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Current Role of Echocardiography in Cardiac Resynchronization Therapy: from Cardiac Mechanics to Flow Dynamics Analysis

  • Imaging in Heart Failure (J Schulz-Menger, Section Editor)
  • Published:
Current Heart Failure Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The aim of this review is to summarily explain what LV synchrony, coordination, myocardial work, and flow dynamics are, trying to clarify their advantages and limitations in the treatment of heart failure patients undergoing or with implanted cardiac resynchronization therapy (CRT).

Recent Findings

CRT is an established treatment for patients with heart failure and left ventricular systolic dysfunction. In the current guidelines, CRT implant indications rely only on electrical dyssynchrony, but in the last years, many aspects of cardiac mechanics (including contractile synchrony, coordination, propagation, and myocardial work) and flow dynamics have been studied using echocardiographic techniques to better characterize patients undergoing or with implanted CRT. However, the concepts, limits, and potential applications of all these echocardiographic evaluations are unclear to most clinicians.

Summary

The use of left ventricular dyssynchrony and discoordination indices may help to identify those significant mechanical alterations whose correction may increase the probability of a favorable CRT response. Assessment of myocardial work and intracardiac flow dynamics may overcome some limitations of the conventional evaluation of cardiac mechanics but more investigations are needed before extensive clinical application.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JG, Coats AJ, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology. Eur J Heart Fail. 2016;18:891–975.

    PubMed  Google Scholar 

  2. Mele D, Campana M, Sclavo M, Seveso G, Aschieri D, Nesta F, et al. Impact of tissue harmonic imaging in patients with distorted left ventricles: improvement in accuracy and reproducibility of visual, manual and automated echocardiographic assessment of left ventricular ejection fraction. Eur J Echocardiography. 2003;4:59–67.

    CAS  Google Scholar 

  3. Mele D, Bertini M, Malagù M, Nardozza M, Ferrari R. Current role of echocardiography in cardiac resynchronization therapy. Heart Fail Rev. 2017;22:699–722.

    CAS  PubMed  Google Scholar 

  4. Mele D, Luisi GA, Malagù M, Laterza A, Ferrari R, Bertini M. Echocardiographic evaluation of cardiac dyssynchrony: does it still matter? Echocardiography. 2018;35:707–15.

    PubMed  Google Scholar 

  5. Sassone B, Nucifora G, Mele D, Valzania C, Bisignani G, Boriani G, et al. Role of cardiovascular imaging in cardiac resynchronization therapy: a literature review. J Cardiovasc Med. 2018;19:211–22.

    Google Scholar 

  6. Mele D, Smarrazzo V, Pedrizzetti G, Capasso F, Pepe M, Severino S, et al. Intracardiac flow analysis: techniques and potential clinical applications. J Am Soc Echocardiogr. 2019;32:319–32.

    PubMed  Google Scholar 

  7. Mele D, Smarrazzo V, Pedrizzetti G, Bertini M, Ferrari R. Intracardiac flow analysis in cardiac resynchronization therapy: a new challenge? Echocardiography. 2019;36:1919–29.

    PubMed  Google Scholar 

  8. Park HE, Chang SA, Kim HK, Shin DH, Kim JH, Seo MK, et al. Impact of loading condition on the 2D speckle tracking-derived left ventricular dyssynchrony index in nonischemic dilated cardiomyopathy. Circ Cardiovasc Imaging. 2010;3:272–81.

    PubMed  Google Scholar 

  9. Lafitte S, Bordachar P, Lafitte M, Garrigue S, Reuter S, Reant P, et al. Dynamic ventricular dyssynchrony: an exercise-echocardiography study. J Am Coll Cardiol. 2006;47:2253–9.

    PubMed  Google Scholar 

  10. Rocchi G, Bertini M, Biffi M, Ziacchi M, Biagini E, Gallelli I, et al. Exercise stress echocardiography is superior to rest echocardiography in predicting left ventricular reverse remodelling and functional improvement after cardiac resynchronization therapy. Eur Heart J. 2009;30:89–97.

    PubMed  Google Scholar 

  11. D’Andrea A, Mele D, Nistri S, Riegler L, Galderisi M, Agricola E, et al. The prognostic impact of dynamic ventricular dyssynchrony in patients with idiopathic dilated cardiomyopathy and narrow QRS. Eur Heart J Cardiovasc Imaging. 2013;14:183–9.

    PubMed  Google Scholar 

  12. Bleeker GB, Mollema SA, Holman ER, Van de Veire N, Ypenburg C, Boersma E, et al. Left ventricular resynchronization is mandatory for response to cardiac resynchronization therapy: analysis in patients with echocardiographic evidence of left ventricular dyssynchrony at baseline. Circulation. 2007;116:1440–8.

