for echocardiographic dyssynchrony analysis. Echocardiographic tissue synchronization imaging (Vivid 7 GE-Vingmed, Horten, Norway), was performed as we previously described in detail.5 Briefly, tissue synchronization imaging detects peak positive myocardial velocity over the scanned regions and color-codes this information based on the time-to-peak velocities. This time-to-peak color-coding is then superimposed on the two-dimensional images in real time. Normal time-to-peak velocity data are color-coded as green, moderate peak velocity delays are color-coded as yellow–orange, and severe peak velocity delays are color-coded as red within the interval which is manually fine-tuned to begin with aortic valve opening and extend to mitral valve opening to include post-systolic dyssynchrony. Color-coding is used to guide the region of interest for time–velocity plot analysis off-line. Three digital cine-loops were obtained from apical 4-chamber, 2-chamber, and long-axis views and analyzed off-line as previously described (EchoPAC PC 3.0, GE-Vingmed). Dyssynchrony, which we defined as the difference in time-to-peak velocity of the septum to its opposing walls averaged from basal and mid segments was 175ms in the 4-chamber view and 155ms in the apical long-axis view (Fig. 2), with an average of 165ms. Septal to free wall difference in time-to-peak velocities≥65ms has been shown to be predictive of acute response to CRT, previously.5 Accordingly with her continued severe symptoms with limited therapeutic options, a biventricular pacing-defibrillator system was implanted with the left ventricular lead positioned in a lateral branch of epicardial vein via the coronary sinus.


Figure 1
View larger version (41K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 1 The 12-lead electrogardiogram in this patient before cardiac resynchronization therapy demonstrating a QRS width of 118ms.

 


Figure 2
View larger version (51K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 2 Tissue synchronization images at end-systole (top panels) with the apical 4-chamber view (left) and apical long-axis view (right) before resynchronization therapy. Delayed time-to-peak velocity is color-coded dark orange in walls opposing the LV septum. Corresponding time–velocity plots (bottom panels) demonstrating delays in time-to-peak velocities with a 175ms delay from inferior-septum to lateral wall (arrows) in the apical 4-chamber view (left) and 155ms delay from anterior-septum to posterior wall in the apical long-axis view (right), consistent with significant dyssynchrony. AVO=timing of aortic valve opening.

 
The patient subsequently had a repeat two-dimensional echocardiographic and quantitative Doppler study the day following CRT. Stroke volume and mitral regurgitation were compared using the volumetric method.6–8 A significant 30% increase in stroke volume was observed from 36ml to 47ml. (Fig. 3). Mitral regurgitation was also acutely reduced with regurgitant volume decreasing from 73ml to 47ml and regurgitant fraction decreasing from 61% to 50% (Fig. 4). She had some subjective improvement in her heart failure symptoms, although long-term follow-up data were not available.


Figure 3
View larger version (83K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 3 Doppler echocardiographic determination of stroke volume before and after cardiac resynchronization therapy (CRT). The time velocity integral (TVI) in the apical 5-chamber view was used to calculate stroke volume using left ventricular outflow tract diameter (D). Stroke volume acutely increased from 36ml to 47ml after CRT.

 


Figure 4
View larger version (61K):
[in this window]
[in a new window]
[Download PowerPoint slide]
  		Figure 4 Images of mitral regurgitation before and after cardiac resynchronization therapy (CRT): inflow velocities (left panels) and color Doppler (right panels). Quantitative measures of mitral regurgitant (MR) volume and fraction using the volumetric method demonstrated an acute decrease in MR after CRT.

