Skip to main content
SpringerLink
Log in

Role of echocardiography in selection of patients for biventricular pacing therapy

  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Cardiac resynchronization therapy (CRT) has demonstrated improved quality of life, New York Heart Association class, left ventricular ejection fraction, and survival in patients with moderate to severe heart failure, left ventricular ejection fraction less than or equal to 35%, and a prolonged QRS duration. QRS duration remains the primary surrogate for mechanical dyssynchrony, defining the pathophysiology of abnormal regional mechanical activation. Studies have demonstrated that 30% to 40% of patients who meet current criteria for CRT are nonresponders. Therefore, there is great interest in the relationship between electrical and mechanical dyssynchrony, and the ability of each alone or together to predict response remains unknown. Echocardiographic approaches have emerged to quantify mechanical dyssynchrony with greater specificity than QRS duration alone. Although these methods are complex, exciting, and highly accurate for predicting response to CRT in single-center studies, they lack widespread applicability and validation to replace current criteria for device implantation. Use of echocardiography to define dyssynchrony and the impact of promising imaging methods for future patient selection for CRT are discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Cazeau S, Leclercq C, Lavergne T, et al.; Multisite Simulation in Cardiomyopathies (MUSTIC) Study Investigators: Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med 2001, 344:873–880.

    Article  PubMed  CAS  Google Scholar 

  2. Abraham WT, Fisher WG, Smith AL, et al.; MIRACLE Study Group: Multicenter InSync Randomized Clinical Evaluation. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002, 346:1845–1853.

    Article  PubMed  Google Scholar 

  3. Bristow MR, Saxon LA, Boehmer J, et al.; Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure (COMPANION) Investigators: Cardiac resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004, 350:2140–2150.

    Article  PubMed  CAS  Google Scholar 

  4. Cleland JG, Daubert JC, Erdmann E, et al.; for the Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators: The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005, 352:1539–1549.

    Article  PubMed  CAS  Google Scholar 

  5. Ypenburg C, Van Bommel RJ, Marsan NA, et al.: Effects of interruption of long-term cardiac resynchronization therapy on left ventricular function and dyssynchrony. Am J Cardiol 2008, 102:718–721.

    Article  PubMed  Google Scholar 

  6. Auricchio A, Stellbrink C, Butter C, et al.; Pacing Therapies in Congestive Heart Failure II Study Group, Guidant Heart Failure Research Group: Clinical efficacy of cardiac resynchronization therapy using left ventricular pacing in heart failure patients stratified by severity of ventricular conduction delay. J Am Coll Cardiol 2003, 42:2109–2116.

    Article  PubMed  Google Scholar 

  7. Hawkins NM, Petrie MC, MacDonald MR, et al.: Selecting patients for cardiac resynchronization therapy: electrical or mechanical dyssynchrony? Eur Heart J 2006, 27:1270–1281.

    Article  PubMed  Google Scholar 

  8. Beshai JF, Khunnawat C, Lin AC: Mechanical dyssynchrony from the perspective of a cardiac electrophysiologist. Curr Opin Cardiol 2008, 23:447–451.

    Article  PubMed  Google Scholar 

  9. Achilli A, Sassara M, Ficili S, et al.: Long-term effectiveness of cardiac resynchronization therapy in patients with refractory heart failure and “narrow” QRS. J Am Coll Cardiol 2003, 42:2117–2124.

    Article  PubMed  Google Scholar 

  10. Bleeker GB, Holman ER, Steendijk P, et al.: Cardiac resynchronization therapy in patients with a narrow QRS complex. J Am Coll Cardiol 2006, 48:2243–2250.

    Article  PubMed  Google Scholar 

  11. Yu CM, Chan YS, Zhang Q, et al.: Benefits of cardiac resynchronization therapy for heart failure patients with narrow QRS complexes and coexisting systolic asynchrony by echocardiography. J Am Coll Cardiol 2006, 48:2215–2217.

    Article  Google Scholar 

  12. Beshai JF, Grimm RA, Nagueh SF, et al.; for the RETHINQ Study Investigators: Cardiac resynchronization therapy in heart failure with narrow QRS complexes. N Engl J Med 2007, 357:2461–2471.

