1. Working Group of Heart Failure and Cardiac Function How to evaluate and treat dyssynchrony ? P Lancellotti, LA Piérard, Liège, BE

2. PATIENT’S HISTORY Idiopathic cardiomyopathy - LV Ejection fraction = 21 % - End-diastolic volume = 341 ml - End-systolic volume = 269 ml QRS width = 118 ms NYHA class III  NYHA class II under maximal tolerated treatment Lisinopril 10 mg, Carvedilol 12.5 mg x 2, Spironolactone 25 mg

3. Live from Liège

4. STEPWISE SELECTION 1.Aortic pre-ejection time > 140 ms

5. STEPWISE SELECTION 1.Aortic pre-ejection time > 140 ms 2.Interventricular delay > 40 ms

6. STEPWISE SELECTION 1.Aortic pre-ejection time > 140 ms 2.Interventricular delay > 40 ms 3.Septal-to-posterior delay > 130 ms

7. STEPWISE SELECTION 1.Aortic pre-ejection time > 140 ms 2.Interventricular delay > 40 ms 3.Septal-to-posterior delay > 130 ms 4.LV filling time < 40 % of cardiac cycle

8. STEPWISE SELECTION 1.Aortic pre-ejection time > 140 ms 2.Interventricular delay > 40 ms 3.Septal-to-posterior delay > 130 ms 4.LV filling time < 40 % of cardiac cycle 5.DTI TPS -Septal-to-lateral delay > 60 ms

9. STEPWISE SELECTION 1.Aortic pre-ejection time > 140 ms 2.Interventricular delay > 40 ms 3.Septal-to-posterior delay > 130 ms 4.LV filling time < 40 % of cardiac cycle 5.DTI TPS -Septal-to-lateral delay > 60 ms -LV dispersion (4 segments) > 65 ms

10. STEPWISE SELECTION 1.Aortic pre-ejection time > 140 ms 2.Interventricular delay > 40 ms 3.Septal-to-posterior delay > 130 ms 4.LV filling time < 40 % of cardiac cycle 5.DTI TPS -Septal-to-lateral delay > 60 ms -LV dispersion (4 segments) > 65 ms -Standard deviation (12 segments) > 31 ms

11. STEPWISE SELECTION 1.Aortic pre-ejection time > 140 ms 2.Interventricular delay > 40 ms 3.Septal-to-posterior WM delay > 130 ms 4.LV filling time < 40 % of cardiac cycle 5.DTI Time to Peak Systolic velocity -Septal-to-lateral delay > 60 ms -LV dispersion (4 segments) > 65 ms -Standard deviation (12 segments) > 31 ms -Inter + Intra V delay > 102 ms

12. STEPWISE SELECTION ESC Guidelines ° NYHA III-IV, QRS > 120 ms, EF < 35 %, Optimal treatment Major criteria (high sensitivity and specificity) (At least 1) ° Intraventricular asynchrony - LV dispersion  65 ms (lateral wall latest activated ) - TPS SD 12  31 ms (ischemic disease) ° Inter + Intra V delay > 102 ms Minor criteria (low sensitivity or specificity) (At least 3) ° Septal-to-posterior delay > 130 ms ° Interventricular delay > 40 ms ° Aortic pre-ejection time > 140 ms ° LV filling time < 40 % of cardiac cycle ° Diastolic mitral regurgitation

13. IMPLANTATION : YES or NO ? NYHA class II  Not recommended in the ESC guidelines QRS width < 120 ms  Not recommended in the ESC guidelines « Paradoxical » asynchrony with severe septal delay - Position of the right ventricular lead ? - Position of the left ventricular lead ? Good exercise capacity  Peak VO 2 : 28 ml/kg/min (Weber A)

16. How to assess the effects of CRT ? Working Group of Heart Failure and Cardiac Function

17. 1994-2006 : 12 years of CRT What did we learn ? Permanent LV pacing is feasible and safe CRT improves functional status and quality of life CRT decreases hospitalization rate (inconsistent) CRT reverts LV remodeling CRT improves survival (CARE-HF)

18. Evaluation of CRT Invasive : pressure-volume loops Exercise capacity : 6-min walk test treadmill ex. : peak VO 2 Holter recording : arrhythmias heart rate variability Biology : changes in BNP and neurohormones Functional status and quality of life Imaging techniques : Doppler Echo, MRI

19. Responder : survival +  NYHA class  1 + 10% increase in peak VO 2, 3 to 6 months after CRT) Responder :  NYHA class  1 Responder :  LVESV >15% (>10%) Responder: persistent decrease of NYHA class  1, irrespective of the changes of other parameters. Non responder (20 to 30%) : therapy considered as neutral or not beneficial (no decrease in NYHA class or QOL score ; need for heart transplant; death due to progressive, drug-refractory pump failure). Definition of Responder and Non Responder

20. ECHO in CRT - selection of pts : documentation and quantitation of dyssynergy - guiding the procedure : best position of RV and venous leads - optimizing of AV and VV delays - evaluation of haemodynamic effects : acutely during follow-up

21. Acute Effects ­ Systolic pressure (6 mmHg) ­ Stroke volume (10 to 30%) ­ dP/dt max (15 to 35%) ­ Arterial pulse pressure ¯ End-systolic volume ¯ Functional MR (  ERO and  RV by 30%)

22. Chronic Effects ­ dP/dt max ­ LV ejection fraction ­ Arterial pulse pressure ¯ End-diastolic volume ¯ End-systolic volume : reverse remodeling (  ESV > 15%) ¯ Functional MR (further  10% at rest and ¯ of dynamic component)

23. Lat Sept Lat

25. ECHO and CRT Acute and long-term effects on mechanical resynchronisation diastolic filling time, stroke volume mitral regurgitation (at rest and exercise) LV reverse remodeling changes in systolic and diastolic function