 

   Discussion
Top
 Abstract
 Case report
 Discussion
Conclusion
 Notes
 References
 
Cardiac resynchronization therapy (CRT) is an important advance for patients with severe symptomatic heart failure on optimal medical therapy. It can result in improvements in symptoms, quality of life, ejection fraction and potentially prolong survival.1–4 Current clinical criteria for implantation include an electrocardiographic QRS duration of at least 120–130ms, along with severe symptomatic heart failure (New York Heart Association Class III or IV) and depressed ejection fraction (≤35%). Most patients in CRT clinical trials have had a QRS duration of >160ms and the most common pattern is that of left bundle branch block.1–4 However, several investigations have demonstrated that electrocardiographic QRS prolongation may not be a satisfactory marker for mechanical dyssynchrony.9–13 Furthermore, others and we have recently shown that mechanical dyssynchrony may be identified in heart failure patients with depressed ejection fraction with relatively narrow QRS duration.14–16 In particular, a pattern of septal to posterolateral delay which mimics left bundle branch block can be identified in a subset of these patients, and this appears to be important as potentially predictive of response to CRT.5,17,18 CRT also resulted in an immediate decrease in mitral regurgitation in this patient likely from improved coordination of papillary muscle forces, which supports the concept that dyssynchrony is mechanistically associated with mitral regurgitation8,19 Improvement of interventricular dyssynchrony may also play a role, but intraventricular dyssynchrony appears to be a major factor for improvement with CRT.20


   Conclusion
Top
 Abstract
 Case report
 Discussion
 Conclusion
Notes
 References
 
CRT has proven to benefit patients with symptomatic heart failure, reduced ejection fraction and prolonged QRS duration. This report demonstrates that CRT can improve stroke volume and reduce mitral regurgitation in a patient with a narrow QRS who had dyssynchrony identified by echocardiographic tissue synchronization imaging. Although the application of CRT to heart failure patients with narrow QRS duration must be studied prospectively in a large clinical trial to conclude its benefit, this case report illustrates how echocardiographic imaging techniques, and in particular tissue synchronization imaging, may play a role in quantifying ventricular dyssynchrony and identifying candidates for CRT.


   Notes
Top
 Abstract
 Case report
 Discussion
 Conclusion
 Notes
References
 
* Dr. Gorcsan was supported in part by N.I.H. awards K24 HL04503-01 and RO1 HL073198-01. Back