    Article  PubMed  CAS  Google Scholar 

  13. Grimm R, Beshai JF, Nagueh S, et al.: The RETHINQ Trial Echocardiographic Sub Study: insights from analysis of TDI data on mechanical dyssynchrony in a randomized clinical trial of cardiac resynchronization therapy in narrow QRS patients with heart failure. Circulation 2008, 118:S868.

    Google Scholar 

  14. Leon AR, Niazi I, Herrman K, et al.: Chronic evaluation of CRT in narrow QRS patients with mechanical dyssynchrony from a multi-center study: ESTEEM-CRT. Heart Rhythm 2008, 5(Suppl 5):S23–S24.

    Google Scholar 

  15. Bax JJ, Bleeker GB, Marwick TH, et al.: Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol 2004, 44:1834–1840.

    Article  PubMed  Google Scholar 

  16. Bader H, Garrique S, Lafitte S, et al.: Intra-left ventricular electromechanical asynchrony. A new independent predictor of severe cardiac events in heart failure patients. J Am Coll Cardiol 2004, 43:248–256.

    Article  PubMed  Google Scholar 

  17. Yu CM, Chau E, Sanderson JE, et al.: Tissue Doppler echocardiographic evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure. Circulation 2002, 105:438–445.

    Article  PubMed  Google Scholar 

  18. Yu CM, Bleeker GB, Fung JW, et al.: Left ventricular reverse remodeling but not clinical improvement predicts long-term survival after cardiac resynchronization therapy. Circulation 2005, 112:1580–1586.

    Article  PubMed  Google Scholar 

  19. Ypenburg C, Van Bommel RJ, Borleffs CJ, et al.: Long term prognosis after cardiac resynchronization therapy is related to the extent of left ventricular reverse remodeling at midterm follow-up. J Am Coll Cardiol 2009, 53:483–490.

    Article  PubMed  Google Scholar 

  20. Bax JJ, Abraham T, Barold SS, et al.: Cardiac resynchronization therapy: part 1-issues before device implantation. J Am Coll Cardiol 2005, 46:2153–2167.

    Article  PubMed  Google Scholar 

  21. Chung ED, Leon AR, Tavazzi L, et al.: Results of the Predictors of Response to CRT (PROSPECT) trial. Circulation 2008, 117:2608–2616.

    Article  PubMed  Google Scholar 

  22. Pitzalis MV, Iacoviello M, Romito R, et al.: Cardiac resynchronization therapy tailored by echocardiographic evaluation of ventricular asynchrony. J Am Coll Cardiol 2002, 40:1615–1622.

    Article  PubMed  Google Scholar 

  23. Pitzalis MV, Iacoviello M, Romito R, et al.: Ventricular asynchrony predicts a better outcome in patients with chronic heart failure receiving cardiac resynchronization therapy. J Am Coll Cardiol 2005, 45:65–69.

    Article  PubMed  Google Scholar 

  24. Marcus G, Rose E, Viloria EM, et al.: Septal to posterior wall motion delay fails to predict reverse remodeling or clinical improvement in patients undergoing cardiac resynchronization therapy. J Am Coll Cardiol 2005, 46:2208–2214.

    Article  PubMed  Google Scholar 

  25. Yu CM, Fung WH, Lin H, et al.: Predictors of left ventricular reverse remodeling after cardiac resynchronization therapy for heart failure secondary to idiopathic dilated or ischemic cardiomyopathy. Am J Cardiol 2003, 91:684–688.

    Article  PubMed  Google Scholar 

  26. Gorscan J 3rd, Kanzaki H, Bazaz R, et al.: Usefulness of echocardiographic tissue synchronization imaging to predict acute response to cardiac resynchronization therapy. Am J Cardiol 2004, 93:1178–1181.

    Article  Google Scholar 

  27. Breinhardt OA, Stellbrink C, Herbots L, et al.: Cardiac resynchronization therapy can reverse abnormal myocardial strain distribution in patients with heart failure and left bundle branch block. J Am Coll Cardiol 2003, 42:486–494.

    Article  Google Scholar 

  28. Dohi K, Suffoletto MS, Schwartzman D, et al.: Utility of echocardiographic radial strain imaging to quantify left ventricular dyssynchrony and predict acute response to cardiac resynchronization therapy. Am J Cardiol 2005, 96:112–116.

