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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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TSI in an 18 year old male with Coxsakie B virus cardiomyopathy and narrow QRS. Significant mechanical dyssynchrony was identified on TSI in the apical 4 (A), 2 (B) and 3 chamber (C) views (red color in the myocardium). Panels D-F are same views post CRT at AVD of 100 and VV delay of 0 ms. LV pre-excitation by 10 ms is shown in panels G-I and by 20 ms in panels J, K and L respectively. Note persistence of mechanical dyssynchrony post CRT (D-F) with worsening of right ventricular delay and mild improved in LV delay. Progressively decreased intra as well as interventricular dyssynchrony occurred with increasing LV pre-excitation (G-L).
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Figure 2: TSI in an 18 year old male with Coxsakie B virus cardiomyopathy and narrow QRS. Significant mechanical dyssynchrony was identified on TSI in the apical 4 (A), 2 (B) and 3 chamber (C) views (red color in the myocardium). Panels D-F are same views post CRT at AVD of 100 and VV delay of 0 ms. LV pre-excitation by 10 ms is shown in panels G-I and by 20 ms in panels J, K and L respectively. Note persistence of mechanical dyssynchrony post CRT (D-F) with worsening of right ventricular delay and mild improved in LV delay. Progressively decreased intra as well as interventricular dyssynchrony occurred with increasing LV pre-excitation (G-L).

Mentions: An 18-year-old Caucasian male with viral cardiomyopathy diagnosed 6 months ago, possibly related to Coxsackie B virus based on viral titers and endomyocardial biopsy presented with NYHA class IV symptoms, LV ejection fraction (EF) of 20% and marked mechanical dyssynchrony on TDI. Following implantation of biv device an optimization of pacemaker was requested. There was sinus rhythm, moderate mitral regurgitation (MR), moderate to severe tricuspid regurgitation and peak pulmonary artery pressure (PAP) was 65 mmHg. Using Ritter's and iterative method, optimal AV delay was determined to be 100 ms. By TSI least dyssynchrony appeared to be present at an LV pre excitation of 20 ms (Figure 2). This was associated with improved LV VTI as well as decrease in pulmonary vein atrial reversal, and improved LV diastolic filling. At an AV delay of 100 ms and LV pre-excitation of 20 ms, the final PA pressure was 47 mmHg (Figure 3) and MR was mild to moderate.


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

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

TSI in an 18 year old male with Coxsakie B virus cardiomyopathy and narrow QRS. Significant mechanical dyssynchrony was identified on TSI in the apical 4 (A), 2 (B) and 3 chamber (C) views (red color in the myocardium). Panels D-F are same views post CRT at AVD of 100 and VV delay of 0 ms. LV pre-excitation by 10 ms is shown in panels G-I and by 20 ms in panels J, K and L respectively. Note persistence of mechanical dyssynchrony post CRT (D-F) with worsening of right ventricular delay and mild improved in LV delay. Progressively decreased intra as well as interventricular dyssynchrony occurred with increasing LV pre-excitation (G-L).
© Copyright Policy - open-access
Related In: Results  -  Collection

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

Figure 2: TSI in an 18 year old male with Coxsakie B virus cardiomyopathy and narrow QRS. Significant mechanical dyssynchrony was identified on TSI in the apical 4 (A), 2 (B) and 3 chamber (C) views (red color in the myocardium). Panels D-F are same views post CRT at AVD of 100 and VV delay of 0 ms. LV pre-excitation by 10 ms is shown in panels G-I and by 20 ms in panels J, K and L respectively. Note persistence of mechanical dyssynchrony post CRT (D-F) with worsening of right ventricular delay and mild improved in LV delay. Progressively decreased intra as well as interventricular dyssynchrony occurred with increasing LV pre-excitation (G-L).
Mentions: An 18-year-old Caucasian male with viral cardiomyopathy diagnosed 6 months ago, possibly related to Coxsackie B virus based on viral titers and endomyocardial biopsy presented with NYHA class IV symptoms, LV ejection fraction (EF) of 20% and marked mechanical dyssynchrony on TDI. Following implantation of biv device an optimization of pacemaker was requested. There was sinus rhythm, moderate mitral regurgitation (MR), moderate to severe tricuspid regurgitation and peak pulmonary artery pressure (PAP) was 65 mmHg. Using Ritter's and iterative method, optimal AV delay was determined to be 100 ms. By TSI least dyssynchrony appeared to be present at an LV pre excitation of 20 ms (Figure 2). This was associated with improved LV VTI as well as decrease in pulmonary vein atrial reversal, and improved LV diastolic filling. At an AV delay of 100 ms and LV pre-excitation of 20 ms, the final PA pressure was 47 mmHg (Figure 3) and MR was mild to moderate.

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