dyssynchronia€¦ · echo : case selection inter ventricular mechanical delay (a0rtic &...
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DYSSYNCHRONIA
Dr.Azimivaghar
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CVE
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DDD
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CRT
CRT
improve :
heart failure FC
exercise capacity
quality of life
reducing hospitalizations
prolonging survival
reductions in (MR)
improvements in LV function
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OUTCOME
approximately 25% to 35% of patients undergoing CRT do not respond favorably
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CRT
ECHO for CRT
Case selection
optimized device settings
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Echo for CRT
No ideal approach has yet been found.
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CRT
ECG:widened QRS is a suboptimal marker for dyssynchrony
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dyssynchrony
Mechanical dyssynchrony WIDE QRS
But not always
Some patients with heart failure and depressed LV function and narrow QRS
Some wide QRS but no mechanical dyssynchrony
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DYSSYNCHRONIA
A substantial minority of patients have little
or no symptomatic improvement after CRT
and some will deteriorate,
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DYSSYNCHRONIA
although this may reflect the natural
history of the disease rather than the
effect of CRT.
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DYSSYNCHRONIA
link between benefits to symptoms and prognosis may not be strong.
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Echo : case selection
Inter ventricular mechanical delay (a0rtic & pulmonic ejection time difference ≥49.2 ms was an independent predictor of response to CRT.
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DYSSYNCHRONIA
LV dyssynchrony ( intraventricular ) is associated with improved outcomes in patients treated with CRT.
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DYSSYNCHRONIA
(PROSPECT) trial :
echo parameters of cardiac mechanical dyssynchrony showed a modest accuracy to predict response to CRT
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ECHO FINDINGS
LV mechanical dyssynchrony by echo is uncertain and should therefore not be used as a selection criterion for CRT.
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DYSSYNCHRONIA
M-mode & COLOR CODED TDI M-mode
PULSED WAVE TDI
COLOR-CODED TDI
STRAIN BASED TDI
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cardiac dyssynchrony
Atrioventricular
Intraventricular
Interventricular
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Atrioventricular dyssynchrony
1-PRE-EJECTION AORTIC TIME > 140ms
2-FILLING RATIO <40%
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Atrioventricular dyssynchrony
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Atrioventricular dyssynchrony
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INTERVENTRICULAR dyssynchrony
Doppler view :
PRE-EJECTION AORTIC & PULMONIC>>>>>>> TIME DIFFERENCE > 40ms
-------------------------------------------------------
APICAL 4.CH.VIEW :
RV FREE WALL & LATERAL WALL
DYSSYNCHRONIA by :
COLOR CODED/PULSED WAVE TDI
>>>>NO CONSENSUS CUT OFF POINT
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INTERVENTRICULAR dyssynchrony
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Intraventricular dyssynchrony
M.MODE
COLOR-CODED TDI
PULSED waved TDI
STRAIN STUDY
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M.MODE
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COLOR TD M-MODE
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M.MODE
Anteroseptal/posterior wall dyssynchrony : cut-off value of 130ms , with a sensitivity of 100 % and specificity of 63% to predict SUCCESSFULL CRT
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M.MODE
the utility of M-mode in patients with
ischemic cardiomyopathy has not been well
demonstrated
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LONGITUDINAL TD VELOCITY
PULSE WAVE TDI
COLOR CODED TDI
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PULSED TD
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PULSED TD
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Color-coded TDI
Color-coded TD data acquisition is simplerand more practical than pulsed TD and is
the preferred method by consensus of this committee IF:
high frame rates (usually 90 frames/s)
Well image
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EVENT TIMING
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Color-coded TDI
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Color-coded TDI
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Color-coded TDI
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Color-coded TDI
The greatest sensitivity and specificity for predicting response to CRT be attained when analysis is limited to the interval from:
AV opening to closure
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Color-coded TDI
An BASAL opposing wall delay 65 ms
& ALL SEGMENTS wall delay 100 ms
& 12-site SD cut-off value of greater than or
equal to 33 ms
The PROSPECT study reported :
12-site SD had a lower yield and
higher variability than more simple
approaches.
