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Echo-driven V-V optimization determines clinical improvement in non responders to cardiac resynchronization treatment.

Naqvi TZ, Rafique AM, Peter CT - Cardiovasc Ultrasound (2006)

Bottom Line: In patients who derive sup-optimal benefit from biventricular pacing, optimization of atrioventricular delay post cardiac resynchronization treatment has been shown to improve cardiac output.In this report we describe the beneficial effect of sequential V-V pacing on inter and intraventricular synchrony, cardiac output and mitral regurgitation severity as the mechanisms whereby sequential biventricular pacing improves cardiac output and functional class in 8 patients who had derived no benefit or had deteriorated after CRT.Online tissue Doppler imaging including tissue velocity imaging, tissue synchronization imaging and strain and strain rate imaging were used in addition to conventional pulsed wave and color Doppler during sequential biventricular pacemaker programming.

View Article: PubMed Central - HTML - PubMed

Affiliation: Cardiac Non-Invasive Laboratory, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA. tasneem.naqvi@cshs.org

ABSTRACT
Echocardiography plays an integral role in the detection of mechanical dyssynchrony in patients with congestive heart failure and in predicting beneficial response to cardiac resynchronization treatment. In patients who derive sup-optimal benefit from biventricular pacing, optimization of atrioventricular delay post cardiac resynchronization treatment has been shown to improve cardiac output. Some recent reports suggest that sequential ventricular pacing may further improve cardiac output. The mechanism whereby sequential ventricular pacing improves cardiac output is likely improved inter and possibly intraventricular synchrony, however these speculations have not been confirmed. In this report we describe the beneficial effect of sequential V-V pacing on inter and intraventricular synchrony, cardiac output and mitral regurgitation severity as the mechanisms whereby sequential biventricular pacing improves cardiac output and functional class in 8 patients who had derived no benefit or had deteriorated after CRT. Online tissue Doppler imaging including tissue velocity imaging, tissue synchronization imaging and strain and strain rate imaging were used in addition to conventional pulsed wave and color Doppler during sequential biventricular pacemaker programming.

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Tissue velocity (A, B and C) and strain rate (D, E and F) maps in the apical 2 chamber view at baseline pre cardiac resynchronization treatment (A and D), post cardiac resynchronization treatment with LV pre-excitation of 20 ms (B and E) and post optimization with RV pre-excitation of 20 ms (C and F). Note delayed longitudinal contraction (shown by white arrows) in the velocity (A) and strain rate maps (D) at baseline indicated by white arrows that is abolished in all segments in the velocity map in B and in mid inferior segment in the strain rate map in E post cardiac resynchronization treatment. In addition note the marked improvement in synchrony in systole between basal and mid segments post cardiac resynchronization treatment in B and E compared to A and D. RV pre-excitation causes further increase in velocities with establishment of a normal velocity gradient between basal and mid segments and improved synchrony in C, as well as improvement in strain rate velocities, synchrony and a reduction of delayed longitudinal contraction velocities in F. Note different velocity calibration settings between D-F. Yellow line represent basal inferior LV segment, blue represents basal anterior LV segment, red represents mid inferior LV segment and green mid anterior LV segment.
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Figure 12: Tissue velocity (A, B and C) and strain rate (D, E and F) maps in the apical 2 chamber view at baseline pre cardiac resynchronization treatment (A and D), post cardiac resynchronization treatment with LV pre-excitation of 20 ms (B and E) and post optimization with RV pre-excitation of 20 ms (C and F). Note delayed longitudinal contraction (shown by white arrows) in the velocity (A) and strain rate maps (D) at baseline indicated by white arrows that is abolished in all segments in the velocity map in B and in mid inferior segment in the strain rate map in E post cardiac resynchronization treatment. In addition note the marked improvement in synchrony in systole between basal and mid segments post cardiac resynchronization treatment in B and E compared to A and D. RV pre-excitation causes further increase in velocities with establishment of a normal velocity gradient between basal and mid segments and improved synchrony in C, as well as improvement in strain rate velocities, synchrony and a reduction of delayed longitudinal contraction velocities in F. Note different velocity calibration settings between D-F. Yellow line represent basal inferior LV segment, blue represents basal anterior LV segment, red represents mid inferior LV segment and green mid anterior LV segment.

Mentions: An 85 year old female underwent CRT for ischemic dilated cardiomyopathy, LVEF of 30%, left bundle branch block and NHYA class III symptoms and presence of marked mechanical dyssynchrony. LV lead was in the lateral coronary sinus branch. She was referred for optimization due to no improvement in symptoms 2 months post CRT. Pacemaker was programmed at an A sensed AVD 110 ms and LV pre-excitation of 20 ms. Native AV delay was 110 ms. LVEF was 35% and there was trace MR. Right ventricular pre-excitation caused improvement in LV velocities, strain and strain rate (Figure 12, C and F) compared to LV pre-excitation (Figure 12, B and E) and both showed marked improvement in these parameters compared to pre CRT study (Figure 12, A and D). Pacemaker programming was changed to an AV delay of 80 ms and right ventricular pre-excitation of 20 ms.


