Skip to main content
SpringerLink
Log in

The Contemporary Role of Echocardiography in Improving Patient Response to Cardiac Resynchronization Therapy

  • Echocardiography (MH Picard, Section Editor)
  • Published:
Current Cardiovascular Imaging Reports Aims and scope Submit manuscript

Abstract

Cardiac resynchronization therapy (CRT) is an important therapy for heart failure patients with widened electrocardiographic QRS complexes and depressed ejection fractions, however, approximately one-third do not respond. This article presents a practical contemporary approach to the utility of echocardiography to improve CRT patient response by assessing mechanical dyssynchrony, optimizing left ventricular lead positioning, and performing appropriate echo-Doppler optimization, along with future potential roles. Specifically, recent long-term outcome data are presented that demonstrates that baseline dyssynchrony is a powerful marker associated with CRT response, in particular for patients with narrower QRS duration or non left bundle branch block morphology. Advances in speckle tracking echocardiography to tailor delivery of CRT by guiding LV lead position is discussed, including data from randomized clinical trials supporting targeting the LV lead toward the site of latest activation. In addition, an update on the current role of Doppler echocardiographic device optimization after CRT implantation is reviewed.

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

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med. 2002;346(24):1845–53.

    Article  PubMed  Google Scholar 

  2. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350(21):2140–50.

    Article  PubMed  CAS  Google Scholar 

  3. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352(15):1539–49.

    Article  PubMed  CAS  Google Scholar 

  4. Dickstein K, Vardas PE, Auricchio A, Daubert JC, Linde C, McMurray J, et al. Focused Update of ESC Guidelines on device therapy in heart failure: an update of the 2008 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure and the 2007 ESC guidelines for cardiac and resynchronization therapy. Developed with the special contribution of the Heart Failure Association and the European Heart Rhythm Association. Eur Heart J. 2010;31(21):2677–87.

    Article  PubMed  Google Scholar 

  5. Stevenson WG, Hernandez AF, Carson PE, Fang JC, Katz SD, Spertus JA, et al. Indications for cardiac resynchronization therapy: 2011 update from the Heart Failure Society of America Guideline Committee. J Card Fail. 2012;18(2):94–106.

    Article  PubMed  Google Scholar 

  6. Bax JJ, Bleeker GB, Marwick TH, Molhoek SG, Boersma E, Steendijk P, et al. Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol. 2004;44(9):1834–40.

    Article  PubMed  Google Scholar 

  7. Birnie DH, Tang AS. The problem of non-response to cardiac resynchronization therapy. Curr Opin Cardiol. 2006;21(1):20–6.

    Article  PubMed  Google Scholar 

  8. Gorcsan 3rd J. Finding pieces of the puzzle of nonresponse to cardiac resynchronization therapy. Circulation. 2011;123(1):10–2.

    Article  PubMed  Google Scholar 

  9. Gorcsan 3rd J, Kanzaki H, Bazaz R, Dohi K, Schwartzman D. Usefulness of echocardiographic tissue synchronization imaging to predict acute response to cardiac resynchronization therapy. Am J Cardiol. 2004;93(9):1178–81.

    Article  PubMed  Google Scholar 

  10. •• Gorcsan 3rd J, Oyenuga O, Habib PJ, Tanaka H, Adelstein EC, Hara H, et al. Relationship of echocardiographic dyssynchrony to long-term survival after cardiac resynchronization therapy. Circulation. 2010;122(19):1910–8. This was the first study to demonstrate the important association of baseline echocardiographic measures of dyssynchrony on long-term survival after cardiac resynchronization therapy.

    Article  PubMed  Google Scholar 

  11. Gorcsan 3rd J, Tanabe M, Bleeker GB, Suffoletto MS, Thomas NC, Saba S, et al. Combined longitudinal and radial dyssynchrony predicts ventricular response after resynchronization therapy. J Am Coll Cardiol. 2007;50(15):1476–83.

