Apical - PowerPoint Presentation

Slide1

Apical Rocking and cardiomyopathySlide2

Current

attempts

of

improving

patient

selection

in

cardiac

resynchronization

therapy

(CRT) are

mainly

based

on

echocardiographic

timing of

myocardial

velocity

peaks

.

Regional

myocardial

function

is

neglected

. Apical transverse

motion (ATM)

is

a new

parameter

to

quantify

apical

rocking

as an

integrative

surrogate

of

both

temporal and

functional

inhomogeneities

within

the

left

ventricle

. In

this

study

,

we

tested

the

predictive

value of apical

rocking

for

response

to CRT.

Methods

and

results

Sixty-nine

patients

eligible

for CRT

were

assessed

by

echocardiography

before

and 11+5

months

after

pacemaker

implantation.

Response

was

defined

as

left

ventricular

(LV) end-

systolic

volume

decrease

.15%.

Rocking

was

quantified

(ATM) and

visually

assessed

by four

blinded

readers

.

Predictive

value for CRT

response

of

both

assessments

was

compared

with

conventional

dyssynchrony

parameters

. ATM in the four-

chamber

view

plane

differentiated

best

between

responders

and non-

responders

(2.2+1.5 vs. 0.06+1.9 mm, P , 0.0001).

Quantified

ATM

predicted

reverse

remodelling

with

a

sensitivity

,

specificity

, and

accuracy

of 75, 96, and 83%

whereas

visual

rocking

assessment

resulted

in 89, 75, and 83%,

respectively

. The

accuracy

of

conventional

parameters

was

significantly

lower

.

Conclusion Apical

rocking

is

a new marker to

assess

LV

dyssynchrony

and

predict

CRT

response

. It

is

superior

to

conventional

parameters

.

Even

its

simple

visual

assessment

may

be

sufficiently

accurate

in the

clinical

setting.

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Slide3
Slide4

A

cut

-off of 1.5 mm

distinguished

between

responders

and

nonresponders

with

a

sensitivity

,

specificity

, and

accuracy

of 75, 96,

and 83%,

respectively

(Figure 2A).Slide5

Contradicting

reports have been

published

regarding

the relation

between

a

dobutamine-induced

increase

in

either

cardiac

dyssynchrony

or

left-ventricular

ejection

fraction (LVEF) and the

response

to

cardiac

resynchronization

therapy

(CRT).

Using

apical

rocking

(

ApRock

) as

surrogate

dyssynchrony

parameter

,

we

investigated

the

dobutamine

stress

echocardiography

(DSE)-

induced

changes in

left-ventricular

(LV)

dyssynchrony

and LVEF and

their

potential

pathophysiological

interdependence

.

Methods

and

results

Fifty-eight

guideline-

selected

CRT candidates

were

prospectively

enrolled

for

low

-dose DSE.

Dyssynchrony

was

quantified

by the amplitude of

ApRock

. An LVEF

increase

during

stress of .5%

was

regarded

significant

.

Scar

burden

was

assessed

by

magnetic

resonance

imaging

.

Mean

follow

-up

after

CRT implantation

was

41+13

months

for the occurrence

of

cardiac

death

.

ApRock

during

DSE

predicted

CRT

response

(AUC 0.88, 95% CI 0.77–0.99, P , 0.001) and

correlated

inversely

with

changes in EF (r 1/4 20.6, P , 0.001).

Left-ventricular

ejection

fraction changes

duringDSEwere

not

associated

with

CRT

response

(P 1/4 0.082).

Linear

regression

analysis

revealed

an inverse association of LVEF changes

during

DSE

with

both

, total

scar

burden

(B 1/4 22.67, 95CI 23.77 to 21.56, P , 0.001) and the DSE-

induced

change

in

ApRock

amplitude (B 1/4 21.23, 95% CI 21.53 to 20.94, P , 0.001). Kaplan–Meier

analysis

revealed

that

DSEinduced

increase

in

ApRock

, but not LVEF,

was

associated

with

improved

long-

term

survival

.

Conclusion

During

low

-dose DSE in CRT candidates

with

baseline

dyssynchrony

,

myocardial

contractile

reserve

predominantly

results

in more

dyssynchrony

, but

less

in an

increase

in LVEF.

Dyssynchrony

at

baseline

and

its

dobutamine-induced

changes are

predictive

of

both

response

and long-

term

survival

following

CRT.Slide6
Slide7
Slide8
Slide9

1,5 mm !!Slide10
Slide11

Current

imaging

techniques

attempt

to

identify

responders

to

cardiac

resynchronization

therapy

(CRT).

However

,

because

CRT

response

may

depend

upon

several

factors

,

it

may

be

clinically

more

useful

to

identify

patients for

whom

CRT

would

not

be

beneficial

even

under

optimal conditions.

We

aimed

to

determine

the

negative

predictive

value of a composite

echocardiographic

index

evaluating

atrial-

ventricular

dyssynchrony

(AV-DYS) and

intraventricular

dyssynchrony

.

Methods

and

results

Subjects

with

standard indications for CRT

underwent

echo

before

and

during

the

month

following

device

implantation.

AV-DYS

was

defined

as a

percentage

of

left

ventricular

(LV)

filling

time over the

cardiac

cycle. AV-DYS,

which

produces

a

characteristic

rocking

of the LV apex,

was

quantified

as the

percentage

of the

cardiac

cycle over

which

tissue Doppler-

derived

displacement

curves

of the septal and

lateral

walls

showed

discordance. CRT

responder

status

was

determined

based

on the

early

haemodynamic

response

to CRT (intra-

individual

improvement

.25%

in the Doppler-

derived

LV

dP

/

dt

).

Among

40 patients, optimal

cut

-points

predicting

CRT

response

were

31% for LV apical

rocking

and 39% for

AV-DYS. The

presence

of

either

apical

rocking

.31% or AV-DYS ≤39%

had

a

sensitivity

of 95%,

specificity

of

80%, positive

predictive

value of 83%, and a

negative

predictive

value of 94% for CRT

response

.

Conclusion

After

pre-selection

of candidates for CRT by QRS duration, application of a simple composite

echocardiographic

index

may

exclude

patients

who

would

be

non-

responders

to CRT and

thus

improve

the global rate of

therapySlide12

Normal apical

kineticsSlide13

% de temps en opposition

Cutt

of à 31% du RR

%

Avdys

temps diastolique/RR *100Slide14
Slide15

%

Ap

rocking

>31%

% Av

dys

<36%Slide16
Slide17