1. Επιλογή ασθενών για θεραπεία καρδιακού επανασυγχρονισμού με εκτίμηση δυσυγχρονισμού και τη χρήση δυναμικής ηχωκαρδιογραφίας με δοβουταμίνη.
Ε. Πουλιδάκης1, Κ. Αγγέλη2, Σ. Σιδερής2,
Ι. Φελέκος2, Ε. Σφενδουράκη2, Ι. Κουτάγιαρ2, Κ. Πολυτάρχου1,
Ε. Γιαννούλης1, M. Κούκος1, Ε. Μαργιούλα1, Ν. Ντόκας1,
Σ. Λιάπης1, Κ. Λιόντου1, Κ. Τριανταφύλλου1, Π. Διλαβέρης2,
Κ. Γκαντζούλης2, Κ. Κάππος1, Α.Σ. Μανώλης2, Χ. Στεφανάδης2,
Δ. Τούσουλης2 
1Γενικό Νοσοκομείο Αθηνών «Ο Ευαγγελισμός»
2Γενικό Νοσοκομείο Αθηνών «Ο Ιπποκράτειο»

2. Survival after CRT

3. Reverse remodeling after CRT
Auricchio A, Prinzen FW. Circulation Journal Vol.75, March 2011

4. Response rate

5. Echo for CRT candidate selection

7. New echo approaches Speckle tracking echocardiography (STE)
Septal flash (SF)
Apical rocking (ApR)
Low dose Dobutamine Stress Echocardigraphy (LD-DSE)
(Real time 3 Dimensional Echocardiography)

8. Speckle tracking Echo Gray-scale based technique Angle-independent
comprehensive assessment of myocardial deformation
Identifies speckles and then tracks them frame-by-frame
Bansal M, Kasliwal RR. Indian heart journal 2013

9. Septal Flash – Apical Rocking
Stankovic I et al. European Heart Journal – Cardiovascular Imaging (2016) 17, 262–269

10. Predictive value of SF and ApR
Stankovic I et al. European Heart Journal – Cardiovascular Imaging (2016) 17, 262–269

11. Kloosterman M. et al

12. Auricchio A, Prinzen FW. Circulation Journal Vol.75, March 2011

13. Late responders

14. Purpose of the study Investigate the role of for the identification of
LD-DSE (for ICR and viability) along with
simple and easy to use dyssynchrony parameters
for the identification of
responders or
late responders to CRT. 

15. Inclusion Criteria Adult patients referred for CRT
Heart failure NYHA II-IV
Fulfilling CRT indications at the time of the enrolment:
EF<35%
QRS>120ms (130)
OMT
Exclusion criteria
Recent revascularisation
Reversible cause of HF
Enrollment 1/2011 – 12/2013

16. Protocol Before CRT Right after CRT 6 months 2-4 years
Clinical assessment √ -
NYHA class
ECG
EF / LV volumes
Dyssynchrony
ICR – Viability
6MWT
MLHFQ

17. Dysynchrony Assessment & LD-DSE
Septal to posterior wall motion delay (SPWMD)
Opposing wall delay by TDI
Intraventricular dyssynchrony
Time to peak circumferential strain by STE
Septal flash and Apical Rocking
Inotropic contractile reserve
Viability of the posterolateral wall

18. Septal to posterior wall motion delay
Parasternal long-axis
M-mode cursor at the midventricular level
TDI enabled
Identify the time delay from peak inward septal motion to peak inward posterior wall.
Reported cut-off value of ≥130ms (252ms)

19. Opposing wall delay by TDI
Optimized 2D imaging – A4C
Position the LV cavity in the center of the sector and aligned as vertically as possible
Set the depth to include the level of the mitral annulus
Activate color TD
Place regions of interest in the basal of opposing LV walls
Determine time from onset of the QRS complex to the peak systolic velocity for each region
Reported cut-off value of >65-100ms

20. Interventricular dyssynchrony
Assessed as the interventricular mechanical delay (IVMD)
time from QRS onset to the onset of LV ejection versus RV ejection
measured as the onset of pulsed Doppler flow velocities in the LV and RV outflow tracts
A5C and PSAX (aortic valve level) views
Reported cut-off value of >40-50ms

21. Time to peak circumferential strain by STE
PSAX – papillary muscles level
Region of interest by tracking the endocardial and epicardial border
6 standard segments
Time to peak circumferential strain
Dyssynchrony defined as difference in earliest and latest segment (TmaxCS)
Reported cut-off value of ≥130ms for radial strain