    Article  PubMed  Google Scholar 

  12. Sogaard P, Egeblad H, Kim WY, Jensen HK, Pedersen AK, Kristensen BO, et al. Tissue Doppler imaging predicts improved systolic performance and reversed left ventricular remodeling during long-term cardiac resynchronization therapy. J Am Coll Cardiol. 2002;40(4):723–30.

    Article  PubMed  Google Scholar 

  13. Yu CM, Chau E, Sanderson JE, Fan K, Tang MO, Fung WH, 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(4):438–45.

    Article  PubMed  Google Scholar 

  14. Yu CM, Fung WH, Lin H, Zhang Q, Sanderson JE, Lau CP. 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(6):684–8.

    Article  PubMed  Google Scholar 

  15. Chung ES, Leon AR, Tavazzi L, Sun JP, Nihoyannopoulos P, Merlino J, et al. Results of the Predictors of Response to CRT (PROSPECT) trial. Circulation. 2008;117(20):2608–16.

    Article  PubMed  Google Scholar 

  16. Bax JJ, Gorcsan 3rd J. Echocardiography and noninvasive imaging in cardiac resynchronization therapy: results of the PROSPECT (Predictors of Response to Cardiac Resynchronization Therapy) study in perspective. J Am Coll Cardiol. 2009;53(21):1933–43.

    Article  PubMed  Google Scholar 

  17. Yu CM, Bax JJ, Gorcsan 3rd J. Critical appraisal of methods to assess mechanical dyssynchrony. Curr Opin Cardiol. 2009;24(1):18–28.

    Article  PubMed  Google Scholar 

  18. Tanaka H, Nesser HJ, Buck T, Oyenuga O, Janosi RA, Winter S, et al. Dyssynchrony by speckle-tracking echocardiography and response to cardiac resynchronization therapy: results of the Speckle Tracking and Resynchronization (STAR) study. Eur Heart J. 2010;31(14):1690–700.

    Article  PubMed  Google Scholar 

  19. • Delgado V, van Bommel RJ, Bertini M, Borleffs CJ, Marsan NA, Arnold CT, et al. Relative merits of left ventricular dyssynchrony, left ventricular lead position, and myocardial scar to predict long-term survival of ischemic heart failure patients undergoing cardiac resynchronization therapy. Circulation. 2011;123(1):70–8. The first study to demonstrate independent predictive values of baseline echocardiographic dyssynchrony, left ventricular lead placement in scar and concordance of left ventricular lead with site of latest mechanical activation on long term outcome.

    Article  PubMed  Google Scholar 

  20. Sipahi I, Chou JC, Hyden M, Rowland DY, Simon DI, Fang JC. Effect of QRS morphology on clinical event reduction with cardiac resynchronization therapy: meta-analysis of randomized controlled trials. Am Heart J. 2012;163(2):260–7 e3.

    Article  PubMed  Google Scholar 

  21. Moss AJ, Hall WJ, Cannom DS, Klein H, Brown MW, Daubert JP, et al. Cardiac-resynchronization therapy for the prevention of heart-failure events. N Engl J Med. 2009;361(14):1329–38.

    Article  PubMed  Google Scholar 

  22. Zareba W, Klein H, Cygankiewicz I, Hall WJ, McNitt S, Brown M, et al. Effectiveness of Cardiac Resynchronization Therapy by QRS Morphology in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT). Circulation. 2011;123(10):1061–72.

    Article  PubMed  Google Scholar 

  23. • Hara H, Oyenuga OA, Tanaka H, Adelstein EC, Onishi T, McNamara DM et al. The relationship of QRS morphology and mechanical dyssynchrony to long-term outcome following cardiac resynchronization therapy. Eur Heart J. 2012. Epub 2012 Feb 19. This study demonstrated the significant association of speckle tracking radial strain dyssynchrony and interventricular mechanical delay on long term survival in cardiac resynchronization patients with non-left bundle branch morphologies.

