Journal of Nuclear Cardiology

, Volume 26, Issue 1, pp 123–132 | Cite as

Effects of cardiac resynchronization therapy on right ventricular function during rest and exercise, as assessed by radionuclide angiography, and on NT-proBNP levels

  • Cinzia ValzaniaEmail author
  • Mauro Biffi
  • Rachele Bonfiglioli
  • Francesco Fallani
  • Cristian Martignani
  • Igor Diemberger
  • Matteo Ziacchi
  • Jessica Frisoni
  • Luciana Tomasi
  • Stefano Fanti
  • Claudio Rapezzi
  • Giuseppe Boriani
Original Article



We carried out this study to investigate mid-term effects of cardiac resynchronization therapy (CRT) on right ventricular (RV) function and neurohormonal response, expressed by N-terminal pro-brain natriuretic peptide (NT-proBNP), in heart failure patients stratified by baseline RV ejection fraction (RVEF).

Methods and Results

Thirty-six patients with nonischemic dilated cardiomyopathy underwent technetium-99m radionuclide angiography with bicycle exercise immediately after CRT implantation (during spontaneous rhythm and after CRT activation) and 3 months later. Plasma NT proBNP was assessed before implantation and after 3 months. At baseline, RVEF was impaired (≤35%) in 14 patients, preserved (>35%) in 22. At 3 months, RVEF improved during rest and exercise (P = .02) in patients with impaired RV function, while remaining unchanged in patients with preserved RV function. Rest and exercise RV dyssynchrony decreased in both groups at follow-up (P < .05). A similar mid-term improvement in left ventricular (LV) function and NT-proBNP was observed in patients with impaired and preserved RVEF. In the former, the decrease in NT-proBNP correlated with the improvements both in LV and RV dyssynchrony and functions.


CRT may improve RV performance, during rest and exercise, and neurohormonal response in heart failure patients with nonischemic dilated cardiomyopathy and baseline RV dysfunction. RV dysfunction should not be considered per se a primary criterion for excluding candidacy to CRT.


Heart failure technetium-99m radionuclide angiography 



Cardiac resynchronization therapy


Left ventricular


Left ventricular ejection fraction


N-terminal pro-brain natriuretic peptide


Right ventricular


Right ventricular ejection fraction



The authors are grateful to Gabriele Cristiani for skilled graphic support.


None to declare.

Supplementary material

12350_2017_971_MOESM1_ESM.pptx (4.3 mb)
Supplementary material 1 (PPTX 4357 kb)