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automated color coding of time-to-peakvelocity data known as (TSI)
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automated color coding of time-to-peakvelocity data known as (TSI)
TSI :TISSUE SYNCHRONIZATION IMAGING
TIME between Q to peak S wave :
<150ms = Nl=GREEN myocardium
150-300ms = mild ABNl =YELLOW myocardium
>300ms = sig. ABNl = RED myocardium
CAUTION IN APICAL SEGMENTS
all of the TSI parameters showed a slight , but consistently lower predictive value than data derived directly from the time-velocity curves
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TISSUE TRACKING
ABSENCE OF DISPLACEMENT = ABSENCE OF COLOR
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TISSUE TRACKING
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Strain and strain rate
Strain and strain rate imaging have the
theoretic advantage of differentiating
active myocardial contraction or deformation from passive movement and have been utilized to identify dyssynchrony
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STRAIN
TD - DERIVED LONGITUDINAL/RADIAL STRAIN
2D ( SPECKLE TACKING ) –DERIVED LONGITUDINAL/RADIAL/CIRCUMFERENTIAL STRAIN
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TD - DERIVED LONGITUDINAL STRAIN
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TD - DERIVED LONGITUDINAL STRAIN
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TD - DERIVED LONGITUDINAL STRAIN
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2D – DERIVED LONGITUDINAL STRAIN
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TD – DERIVED RADIAL STRAIN
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Speckle-tracking images demonstrating synchrony of peak segmental radial strain in healthy individual
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Severe dyssynchrony(radial strain) in patient with heart failure and LBBB
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Strain in LBBB
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strain and strain rate
strain and strain rate measurements are helpful in:
1-Early detection of myocardial dysfunction of different etiologies
2-assessment of myocardial viability
3-detection of acute allograft rejection
4-early detection of patients with CAD
5-selection of different therapies (CRT, coronary revascularization)
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Strain and strain rate
Color-coded TD longitudinal strain can be technically challenging beacause
Doppler angle dependent,
and is difficult in patients with spherical LV geometry, often seen in severe heart failure
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STRAIN & STRAIN RATE
Yu et al : parameters of strain rate imaging are not useful to predict reverse remodeling response.
TD strain rate is restricted by a poor signal-to-noise ratio, which adversely affects reproducibility.
Improvements in strain analysis, including software developments such as strain determined by speckle tracking of routine gray-scale images, are promising as useful markers of systolic dyssynchrony
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Speckle tracking derived 2D-strain
Speckle tracking derived 2D-strain measurements have the advantage of angle independency but are sensitive to image quality
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RADIAL STRAIN
RADIAL or LONGITUDINAL STRAIN BY
SPECKLE TRACKING IS MORE
PREDICTIVE FOR RESPONDERS THAN TDI
It is not mentioned comparison of radial or
longitudinal stain….(especially in speckle tracking)
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radial Strain
Strain has an advantage over M-mode of differentiating active from passive motion and identifying radial mechanical activation
Radial strain was calculated from TD velocity data from the anteroseptum and posterior wall in the mid LV PSAX view
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radial Strain
Disadvantages of TD radial strain included signal noise without adequate image quality and the effect of the Doppler angle of incidence.
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speckle-tracking RADIAL STRAIN
Baseline speckle-tracking radial dyssynchrony (defined as a time difference in peak septal to posterior wall strain 130 milliseconds) predicted a significant increase in LVEF after CRT
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DYSSYNCHRONY
1-TD OVERALLY NOT GOOD(ANGLE DEPENDENT)
2-TD-DERIVED Q ANALYSIS :PASSIVE MOTION 3-TD-DERIVED STRAIN/STRAIN RATE :REJECT
PASSIVE MOTION BUT:SIGNAL TO NOISE IS POOR ESPECIALLY STRAIN RATE
4-STRAIN RATE IS VARIABLE AMONG DIFFERENT MASHINES(ELSE RADIAL STRAIN)
STRAIN BY SPECKLE TRACKING :NOT CUT OFF POINT