  24. Beshai JF, Grimm RA, Nagueh SF, Baker 2nd JH, Beau SL, Greenberg SM, et al. Cardiac-resynchronization therapy in heart failure with narrow QRS complexes. N Engl J Med. 2007;357(24):2461–71.

    Article  PubMed  CAS  Google Scholar 

  25. Holzmeister J, Hurlimann D, Steffel J, Ruschitzka F. Cardiac resynchronization therapy in patients with a narrow QRS. Curr Heart Fail Rep. 2009;6(1):49–56.

    Article  PubMed  Google Scholar 

  26. Ansalone G, Giannantoni P, Ricci R, Trambaiolo P, Fedele F, Santini M. Doppler myocardial imaging to evaluate the effectiveness of pacing sites in patients receiving biventricular pacing. J Am Coll Cardiol. 2002;39(3):489–99.

    Article  PubMed  Google Scholar 

  27. Murphy RT, Sigurdsson G, Mulamalla S, Agler D, Popovic ZB, Starling RC, et al. Tissue synchronization imaging and optimal left ventricular pacing site in cardiac resynchronization therapy. Am J Cardiol. 2006;97(11):1615–21.

    Article  PubMed  Google Scholar 

  28. Suffoletto MS, Dohi K, Cannesson M, Saba S, Gorcsan 3rd J. 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(7):960–8.

    Article  PubMed  Google Scholar 

  29. Ypenburg C, van Bommel RJ, Delgado V, Mollema SA, Bleeker GB, Boersma E, et al. Optimal left ventricular lead position predicts reverse remodeling and survival after cardiac resynchronization therapy. J Am Coll Cardiol. 2008;52(17):1402–9.

    Article  PubMed  Google Scholar 

  30. •• Khan FZ, Virdee MS, Palmer CR, Pugh PJ, O'Halloran D, Elsik M, et al. Targeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization Therapy: The TARGET Study: A Randomized, Controlled Trial. J Am Coll Cardiol. 2012;59(17):1509–18. The first randomized clinical trial to demonstrate the benefit of targeted left ventricular lead placement toward non-scared site of latest activation on primary endpoint of reverse remodeling in cardiac resyncrhonization patients. In addition, improvements were observed in clinical status as secondary enpoints.

    Article  PubMed  Google Scholar 

  31. Saba S, Schwartzman D, Jain S, Adelstein D, Marek J, White P et al. A Prospective Randomized Controlled Study Of Echocardiographic-Guided Lead Placement For Cardiac Resynchronization Therapy: Results Of The STARTER Trial. (Abstract) Heart Rhythm. September 2012 (In press).

  32. Tanaka H, Hara H, Saba S, Gorcsan 3rd J. Usefulness of three-dimensional speckle tracking strain to quantify dyssynchrony and the site of latest mechanical activation. Am J Cardiol. 2010;105(2):235–42.

    Article  PubMed  Google Scholar 

  33. Tanaka H, Tanabe M, Simon MA, Starling RC, Markham D, Thohan V, et al. Left ventricular mechanical dyssynchrony in acute onset cardiomyopathy: association of its resolution with improvements in ventricular function. JACC Cardiovasc Imaging. 2011;4(5):445–56.

    Article  PubMed  Google Scholar 

  34. Bleeker GB, Kaandorp TA, Lamb HJ, Boersma E, Steendijk P, de Roos A, et al. Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy. Circulation. 2006;113(7):969–76.

    Article  PubMed  Google Scholar 

  35. • Leyva F, Foley PW, Chalil S, Ratib K, Smith RE, Prinzen F, et al. Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance. J Cardiovasc Magn Reson. 2011;13:29. A large group of patinets studied by cardiac magnetic resonance imaging utilizing guided left ventricualr lead implanting to avoid scarred regions and observing benefits on long term outcome.