    PubMed  Google Scholar 

  13. Sassone B, Capecchi A, Boggian G, Gabrieli L, Saccà S, Vandelli R, et al. Value of baseline left lateral wall postsystolic displacement assessed by M-mode to predict reverse remodeling by cardiac resynchronization therapy. Am J Cardiol. 2007;100:470–5.

    PubMed  Google Scholar 

  14. Mele D, Pasanisi G, Capasso F, De Simone A, Morales MA, Poggio D, et al. Left intraventricular myocardial deformation dyssynchrony identifies responders to cardiac resynchronization therapy in patients with heart failure. Eur Heart J. 2006;27:1070–8.

    PubMed  Google Scholar 

  15. Mele D, Toselli T, Capasso F, Stabile G, Piacenti M, Piepoli M, et al. Comparison of myocardial deformation and velocity dyssynchrony for identification of responders to cardiac resynchronization therapy. Eur J Heart Fail. 2009;11:391–9.

    PubMed  Google Scholar 

  16. Chung ES, Leon AR, Tavazzi L, Sun JP, Nihoyannopoulos P, Merlino J, et al. Results of the predictors of response to CRT (PROSPECT) trial. Circulation. 2008;117:2608–16.

    PubMed  Google Scholar 

  17. Suffoletto MS, Dohi K, Cannesson M, Saba S, Gorcsan J 3rd. Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation. 2006;113:960–8.

    PubMed  Google Scholar 

  18. Kleijn SA, Aly MF, Knol DL, Terwee CB, Jansma EP, Abd El-Hady YA, et al. A meta-analysis of left ventricular dyssynchrony assessment and prediction of response to cardiac resynchronization therapy by three-dimensional echocardiography. Eur Heart J Cardiovasc Imaging. 2012;13:763–75.

    PubMed  Google Scholar 

  19. Ruschitzka F, AbrahamWT SJP, Bax JJ, Borer JS, Brugada J, et al. Cardiac-resynchronization therapy in heart failure with a narrow QRS complex. N Engl J Med. 2013;369:1395–405.

    CAS  PubMed  Google Scholar 

  20. Tomlinson DR, Bashir Y, Betts TR, Rajappan K. Accuracy of manual QRS duration assessment: its importance in patient selection for cardiac resynchronization and implantable cardioverter defibrillator therapy. Europace. 2009;11:638–42.

    PubMed  Google Scholar 

  21. Vancura V, Wichterle D, Ulc I, Šmíd J, Brabec M, Zárybnická M, et al. The variability of automated QRS duration measurement. Europace. 2017;19:636–43.

    PubMed  Google Scholar 

  22. Caputo ML, van Stipdonk A, Illner A, D’Ambrosio G, Regoli F, Conte G, et al. The definition of left bundle branch block influences the response to cardiac resynchronization therapy. Int J Cardiol. 2018;269:165–9.

    PubMed  Google Scholar 

  23. Fantoni C, Kawabata M, Massaro R, Regoli F, Raffa S, Arora V, et al. Right and left ventricular activation sequence in patients with heart failure and right bundle branch block: a detailed analysis using three-dimensional non-fluoroscopic electroanatomic map** system. J Cardiovasc Electrophysiol. 2005;16:112–9 discussion 120-1.

    PubMed  Google Scholar 

  24. Hara H, Oyenuga OA, Tanaka H, Adelstein EC, Onishi T, McNamara DM, et al. The relationship of QRS morphology and mechanical dyssynchrony to long-term outcome following cardiac resynchronization therapy. Eur Heart J. 2012;33:2680–91.

    PubMed  PubMed Central  Google Scholar 

  25. • Auricchio A, Lumens J, Prinzen FW. Does cardiac resynchronization therapy benefit patients with right bundle branch block: cardiac resynchronization therapy has a role in patients with right bundle branch block. Circ Arrhythm Electrophysiol. 2014;7:532–42 This study shows that echocardiographic indices of dyssynchrony may be helpful in patients with right bundle branch block to recognize CRT candidates who have the highest probability to respond.

    PubMed  Google Scholar 

  26. Mele D, Agricola E, Monte AD, Galderisi M, D’Andrea A, Rigo F, et al. Pacing transmural scar tissue reduces left ventricle reverse remodeling after cardiac resynchronization therapy. Int J Cardiol. 2013;167:94–101.

    PubMed  Google Scholar 

  27. Khan FZ, Virdee MS, Palmer CR, Pugh PJ, O’Halloran D, Elsik M, et al. Targeted left ventricular lead placement to guide cardiac resynchronization therapy. The TARGET study: a randomized, controlled trial. J Am Coll Cardiol. 2012;59:1509–18.