    Article  PubMed  Google Scholar 

  29. Nesser HJ, Mor-Avi V, Gorrisen W, et al.: Three-dimensional echocardiographic speckle tracking as a basis for accurate quantification of left ventricular volumes: comparison with MRI. Eur Heart J 2009 (in press).

  30. Gorscan J 3rd: Cardiac resynchronization in 2008: an echo approach. Curr Cardiol Rep 2008, 10:211–217.

    Article  Google Scholar 

  31. Suffoletto MS, Dohi K, Cannesson M, et al.: Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation 2006, 113:960–968.

    Article  PubMed  Google Scholar 

  32. Gorcsan J 3rd, Tanabe M, Bleeker GB, et al.: Combined longitudinal and radial dyssynchrony predicts ventricular response after resynchronization therapy. J Am Coll Cardiol 2007, 50:1476–1483.

    Article  PubMed  Google Scholar 

  33. Sugeng L, Weinert L, Lang RM: Left ventricular assessment using real time three dimensional echocardiography. Heart 2003, 89(Suppl 3):29–36.

    Google Scholar 

  34. Kapetanakis S, Kearney MT, Siva A, et al.: Real-time three dimensional echocardiography: a novel technique to quantify global left ventricular mechanical dyssynchrony. Circulation 2005, 112:992–1000.

    Article  PubMed  CAS  Google Scholar 

  35. Sonne C, Sugeng L, Takeuchi M, et al.: Real-time three dimensional echocardiographic assessment of left ventricular dyssynchrony in normal subjects and in patients with dilated cardiomyopathy: redefinition of abnormality. JACC Cardiovasc Imaging 2009 (in press).

  36. Zhang Q, Yu CM, Fung JW, et al.: Assessment of the effect of cardiac resynchronization therapy on intraventricular mechanical synchronicity by regional volumetric changes. Am J Cardiol 2005, 95:126–129.

    Article  PubMed  Google Scholar 

  37. Takeuchi M, Jacobs A, Sugeng L, et al.: Assessment of left ventricular dyssynchrony with real-time 3-dimensional echocardiography: comparison with Doppler tissue imaging. J Am Soc Echocardiogr 2007, 20:1321–1329.

    Article  PubMed  Google Scholar 

  38. Marsan NA, Henneman MM, Chen J, et al.: Real-time three-dimensional echocardiography as a novel approach to quantify left ventricular dyssynchrony: a comparison study with phase analysis of gated myocardial perfusion single photon emission computed tomography. J Am Soc Echocardiogr 2008, 21:801–807.

    Article  PubMed  Google Scholar 

  39. Bleeker GB, Mollema SA, Holman ER, et al.: Left ventricular resynchronization is mandatory for response to cardiac resynchronization therapy: analysis in patients with echocardiographic evidence of left ventricular dyssynchrony at baseline. Circulation 2007, 116:1440–1448.

    Article  PubMed  Google Scholar 

  40. Ypenburg C, van Bommel RJ, Delgado V, et al.: Optimal left ventricular lead position predicts reverse remodeling and survival after cardiac resynchronization therapy. J Am Coll Cardiol 2008, 52:1402–1409.

    Article  PubMed  Google Scholar 

  41. Marsan NA, Bleeker GB, Ypenburg C, et al.: Real-time threedimensional echocardiography permits quantification of left ventricular mechanical dyssynchrony and predicts acute response to cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2008, 19:392–399.

    Article  PubMed  Google Scholar 

  42. Notomi Y, Lysyansky P, Setser RM, et al.: Measurement of ventricular torsion by two-dimensional ultrasound speckle tracking imaging. J Am Coll Cardiol 2005, 45:2034–2041.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. University of Chicago Medical Center, 5858 South Maryland Avenue, MC 9024, Chicago, IL, 60637, USA

    John F. Beshai

Authors
  1. Richa Agarwal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Roberto M. Lang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John F. Beshai
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to John F. Beshai.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Agarwal, R., Lang, R.M. & Beshai, J.F. Role of echocardiography in selection of patients for biventricular pacing therapy. Curr Cardiol Rep 11, 352–359 (2009). https://doi.org/10.1007/s11886-009-0049-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11886-009-0049-1

Keywords

Search

Navigation