    Article  PubMed  Google Scholar 

  36. Khan FZ, Virdee MS, Read PA, Pugh PJ, O'Halloran D, Fahey M, et al. Effect of low-amplitude two-dimensional radial strain at left ventricular pacing sites on response to cardiac resynchronization therapy. J Am Soc Echocardiogr. 2010;23(11):1168–76.

    Article  PubMed  Google Scholar 

  37. Gorcsan 3rd J, Abraham T, Agler DA, Bax JJ, Derumeaux G, Grimm RA, et al. Echocardiography for cardiac resynchronization therapy: recommendations for performance and reporting–a report from the American Society of Echocardiography Dyssynchrony Writing Group endorsed by the Heart Rhythm Society. J Am Soc Echocardiogr. 2008;21(3):191–213.

    Article  PubMed  Google Scholar 

  38. Ritter P, Padeletti L, Gillio-Meina L, Gaggini G. Determination of the optimal atrioventricular delay in DDD pacing. Comparison between echo and peak endocardial acceleration measurements. Europace. 1999;1(2):126–30.

    Article  PubMed  CAS  Google Scholar 

  39. Kedia N, Ng K, Apperson-Hansen C, Wang C, Tchou P, Wilkoff BL, et al. Usefulness of atrioventricular delay optimization using Doppler assessment of mitral inflow in patients undergoing cardiac resynchronization therapy. Am J Cardiol. 2006;98(6):780–5.

    Article  PubMed  Google Scholar 

  40. Abraham WT, Gras D, Yu CM, Guzzo L, Gupta MS. Rationale and design of a randomized clinical trial to assess the safety and efficacy of frequent optimization of cardiac resynchronization therapy: the Frequent Optimization Study Using the QuickOpt Method (FREEDOM) trial. Am Heart J. 2010;159(6):944–8 e1.

    Article  PubMed  Google Scholar 

  41. • Ellenbogen KA, Gold MR, Meyer TE, Fernndez Lozano I, Mittal S, Waggoner AD, et al. Primary results from the SmartDelay determined AV optimization: a comparison to other AV delay methods used in cardiac resynchronization therapy (SMART-AV) trial: a randomized trial comparing empirical, echocardiography-guided, and algorithmic atrioventricular delay programming in cardiac resynchronization therapy. Circulation. 2010;122(25):2660–8. A randomized clinical trial demonstrating similar results of AV optimization by echocardiography, a device based algorithm, or empiric settings. Subgroup analysis revealed that only females seemed to benefit from device based or echocardiographic optimization.

    Article  PubMed  Google Scholar 

  42. Cheng A, Gold MR, Waggoner AD, Meyer TE, Seth M, Rapkin J, et al. Potential mechanisms underlying the effect of gender on response to cardiac resynchronization therapy: insights from the SMART-AV multicenter trial. Hear Rhythm. 2012;9(5):736–41.

    Article  Google Scholar 

  43. Mullens W, Grimm RA, Verga T, Dresing T, Starling RC, Wilkoff BL, et al. Insights from a cardiac resynchronization optimization clinic as part of a heart failure disease management program. J Am Coll Cardiol. 2009;53(9):765–73.

    Article  PubMed  Google Scholar 

Download references

Disclosure

J. Gorcsan: consultant to Medtronic, Biotronik, and St. Jude Medical; J. J. Marek: none; T. Onishi: none.

Author information

Authors and Affiliations

  1. The University of Pittsburgh, Scaife Hall Room S-564, 200 Lothrop Street, Pittsburgh, PA, 15213-2582, USA

    John Gorcsan III, Josef J. Marek & Tetsuari Onishi

Authors
  1. John Gorcsan III
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Josef J. Marek
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tetsuari Onishi
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to John Gorcsan III.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gorcsan, J., Marek, J.J. & Onishi, T. The Contemporary Role of Echocardiography in Improving Patient Response to Cardiac Resynchronization Therapy. Curr Cardiovasc Imaging Rep 5, 462–472 (2012). https://doi.org/10.1007/s12410-012-9172-2

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12410-012-9172-2

Keywords

Search

Navigation