Echo-driven V-V optimization determines clinical improvement in non responders to cardiac resynchronization treatment.

Naqvi TZ, Rafique AM, Peter CT - Cardiovasc Ultrasound (2006)

Tissue velocity (A, B and C) and strain rate (D, E and F) maps in the apical 2 chamber view at baseline pre cardiac resynchronization treatment (A and D), post cardiac resynchronization treatment with LV pre-excitation of 20 ms (B and E) and post optimization with RV pre-excitation of 20 ms (C and F). Note delayed longitudinal contraction (shown by white arrows) in the velocity (A) and strain rate maps (D) at baseline indicated by white arrows that is abolished in all segments in the velocity map in B and in mid inferior segment in the strain rate map in E post cardiac resynchronization treatment. In addition note the marked improvement in synchrony in systole between basal and mid segments post cardiac resynchronization treatment in B and E compared to A and D. RV pre-excitation causes further increase in velocities with establishment of a normal velocity gradient between basal and mid segments and improved synchrony in C, as well as improvement in strain rate velocities, synchrony and a reduction of delayed longitudinal contraction velocities in F. Note different velocity calibration settings between D-F. Yellow line represent basal inferior LV segment, blue represents basal anterior LV segment, red represents mid inferior LV segment and green mid anterior LV segment.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC1636667&req=5

Figure 12: Tissue velocity (A, B and C) and strain rate (D, E and F) maps in the apical 2 chamber view at baseline pre cardiac resynchronization treatment (A and D), post cardiac resynchronization treatment with LV pre-excitation of 20 ms (B and E) and post optimization with RV pre-excitation of 20 ms (C and F). Note delayed longitudinal contraction (shown by white arrows) in the velocity (A) and strain rate maps (D) at baseline indicated by white arrows that is abolished in all segments in the velocity map in B and in mid inferior segment in the strain rate map in E post cardiac resynchronization treatment. In addition note the marked improvement in synchrony in systole between basal and mid segments post cardiac resynchronization treatment in B and E compared to A and D. RV pre-excitation causes further increase in velocities with establishment of a normal velocity gradient between basal and mid segments and improved synchrony in C, as well as improvement in strain rate velocities, synchrony and a reduction of delayed longitudinal contraction velocities in F. Note different velocity calibration settings between D-F. Yellow line represent basal inferior LV segment, blue represents basal anterior LV segment, red represents mid inferior LV segment and green mid anterior LV segment.
Mentions: An 85 year old female underwent CRT for ischemic dilated cardiomyopathy, LVEF of 30%, left bundle branch block and NHYA class III symptoms and presence of marked mechanical dyssynchrony. LV lead was in the lateral coronary sinus branch. She was referred for optimization due to no improvement in symptoms 2 months post CRT. Pacemaker was programmed at an A sensed AVD 110 ms and LV pre-excitation of 20 ms. Native AV delay was 110 ms. LVEF was 35% and there was trace MR. Right ventricular pre-excitation caused improvement in LV velocities, strain and strain rate (Figure 12, C and F) compared to LV pre-excitation (Figure 12, B and E) and both showed marked improvement in these parameters compared to pre CRT study (Figure 12, A and D). Pacemaker programming was changed to an AV delay of 80 ms and right ventricular pre-excitation of 20 ms.

Bottom Line: In patients who derive sup-optimal benefit from biventricular pacing, optimization of atrioventricular delay post cardiac resynchronization treatment has been shown to improve cardiac output.In this report we describe the beneficial effect of sequential V-V pacing on inter and intraventricular synchrony, cardiac output and mitral regurgitation severity as the mechanisms whereby sequential biventricular pacing improves cardiac output and functional class in 8 patients who had derived no benefit or had deteriorated after CRT.Online tissue Doppler imaging including tissue velocity imaging, tissue synchronization imaging and strain and strain rate imaging were used in addition to conventional pulsed wave and color Doppler during sequential biventricular pacemaker programming.

View Article: PubMed Central - HTML - PubMed

Affiliation: Cardiac Non-Invasive Laboratory, Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA. tasneem.naqvi@cshs.org

ABSTRACT
Echocardiography plays an integral role in the detection of mechanical dyssynchrony in patients with congestive heart failure and in predicting beneficial response to cardiac resynchronization treatment. In patients who derive sup-optimal benefit from biventricular pacing, optimization of atrioventricular delay post cardiac resynchronization treatment has been shown to improve cardiac output. Some recent reports suggest that sequential ventricular pacing may further improve cardiac output. The mechanism whereby sequential ventricular pacing improves cardiac output is likely improved inter and possibly intraventricular synchrony, however these speculations have not been confirmed. In this report we describe the beneficial effect of sequential V-V pacing on inter and intraventricular synchrony, cardiac output and mitral regurgitation severity as the mechanisms whereby sequential biventricular pacing improves cardiac output and functional class in 8 patients who had derived no benefit or had deteriorated after CRT. Online tissue Doppler imaging including tissue velocity imaging, tissue synchronization imaging and strain and strain rate imaging were used in addition to conventional pulsed wave and color Doppler during sequential biventricular pacemaker programming.

Show MeSH
Related in: MedlinePlus