European Journal of Echocardiography Advance Access originally published online on February 8, 2008
European Journal of Echocardiography 2008 9(3):319-320; doi:10.1093/ejechocard/jen010
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Echocardiographic selection of candidates for cardiac resynchronization therapy: the lack of evidence!
Department of Cardiology
Thoraxcenter
Erasmus University Medical Center
Rotterdam
The Netherlands
Department of Cardiology
Thoraxcenter
Erasmus University Medical Center
Rotterdam
The Netherlands
Department of Cardiology
Thoraxcenter
Erasmus Medical Center Rotterdam
'S-Gravendijkwal 230
3015 CE
Room Ba304
Rotterdam
The Netherlands
Tel: +31 10 7035669
Fax: +31 10 7035498
E-mail address: f.j.tencate{at}erasmusmc.nl
We read with interest the recent review by Vitarelli et al. in a recent issue of European Journal of Echocardiography.1 The authors recommended the use of tissue Doppler imaging (TDI) based left ventricular (LV) dyssynchrony for selection of candidates for cardiac resynchronization therapy (CRT). However, to date, in the absence of sound, prospective multicentre echocardiographic data, any advice to use TDI for patient selection is speculative. Despite the unquestioned benefits of CRT, the lack of response in 
40% of patients remains the major dilemma in implanting a CRT device. In the ‘real world’ echocardiographic LV dyssynchrony is not measured at all (CRT is given according to current guidelines) or assessed by the spectral TDI lateral-to-septal delay. Others and we have shown that this method does not contribute in prediction of CRT responders.2,3 Also, colour-encoded TDI (regardless of the LV segment model used) will be of limited value because several inherited physiologic and technical limitations, such as angle dependency, myocardial tethering and cardiac translational movements. These limitations may become even more significant when for severe heart failure patients so characteristic low myocardial velocities are present. The latter can be easily appreciated from Figure 2 in the article of Vitarelli et al.1 in which a very characteristic septal curve with a not well-defined peak is shown. Not surprisingly, in the ‘Predictors of response to cardiac resynchronization therapy (PROSPECT) study’,4 initiated by the protagonists of TDI use for CRT selection, the initial results presented at the recent ESC meeting 2007 (not published yet) were disappointing (with unacceptable interobserver variabilities). Even when you believe single centre data presented by colour-encoded TDI protagonists,5 the results are still problematic to interpret. From approximately a third of patients who would have denied CRT on the basis of absent LV dyssynchrony half of those patients would have responded well. Therefore, at this moment, no single patient should be denied CRT on the basis of absent TDI-derived LV dyssynchrony.
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- Vitarelli A, Franciosa P, Rosanio S. Tissue Doppler imaging in the assessment of selection and response from cardiac resynchronization therpy. Eur J Echocardiogr (2007) 8:309–16.
[Abstract/Free Full Text] - Soliman OI, Theuns DA, Geleijnse ML, Anwar AM, Nemes A, Caliskan K, Vletter WB, Jordaens LJ, Cate FJ. Spectral pulsed-wave tissue Doppler imaging lateral-to-septal delay fails to predict clinical or echocardiographic outcome after cardiac resynchronization therapy. Europace (2007) 9:113–8.
[Abstract/Free Full Text] - Jansen AH, Bracke F, van Dantzig JM, Meijer A, Korsten EH, Peels KH, van Hemel NM. Optimization of pulsed wave tissue Doppler to predict left ventricular reverse remodeling after cardiac resynchronization therapy. J Am Soc Echocardiogr (2006) 19:185–91.[CrossRef][Web of Science][Medline]
- Yu CM, Abraham WT, Bax J, Chung E, Fedewa M, Ghio S, Leclercq C, Leon AR, Merlino J, Nihoyannopoulos P, Notabartolo D, Sun JP, Tavazzi L. Predictors of response to cardiac resynchronization therapy (PROSPECT)—study design. Am Heart J (2005) 149:600–5.[CrossRef][Web of Science][Medline]
- Gorcsan J III, Tanabe M, Bleeker GB, Suffoletto MS, Thomas NC, Saba S, Tops LF, Schalij MJ, Bax JJ. Combined longitudinal and radial dyssynchrony predicts ventricular response after resynchronization therapy. J Am Coll Cardiol (2007) 50:1476–83.
[Abstract/Free Full Text]
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