1 / 25

Working Group of Heart Failure and Cardiac Function

Working Group of Heart Failure and Cardiac Function. How to evaluate and treat dyssynchrony ? P Lancellotti , LA Piérard , Liège , BE. PATIENT’S HISTORY. Idiopathic cardiomyopathy - LV Ejection fraction = 21 % - End-diastolic volume = 341 ml - End-systolic volume = 269 ml

carl
Download Presentation

Working Group of Heart Failure and Cardiac Function

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Working Group ofHeart Failure and Cardiac Function How to evaluate and treat dyssynchrony ? P Lancellotti , LA Piérard , Liège , BE

  2. PATIENT’S HISTORY Idiopathic cardiomyopathy - LV Ejection fraction = 21 % - End-diastolic volume = 341 ml - End-systolic volume = 269 ml QRS width = 118 ms NYHA class III  NYHA class II under maximal tolerated treatment Lisinopril 10 mg , Carvedilol 12.5 mg x 2, Spironolactone 25 mg

  3. Live from Liège

  4. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms

  5. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms

  6. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms

  7. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms • LV filling time < 40 % of cardiac cycle

  8. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms • LV filling time < 40 % of cardiac cycle • DTI TPS • Septal-to-lateral delay > 60 ms

  9. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms • LV filling time < 40 % of cardiac cycle • DTI TPS • Septal-to-lateral delay > 60 ms • LV dispersion (4 segments) > 65 ms

  10. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior delay > 130 ms • LV filling time < 40 % of cardiac cycle • DTI TPS • Septal-to-lateral delay > 60 ms • LV dispersion (4 segments) > 65 ms • Standard deviation (12 segments) > 31 ms

  11. STEPWISE SELECTION • Aortic pre-ejection time > 140 ms • Interventricular delay > 40 ms • Septal-to-posterior WM delay > 130 ms • LV filling time < 40 % of cardiac cycle • DTI Time to Peak Systolic velocity • Septal-to-lateral delay > 60 ms • LV dispersion (4 segments) > 65 ms • Standard deviation (12 segments) > 31 ms • Inter + Intra V delay > 102 ms

  12. STEPWISE SELECTION ESC Guidelines ° NYHA III-IV, QRS > 120 ms, EF < 35 %, Optimal treatment Major criteria(high sensitivity and specificity) (At least 1) ° Intraventricular asynchrony -LV dispersion  65 ms (lateral wall latest activated ) - TPS SD 12  31 ms (ischemic disease) ° Inter + Intra V delay > 102 ms Minor criteria(low sensitivity or specificity) (At least 3) ° Septal-to-posterior delay > 130 ms ° Interventricular delay > 40 ms ° Aortic pre-ejection time > 140 ms ° LV filling time < 40 % of cardiac cycle ° Diastolic mitral regurgitation

  13. IMPLANTATION : YES or NO ? NYHA class II  Not recommended in the ESC guidelines QRS width < 120 ms  Not recommended in the ESC guidelines « Paradoxical » asynchrony with severe septal delay - Position of the right ventricular lead ? - Position of the left ventricular lead ? Good exercise capacity  Peak VO2 :28 ml/kg/min (Weber A)

  14. 160 VE (L/min) 24 VE/VCO2slope 120 25 38 80 40 0 5 4 0 3 1 2 VCO2 (L/min) = Normal = Patient = NYHA class III

  15. Working Group ofHeart Failure and Cardiac Function How to assess the effects of CRT ?

  16. 1994-2006 : 12 years of CRT What did we learn ? • Permanent LV pacing is feasible and safe • CRT improves functional status and quality of life • CRT decreases hospitalization rate (inconsistent) • CRT reverts LV remodeling • CRT improves survival (CARE-HF)

  17. Evaluation of CRT Invasive : pressure-volume loops Exercise capacity : 6-min walk test treadmill ex. : peak VO2 Holter recording : arrhythmias heart rate variability Biology : changes in BNP and neurohormones Functional status and quality of life Imaging techniques : Doppler Echo , MRI

  18. Definition of Responder and Non Responder • Responder : survival +  NYHA class 1 + 10% increase in peak VO2, 3 to 6 months after CRT) • Responder :  NYHA class  1 • Responder :  LVESV >15% (>10%) • Responder: persistent decrease of NYHA class 1, irrespective of the changes of other parameters. • Non responder (20 to 30%): therapy considered as neutral or not beneficial (no decrease in NYHA class or QOL score ; need for heart transplant; death due to progressive, drug-refractory pump failure).

  19. ECHO in CRT • selection of pts : documentation and quantitation of dyssynergy • guiding the procedure : best position of RV and venous leads • optimizing of AV and VV delays • evaluation of haemodynamic effects : acutely • during follow-up

  20. Acute Effects • Systolic pressure (6 mmHg) • Stroke volume (10 to 30%) • dP/dt max (15 to 35%) • Arterial pulse pressure • End-systolic volume • Functional MR ( ERO and  RV by 30%)

  21. Chronic Effects • dP/dt max • LV ejection fraction • Arterial pulse pressure • End-diastolic volume • End-systolic volume : reverse remodeling ( ESV > 15%) • Functional MR (further 10% at rest and • of dynamic component)

  22. Lat Lat Sept Sept

  23. ECHO and CRT Acute and long-term effects on mechanical resynchronisation diastolic filling time , stroke volume mitral regurgitation (at rest and exercise) LV reverse remodeling changes in systolic and diastolic function

More Related