22. Septal flash and Apical Rocking
The presence of ApRock and SF was visually assessed pre-implantation.
A4C view and PLAX m-mode respectively
All readings were initially performed by two readers.
Stankovic I et al. European Heart Journal – Cardiovascular Imaging (2016) 17, 262–269

23. Patient Chart 123 screened 5-> withdrew consent
4-> received ICD only
1-> died before implantation
5->unsuccessful LV lead implantation
1->died during hospitalization
1-> CRT suspended due to proarrhythmia
106 patients

24. Study Population Demographics Age (y) 66.7 ± 9.8 Male/Female 84 / 22
Ischemic /Non-ischemic
62 / 44
NYHA (class)
II-IV
LVEF (%)
28± 7.8
ECG & Treatment
LBBB
64 (60.4%)
B-blockers
99 (94.3%)
ACEIs/ARBs
100 (93.3%)
MRA
89 (83.9%)
Diuretic
101 (95.3%)
Risk factors
HTN
32 (30.2%) DM
19 (17.9%)
Smoking
13 (12.2%)
Dyslipidemia
31 (29.2%) FH
22 (20.7%)
Comorbidities
CKD
24 (22.6%)
COPD
10 (9.4%)
STROKE/TIA
PAD
6 (5.6%)

25. Outcomes 74 (69.8%) had clinical improvement (in NYHA)
54 (50.9%) classified as responders (-15%LVESV)
12 (11.3%) additional late responders
2 patients died within 6 months
10 non-responders died after the initial follow up
Parameter
Baseline
6month FU
NYHA
2.5 ± 0.7
1.8 ± 0.9
QRS
152 ± 33.8
136.5 ± 22.6 EF
28 ± 7.8
35 ± 9.8
LVESV
133.6 ± 49.7
115.6 ± 50.3
6MWT
318.5±116.4
367.7±142.6
MLHFQ
33 ± 14.3
26.1 ± 14.4

26. Predictive ability Test AUC Cutoff Sens% Spec% QRS 145 81.5 50 LBBB
0.597
145
81.5 50
LBBB
0.658
75.9
55.8
Intra
0.543
37.5
42.3
Inter
0.655
26.5
64.8
67.3
SPWMD
0.775
158
57.4
98.1
Strain
0.835
53.5 87
71.2
ApR
0.709 63
78,8 SF
0.736
82.7
ApR/SF
0.772
83.3
ICR
0.768
19.7
96.3
69.2
Viability
0.587
19.2
ICR+Viab
0.799 94
65.4

27. Predictive ability Late Responders Clinical Improvement Test AUC QRS
0,514
LBBB
0,603
Intra
0,482
Inter
0,634
SPWMD
0,761
Strain (TmaxCS)
0,83
ApR
0,72 SF
0,652
ApR/SF
0,754
ICR
0,791
Viability
0,617
ICR+Viability
0,802
Test
AUC
QRS
0,433
LBBB
0,619
Intra
0,466
Inter
0,612
SPWMD
0,645
Strain (TmaxCS)
0,754
ApR
0,715 SF
0,614
ApR/SF
0,726
ICR
0,788
Viability
0,649
ICR+Viability
0,81

28. Predictive ability of dyssynchrony in those with both ICR & Viability
Absence of either ICR and IL wall viability had a negative predictive value of 94,4%
If these patients are excluded from the analysis, the performance of dyssynchrony parameters is enhanced
Test
AUC
QRS
0,669
LBBB
0,645
Intra
0,454
Inter
0,664
SPWMD
0,855
Strain (TmaxCS)
0,916
AR/SF
0,874

29. Discussion Results, in general, consistent with the literature
Selected indices are widely used and easily implemented
We compared the predictive value of LD-DSE in identifying CRT responders with that of multiple commonly used echo modalities and indices
Our study also addresses the issue of late response to CRT

30. Limitations Number of patients Rather low percentage of responders
Strain in one axis

31. Conclusion
LD-DSE and dyssynchrony parameters outperformed ECG criteria for CRT patient selection.
A stepwise approach with an initial assessment of ICR and viability in CRT candidates and further dyssynchrony analysis, in those with both ICR>20% and viable IL wall, could help decision making for possible CRT in equivocal cases.
TmaxCS, SPWMD, ApR and SF, are simple and reliable predictors of CRT response.

32. ΕΥΧΑΡΙΣΤΩ ΓΙΑ ΤΗΝ ΠΡΟΣΟΧΗ ΣΑΣ!