   References
Top
 Abstract
 Case report
 Discussion
 Conclusion
 Notes
 References
 

  1. Cazeau S., Leclercq C., Lavergne T., Walker S., Varma C., Linde C., et al. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med (2001) 344:873–880.[Abstract/Free Full Text]
  2. Abraham W.T., Fisher W.G., Smith A.L., Delurgio D.B., Leon A.R., Loh E., et al. Cardiac resynchronization in chronic heart failure. N Engl J Med (2002) 346:1845–1853.[Abstract/Free Full Text]
  3. Bristow M.R., Saxon L.A., Boehmer J., Krueger S., Kass D.A., De Marco T., et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med (2004) 350:2140–2150.[Abstract/Free Full Text]
  4. Nelson G.S., Curry C.W., Wyman B.T., Kramer A., Declerck J., Talbot M., et al. Predictors of systolic augmentation from left ventricular preexcitation in patients with dilated cardiomyopathy and intraventricular conduction delay. Circulation (2000) 101:2703–2709.[Abstract/Free Full Text]
  5. Gorcsan J. III, Kanzaki H., Bazaz R., Dohi K., Schwartzman D. Usefulness of echocardiographic tissue synchronization imaging to predict acute response to cardiac resynchronization therapy. Am J Cardiol (2004) 93:1178–1181.[CrossRef][Web of Science][Medline]
  6. Enriquez-Sarano M., Bailey K.R., Seward J.B., Tajik A.J., Krohn M.J., Mays J.M. Quantitative Doppler assessment of valvular regurgitation. Circulation (1993) 87:841–848.[Abstract/Free Full Text]
  7. Thomas J.D., Liu C.M., Flachskampf F.A., O'Shea J.P., Davidoff R., Weyman A.E. Quantification of jet flow by momentum analysis. An in vitro color Doppler flow study. Circulation (1990) 81:247–259.[Abstract/Free Full Text]
  8. Kanzaki H., Bazaz R., Schwartzman D., Dohi K., Sade L.E., Gorcsan J. III. A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy: insights from mechanical activation strain mapping. J Am Coll Cardiol (2004) 44:1619–1625.[Abstract/Free Full Text]
  9. Bleeker G.B., Schalij M.J., Molhoek S.G., Verwey H.F., Holman E.R., Boersma E., et al. Relationship between QRS duration and left ventricular dyssynchrony in patients with end-stage heart failure. J Cardiovasc Electrophysiol (2004) 15:544–549.[Web of Science][Medline]
  10. 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]
  11. Pitzalis M.V., Iacoviello M., Romito R., Massari F., Rizzon B., Luzzi G., et al. Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony. J Am Coll Cardiol (2002) 40:1615–1622.[Abstract/Free Full Text]
  12. Yu C.M., Yang H., Lau C.P., Wang Q., Wang S., Lam L., et al. Regional left ventricle mechanical asynchrony in patients with heart disease and normal QRS duration: implication for biventricular pacing therapy. Pacing Clin Electrophysiol (2003) 26:562–570.[CrossRef][Medline]
  13. Kanzaki H., Jacques D., Sade L.E., Severyn D., Schwartzman D., Gorcsan J. III. Regional correlation by color-coded tissue Doppler to quantify improvements in mechanical left ventricular synchrony after biventricular pacing therapy. Am J Cardiol (2003) 92:752–755.[CrossRef][Web of Science][Medline]
  14. Achilli A., Sassara M., Ficili S., Pontillo D., Achilli P., Alessi C., et al. Long-term effectiveness of cardiac resynchronization therapy in patients with refractory heart failure and "narrow" QRS. J Am Coll Cardiol (2003) 42:2117–2124.[Abstract/Free Full Text]
  15. Yu C.M., Lin H., Zhang Q., Sanderson J.E. High prevalence of left ventricular systolic and diastolic asynchrony in patients with congestive heart failure and normal QRS duration. Heart (2003) 89:54–60.[Abstract/Free Full Text]
  16. Sade L.E., Kanzaki H., Severyn D., Dohi K., Gorcsan J. III. Quantification of radial mechanical dyssynchrony in patients with left bundle branch block and idiopathic dilated cardiomyopathy without conduction delay by tissue displacement imaging. Am J Cardiol (2004) 94:514–518.[CrossRef][Web of Science][Medline]
  17. Grines C.L., Bashore T.M., Boudoulas H., Olson S., Shafer P., Wooley C.F. Functional abnormalities in isolated left bundle branch block. The effect of interventricular asynchrony. Circulation (1989) 79:845–853.[Abstract/Free Full Text]
  18. Kass D.A., Chen C.H., Curry C., Talbot M., Berger R., Fetics B., et al. Improved left ventricular mechanics from acute VDD pacing in patients with dilated cardiomyopathy and ventricular conduction delay. Circulation (1999) 99:1567–1573.[Abstract/Free Full Text]
  19. Breithardt O.A., Sinha A.M., Schwammenthal E., Bidaoui N., Markus K.U., Franke A., et al. Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure. J Am Coll Cardiol (2003) 41:765–770.[Abstract/Free Full Text]
  20. Bader H., Garrigue S., Lafitte S., Reuter S., Jais P., Haissaguerre M., et al. Intra-left ventricular electromechanical asynchrony. A new independent predictor of severe cardiac events in heart failure patients. J Am Coll Cardiol (2004 Jan) 43:248–256.[Abstract/Free Full Text]

Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?


This article has been cited by other articles:


Home page
 J Ultrasound MedHome page
J.-W. Tian, G.-Q. Du, M. Ren, L.-T. Sun, X.-P. Leng, and Y.-X. Su
Tissue Synchronization Imaging of Myocardial Dyssynchronicity of the Left Ventricle in Patients With Coronary Artery Disease
J. Ultrasound Med., July 1, 2007; 26(7): 893 - 897.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrowRequest Permissions
Right arrow Disclaimer
Google Scholar
Right arrow Articles by Dohi, K.
Right arrow Articles by Gorcsan, J.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Dohi, K.
Right arrow Articles by Gorcsan, J.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?