    PubMed  Google Scholar 

  28. • Kydd AC, Khan FZ, Watson WD, Pugh PJ, Virdee MS, Dutka DP. Prognostic benefit of optimum left ventricular lead position in cardiac resynchronization therapy: follow-up of the TARGET Study Cohort (Targeted Left Ventricular Lead Placement to guide Cardiac Resynchronization Therapy). JACC Heart Fail. 2014;2:205–12 This study shows that an optimal left ventricular lead position at the site of latest mechanical activation, avoiding myocardial scar, is associated with superior CRT response and improved survival that persists during follow-up.

    PubMed  Google Scholar 

  29. Adelstein E, Alam MB, Schwartzman D, Jain S, Marek J, Gorcsan J, et al. Effect of echocardiography-guided left ventricular lead placement for cardiac resynchronization therapy on mortality and risk of defibrillator therapy for ventricular arrhythmias in heart failure patients (from the Speckle Tracking Assisted Resynchronization Therapy for Electrode Region [STARTER] trial). Am J Cardiol. 2014;113:1518–22.

    PubMed  Google Scholar 

  30. Daya HA, Alam MB, Adelstein E, Schwartzman D, Jain S, Marek J, et al. Echocardiography-guided left ventricular lead placement for cardiac resynchronization therapy in ischemic vs nonischemic cardiomyopathy patients. Heart Rhythm. 2014;11:614–9.

    PubMed  Google Scholar 

  31. Mele D, Fiorencis A, Chiodi E, Gardini C, Benea G, Ferrari R. Polar plot maps by parametric strain echocardiography allow accurate evaluation of non-viable transmural scar tissue in ischaemic heart disease. Eur Heart J Cardiovasc Imaging. 2016;17:668–77.

    PubMed  Google Scholar 

  32. Bertini M, Mele D, Malagù M, Fiorencis A, Toselli T, Casadei F, et al. Cardiac resynchronization therapy guided by multimodality cardiac imaging. Eur J Heart Fail. 2016;18:1375–82.

    PubMed  Google Scholar 

  33. Mele D, Nardozza M, Malagù M, Leonetti E, Fragale C, Rondinella A, et al. Left ventricular lead position guided by parametric strain echocardiography improves response to cardiac resynchronization therapy. J Am Soc Echocardiogr. 2017;30:1001–11.

    PubMed  Google Scholar 

  34. Kirn B, Jansen A, Bracke F, van Gelder B, Arts T, Prinzen FW. Mechanical discoordination rather than dyssynchrony predicts reverse remodeling upon cardiac resynchronization. Am J Physiol Heart Circ Physiol. 2008;295:H640–6.

    CAS  PubMed  Google Scholar 

  35. Wang CL, Wu CT, Yeh YH, Wu LS, Chang CJ, Ho WJ, et al. Recoordination rather than resynchronization predicts reverse remodeling after cardiac resynchronization therapy. J Am Soc Echocardiogr. 2010;23:611–20.

    CAS  PubMed  Google Scholar 

  36. Risum N, Jons C, Olsen NT, Fritz-Hansen T, Bruun NE, Hojgaard MV, et al. Simple regional strain pattern analysis to predict response to cardiac resynchronization therapy: rationale, initial results, and advantages. Am Heart J. 2012;163:697–704.

    PubMed  Google Scholar 

  37. • Seo Y, Ishizu T, Kawamura R, Yamamoto M, Kuroki K, Igarashi M, et al. Three-dimensional propagation imaging of left ventricular activation by speckle-tracking echocardiography to predict responses to cardiac resynchronization therapy. J Am Soc Echocardiogr. 2015;28:606–14 This study used three-dimensional speckle tracking echocardiography to demonstrate that a U-shaped pattern of contraction has a greater predictive value of CRT response.

    PubMed  Google Scholar 

  38. Duckett SG, Camara O, Ginks MR, Bostock J, Chinchapatnam P, Sermesant M, et al. Relationship between endocardial activation sequences defined by high-density map** to early septal contraction (septal flash) in patients with left bundle branch block undergoing cardiac resynchronization therapy. Europace. 2012;14:99–106.

    PubMed  Google Scholar 

  39. Stankovic I, Prinz C, Ciarka A, Daraban AM, Kotrc M, Aarones M, et al. Relationship of visually assessed apical rocking and septal flash to response and long-term survival following cardiac resynchronization therapy (PREDICT-CRT). Eur Heart J Cardiovasc Imaging. 2016;17:262–9.

    PubMed  Google Scholar 

  40. Voigt JU, Schneider TM, Korder S, Szulik M, Gürel E, Daniel WG, et al. Apical transverse motion as surrogate parameter to determine regional left ventricular function inhomogeneities: a new, integrative approach to left ventricular asynchrony assessment. Eur Heart J. 2009;30:959–68.