  1. 1.
    Ghio S, Recusani F, Klersy C, Sebastiani R, Laudisa ML, Campana C, et al. Prognostic usefulness of the tricuspid annular plane systolic excursion in patients with congestive heart failure secondary to idiopathic or ischemic dilated cardiomyopathy. Am J Cardiol 2000;85:837-42.Google Scholar
  2. 2.
    Linde C, Ellenbogen K, McAlister FA. Cardiac resynchronization therapy (CRT): Clinical trials, guidelines, and target populations. Heart Rhythm 2012;9:S3-13.Google Scholar
  3. 3.
    Boriani G, Fallani F, Martignani C, Biffi M, Saporito D, Greco C, et al. Cardiac resynchronization therapy: Effects on left and right ventricular ejection fraction during exercise. Pacing Clin Electrophysiol 2005;28:S11-4.Google Scholar
  4. 4.
    Bleeker GB, Schalij MJ, Nihoyannopoulos P, Steendijk P, Molhoek SG, van Erven L, et al. Left ventricular dyssynchrony predicts right ventricular remodeling after cardiac resynchronization therapy. J Am Coll Cardiol 2005;46:2264-9.Google Scholar
  5. 5.
    Rajagopalan N, Suffoletto MS, Tanabe M, Miske G, Thomas NC, Simon MA, et al. Right ventricular function following cardiac resynchronization therapy. Am J Cardiol 2007;100:1434-6.Google Scholar
  6. 6.
    Donal E, Thibault H, Bergerot C, Leroux PY, Cannesson M, Thivolet S, et al. Right ventricular pump function after cardiac resynchronization therapy: A strain imaging study. Arch Cardiovasc Dis 2008;101:475-84.Google Scholar
  7. 7.
    D’Andrea A, Scarafile R, Riegler L, Salerno G, Gravino R, Cocchia R, et al. Right atrial size and deformation in patients with dilated cardiomyopathy undergoing cardiac resynchronization therapy. Eur J Heart Fail 2009;11:1169-77.Google Scholar
  8. 8.
    Burri H, Domenichini G, Sunthorn H, Fleury E, Stettler C, Foulkes I, et al. Right ventricular systolic function and cardiac resynchronization therapy. Europace 2010;12:389-94.Google Scholar
  9. 9.
    Ogunyankin KO, Puthumana JJ. Effect of cardiac resynchronization therapy on right ventricular function. Curr Opin Cardiol 2010;25:464-8.Google Scholar
  10. 10.
    Sharma A, Bax JJ, Vallakati A, Goel S, Lavie CJ, Kassotis J, et al. Meta-analysis of the relation of baseline right ventricular function to response to cardiac resynchronization therapy. Am J Cardiol 2016;117:1315-21.Google Scholar
  11. 11.
    La Gerche A, Burns AT, Mooney DJ, Inder WJ, Taylor AJ, Bogaert J, et al. Exercise-induced right ventricular dysfunction and structural remodelling in endurance athletes. Eur Heart J 2012;33:998-1006.Google Scholar
  12. 12.
    La Gerche A, Roberts T, Claessen G. The response of the pulmonary circulation and right ventricle to exercise: Exercise-induced right ventricular dysfunction and structural remodeling in endurance athletes (2013 Grover conference series). Pulm Circ 2014;4:407-16.Google Scholar
  13. 13.
    La Gerche A, Inder WJ, Roberts TJ, Brosnan MJ, Heidbuchel H, Prior DL. Relationship between inflammatory cytokines and indices of cardiac dysfunction following intense endurance exercise. PLoS ONE 2015;10:e0130031.Google Scholar
  14. 14.
    Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. 2013 ESC guidelines on cardiac pacing and cardiac resynchronization therapy: The task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Europace 2013;15:1070-118.Google Scholar
  15. 15.
    Valzania C, Fallani F, Gavaruzzi G, Biffi M, Martignani C, Diemberger I, et al. Radionuclide angiographic determination of regional left ventricular systolic function during rest and exercise in patients with nonischemic cardiomyopathy treated with cardiac Resynchronization therapy. Am J Cardiol 2010;106:389-94.Google Scholar
  16. 16.
    Domenichini G, Burri H, Valzania C, Gavaruzzi G, Fallani F, Biffi M, et al. QRS pattern and improvement in right and left ventricular function after cardiac resynchronization therapy: A radionuclide study. BMC Cardiovasc Disord 2012;12:27.Google Scholar
  17. 17.
    Fauchier L, Marie O, Casset-Senon D, Babuty D, Cosnay P, Fauchier JP. Interventricular and intraventricular dyssynchrony in idiopathic dilated cardiomyopathy: A prognostic study with fourier phase analysis of radionuclide angioscintigraphy. J Am Coll Cardiol 2002;40:2022-30.Google Scholar
  18. 18.
    Scuteri L, Rordorf R, Marsan NA, Landolina M, Magrini G, Klersy C, et al. Relevance of echocardiographic evaluation of right ventricular function in patients undergoing cardiac resynchronization therapy. Pacing Clin Electrophysiol 2009;32:1040-9.Google Scholar
  19. 19.
    Tabereaux PB, Doppalapudi H, Kay GN, McElderry HT, Plumb VJ, Epstein AE. Limited response to cardiac resynchronization therapy in patients with concomitant right ventricular dysfunction. J Cardiovasc Electrophysiol 2010;21:431-5.Google Scholar
  20. 20.
    Leong DP, Höke U, Delgado V, Auger D, Witkowski T, Thijssen J, et al. Right ventricular function and survival following cardiac resynchronisation therapy. Heart 2013;99:722-8.Google Scholar
  21. 21.
    Damy T, Ghio S, Rigby AS, Hittinger L, Jacobs S, Leyva F, et al. Interplay between right ventricular function and cardiac resynchronization therapy: An analysis of the CARE-HF trial (Cardiac Resynchronization-Heart Failure). J Am Coll Cardiol 2013;61:2153-60.Google Scholar
  22. 22.
    Mariano-Goulart D, Eberlé MC, Boudousq V, Hejazi-Moughari A, Piot C, Caderas de Kerleau C, et al. Major increase in brain natriuretic peptide indicates right ventricular systolic dysfunction in patients with heart failure. Eur J Heart Fail 2003;5:481-8.Google Scholar
  23. 23.
    Murninkas D, Alba AC, Delgado D, McDonald M, Billia F, Chan WS, et al. Right ventricular function and prognosis in stable heart failure patients. J Card Fail 2014;20:343-9.Google Scholar
  24. 24.
    Passino C, Sironi AM, Favilli B, Poletti R, Prontera C, Ripoli A, et al. Right heart overload contributes to cardiac natriuretic hormone elevation in patients with heart failure. Int J Cardiol 2005;104:39-45.Google Scholar
  25. 25.
    Wackers FJ. Equilibrium gated radionuclide angiocardiography: Its invention, rise, and decline and … comeback? J Nucl Cardiol 2016;23:362-5.Google Scholar
  26. 26.
    Normand C, Dickstein K. Predicting outcomes following CRT: The quest continues. Eur J Heart Fail 2015;17:645-6.Google Scholar
  27. 27.
    Herscovici R, Kutyifa V, Barsheshet A, Solomon S, McNitt S, Polonsky B, et al. Early intervention and long-term outcome with cardiac resynchronization therapy in patients without a history of advanced heart failure symptoms. Eur J Heart Fail 2015;17:964-70.Google Scholar

Copyright information

© American Society of Nuclear Cardiology 2017

Authors and Affiliations

  • Cinzia Valzania
    • 1
    Email author
  • Mauro Biffi
    • 1
  • Rachele Bonfiglioli
    • 2
  • Francesco Fallani
    • 1
  • Cristian Martignani
    • 1
  • Igor Diemberger
    • 1
  • Matteo Ziacchi
    • 1
  • Jessica Frisoni
    • 1
  • Luciana Tomasi
    • 1
  • Stefano Fanti
    • 2
  • Claudio Rapezzi
    • 1
  • Giuseppe Boriani
    • 3
  1. 1.Department of Cardiology, S.Orsola Malpighi HospitalUniversity of BolognaBolognaItaly
  2. 2.Department of Nuclear Medicine, S.Orsola Malpighi HospitalUniversity of BolognaBolognaItaly
  3. 3.Division of Cardiology, Modena University HospitalUniversity of Modena and Reggio EmiliaModenaItaly

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