Echocardiographic Assessment of Dyssynchrony for Predicting a Favorable Response to Cardiac Resynchronization Therapy

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US Cardiology, 2006;3(1):1-5

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Numerous clinical trials involving patients with severe, symptomatic heart failure and a wide QRS complex have shown benefits from cardiac resynchronization therapy (CRT). CRT can increase left ventricular ejection fraction (LVEF), decrease LV volume and mitral regurgitation, improve symptoms caused by heart failure,1-3 and may also improve mortality.4,5 Current American College of Cardiology/ American Heart Association (ACC/AHA) guidelines suggest CRT implantation for patients with LVEF <35%, New York Heart Association (NYHA) class III or ambulatory class IV heart failure, and dyssynchrony defined by a QRS >120ms.6 However, among patients who receive a CRT based on this criteria, one-third will fail to respond to CRT therapy.This may be due to either inadequate placement of the coronary sinus lead or the absence of mechanical LV dyssynchrony prior to implant-ation. Many non-responders do not exhibit intra-ventricular mechanical dyssynchrony at baseline, and it may be that CRT most benefits those with underlying dyssynchrony.

Due to its ease of use and wide availability, echocardiography has emerged as the preferred modality to assess dyssynchrony. There are several echocardiographic techniques under investigation, including tissue Doppler imaging, real-time three-dimensional echocardiography, and speckle tracking, although currently there is no clearly accepted standard.

What Is Dyssynchrony?

Patients who have LV systolic dysfunction and dilatation frequently have a prolonged QRS complex, often in an left bundle-branch block (LBBB) pattern. QRS prolongation is generally associated with delayed electrical activation of the left ventricle, leading to unco-ordinated ventricular motion, decreased stroke volume, and mitral regurgitation. Because of this association, QRS duration has been used as a surrogate marker for ventricular dyssynchrony. However, several studies have demonstrated that not all patients with a wide QRS complex exhibit evidence of mechanical dyssynchrony.7 Furthermore, up to 30-50% of patients with a narrow QRS complex may have mechanical dyssynchrony measured by echocardiography. Some of these patients with narrow QRS may benefit from CRT.8,9

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