    PubMed  Google Scholar 

  41. Szulik M, Tillekaerts M, Vangeel V, Ganame J, Willems R, Lenarczyk R, et al. Assessment of apical rocking: a new, integrative approach for selection of candidates for cardiac resynchronization therapy. Eur J Echocardiogr. 2010;11:863–9.

    PubMed  Google Scholar 

  42. Stankovic I, Aarones M, Smith H-J, Vörös G, Kongsgaard E, Neskovic AN, et al. Dynamic relationship of left ventricular dyssynchrony and contractile reserve in patients undergoing cardiac resynchronization therapy. Eur Heart J. 2014;35:48–55.

    CAS  PubMed  Google Scholar 

  43. • Beela AS, Unlu S, Duchenne J, Ciarka A, Daraban AM, Kotrc M, et al. Assessment of mechanical dyssynchrony can improve the prognostic value of guideline-based patient selection for cardiac resynchronization therapy. Eur Heart J Cardiovasc Imaging. 2018;20(1):66–7 This study shows that current guideline criteria for CRT candidate selection could be improved by assessments of mechanical discoordination indices.

    Google Scholar 

  44. Mada RO, Lysyansky P, Duchenne J, Beyer R, Mada C, Muresan L, et al. New automatic tools to identify responders to cardiac resynchronization therapy. J Am Soc Echocardiogr. 2016;29:966–72.

    PubMed  Google Scholar 

  45. Russell K, Eriksen M, Aaberge L, Wilhelmsen N, Skulstad H, Remme EW, et al. A novel clinical method for quantification of regional left ventricular pressure-strain loop area: a non-invasive index of myocardial work. Eur Heart J. 2012;33:724–33.

    PubMed  PubMed Central  Google Scholar 

  46. Galli E, Leclercq C, Fournet M, Hubert A, Bernard A, Smiseth OA, et al. Value of myocardial work estimation in the prediction of response to cardiac resynchronization therapy. J Am Soc Echocardiogr. 2018;31:220–30.

    PubMed  Google Scholar 

  47. van der Bijl P, Vo NM, Kostyukevich MV, Mertens B, Ajmone Marsan N, Delgado V, et al. Prognostic implications of global, left ventricular myocardial work efficiency before cardiac resynchronization therapy. Eur Heart J Cardiovasc Imaging. 2019;20:1388–94.

    PubMed  Google Scholar 

  48. •• Duchenne J, Aalen JM, Cvijic M, Larsen CK, Galli E, Bézy S, et al. Acute redistribution of regional left ventricular work by cardiac resynchronization therapy determines long-term remodelling. Eur Heart J Cardiovasc Imaging. 2020;21:619–28 This study investigates the acute impact of CRT on regional myocardial work distribution in the left ventricle and suggests that the treatment of the loading imbalance should be the main aim of CRT.

    PubMed  Google Scholar 

  49. Pedrizzetti G, Martiniello AR, Bianchi V, D’Onofrio A, Caso P, Tonti G. Cardiac fluid dynamics anticipates heart adaptation. J Biomech. 2015;48:388–91.

    PubMed  Google Scholar 

  50. Pedrizzetti G, Martiniello AR, Bianchi V, D’Onofrio A, Caso P, Tonti G. Changes in electrical activation modify the direction of left ventricular flow momentum: novel observations using echocardiographic particle image velocimetry. Eur Heart J Cardiovasc Imaging. 2016;17:203–9.

    PubMed  Google Scholar 

  51. Cimino S, Palombizio D, Cicogna F, Cantisani D, Reali M, Filomena D, et al. Significant increase of flow kinetic energy in “nonresponders” patients to cardiac resynchronization therapy. Echocardiography. 2017;34:709–15.

    PubMed  Google Scholar 

  52. Rodríguez Muñoz D, Moya Mur JL, Moreno J, Fernández-Golfín C, Franco E, Monteagudo JM, et al. Energy dissipation in resynchronization therapy: impact of atrioventricular delay. J Am Soc Echocardiogr. 2019;32:744–54.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Cardiac Unit, Azienda Ospedaliero-Universitaria, Via Aldo Moro 8, 44124, Cona (Ferrara), Italy

    Donato Mele, Filippo Trevisan, Andrea Fiorencis, Vittorio Smarrazzo, Matteo Bertini & Roberto Ferrari

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  1. Donato Mele
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  2. Filippo Trevisan
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Correspondence to Donato Mele.

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Mele, D., Trevisan, F., Fiorencis, A. et al. Current Role of Echocardiography in Cardiac Resynchronization Therapy: from Cardiac Mechanics to Flow Dynamics Analysis. Curr Heart Fail Rep 17, 384–396 (2020). https://doi.org/10.1007/s11897-020-00484-w

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