scholarly journals Imaging predictors of response to cardiac resynchronization therapy: left ventricular work asymmetry by echocardiography and septal viability by cardiac magnetic resonance

2020 ◽  
Vol 41 (39) ◽  
pp. 3813-3823 ◽  
Author(s):  
John M Aalen ◽  
Erwan Donal ◽  
Camilla K Larsen ◽  
Jürgen Duchenne ◽  
Mathieu Lederlin ◽  
...  
Keyword(s):  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Term Survival ◽  
Entire Study ◽  
Systolic Volume ◽  
Crt Response

Abstract Aims  Left ventricular (LV) failure in left bundle branch block is caused by loss of septal function and compensatory hyperfunction of the LV lateral wall (LW) which stimulates adverse remodelling. This study investigates if septal and LW function measured as myocardial work, alone and combined with assessment of septal viability, identifies responders to cardiac resynchronization therapy (CRT). Methods and results  In a prospective multicentre study of 200 CRT recipients, myocardial work was measured by pressure-strain analysis and viability by cardiac magnetic resonance (CMR) imaging (n = 125). CRT response was defined as ≥15% reduction in LV end-systolic volume after 6 months. Before CRT, septal work was markedly lower than LW work (P < 0.0001), and the difference was largest in CRT responders (P < 0.001). Work difference between septum and LW predicted CRT response with area under the curve (AUC) 0.77 (95% CI: 0.70–0.84) and was feasible in 98% of patients. In patients undergoing CMR, combining work difference and septal viability significantly increased AUC to 0.88 (95% CI: 0.81–0.95). This was superior to the predictive power of QRS morphology, QRS duration and the echocardiographic parameters septal flash, apical rocking, and systolic stretch index. Accuracy was similar for the subgroup of patients with QRS 120–150 ms as for the entire study group. Both work difference alone and work difference combined with septal viability predicted long-term survival without heart transplantation with hazard ratio 0.36 (95% CI: 0.18–0.74) and 0.21 (95% CI: 0.072–0.61), respectively. Conclusion Assessment of myocardial work and septal viability identified CRT responders with high accuracy.

scholarly journals 561 Targeting septal work and viability identifies responders to cardiac resynchronization therapy

2020 ◽  
Vol 21 (Supplement_1) ◽  
Author(s):  
J Aalen ◽  
E Donal ◽  
C K Larsen ◽  
J Duchenne ◽  
M Cvijic ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Myocardial Strain ◽  
Lateral Wall ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Lv Function ◽  
Resynchronization Therapy ◽  
Entire Study ◽  
Systolic Volume ◽  
Crt Response

Abstract Funding Acknowledgements The study was supported by Center for Cardiological Innovation. Introduction Septal dysfunction is the dominant mechanism of left ventricular (LV) failure in left bundle branch block (LBBB). We hypothesize that, provided septum is viable, septal function can recover and hence LV function improve after cardiac resynchronization therapy (CRT). Purpose To determine if combined assessment of septal function and viability identifies responders to CRT. Methods In a prospective multicenter study of 200 unselected patients referred for CRT, we measured myocardial strain by speckle-tracking echocardiography and regional work by pressure-strain analysis before and 7 ± 1 months after CRT. Viability was assessed by late gadolinium enhancement cardiac magnetic resonance imaging (n = 123). CRT response was defined as ≥15% reduction in LV end-systolic volume. Results Before CRT, septal work was 258 ± 463 and LV lateral wall work 1469 ± 674 mmHg·% (p < 0.0001). In CRT responders, septal work was restored to 1243 ± 495 mmHg·%, whereas non-responders showed less marked improvement (p < 0.0001). The figure illustrates a typical CRT responder with negative septal work and a large difference between work in the LV lateral wall and septum (panel A). There was no septal scar (panel B) and, after 6 months with CRT, septal work was recovered (panel C). Pressure-strain loops illustrate that CRT converted inefficient septal contractions with substantial negative (wasted) work to positive work throughout systole. For the entire study population, the difference between work in the LV lateral wall and septum predicted CRT response with area under the curve (AUC) 0.75 (95% CI: 0.68-0.83) and was feasible in 98% of patients. Furthermore, septal scar predicted non-response to CRT with AUC 0.76 (95% CI: 0.65-0.86). Combining work difference and septal viability improved AUC for CRT response to 0.85 (95% CI: 0.76-0.94) (figure panel D). The AUC was similar for QRS 120-150 and >150 ms. Conclusions The proposed combined approach with assessment of septal work and viability identified CRT responders with high precision. Abstract 561 Figure.

scholarly journals Non-invasive myocardial workiIndices derived from left ventricular pressure-strain loops in predicting the response to cardiac resynchronization therapy

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M.R Zhu ◽  
X Shu ◽  
H.Y Chen ◽  
Y.N Wang ◽  
Y.F Cheng ◽  
...  
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Left Ventricular Pressure ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Systolic Volume ◽  
Non Invasive ◽  
Work Distribution ◽  
Constructive Work ◽  
Crt Response

Abstract Background Non-invasive left ventricular (LV) pressure-strain loops (PSLs) which generated by combining LV longitudinal strain with brachial artery blood pressure, provide a novel method of quantifying global and segmental myocardial work (MW) indices with potential advantages over conventional echocardiographic strain which is load-dependent. The method has been introduced in echocardiographic software recently, making MW calculations more effectively and rapidly. The aim was to evaluate the role of non-invasive MW indices derived from LV PSLs in the prediction of cardiac resynchronization therapy (CRT) response. Methods 106 heart failure (HF) patients scheduled for CRT were included for MW analysis. Global and segmental (septal and lateral at the mid-ventricular level) MW indices were accessed before CRT. Response to CRT was defined as ≥15% reduction in LV end-systolic volume at 6-month follow-up in comparison with baseline value. Results CRT response was observed in 78 (74%) patients. At baseline, global work index (GWI) and global constructive work (GCW) were significant higher in CRT responders than in non-responders (both P<0.05). Besides, responders exhibited a significantly higher Mid Lateral MW and Mid Lateral constructive work (CW) (both P<0.001) but a significantly lower Mid Septal MW and Mid Septal myocardial work efficiency (MWE), as well as a significantly higher Mid Septal wasted work (WW) than non-responders (all P<0.01). Baseline Mid Septal MWE (OR 0.975, 95% CI 0.959–0.990, P=0.002) and Mid Lateral MW (OR 1.003, 95% CI 1.002–1.004, P<0.001) were identified as independent predictors of CRT response in multivariate regression analysis. Mid Septal MWE ≤42% combined with Mid Lateral MW ≥740 mm Hg% predicted CRT response with the optimal sensitivity of 79% and specificity of 82% (AUC = 0.830, P<0.001). Conclusion Mid Septal MWE and Mid Lateral MW can successfully predict response to CRT, and their combination can further improve the prediction accuracy. Assessment of MW indices before CRT could identify the marked misbalance in LV myocardial work distribution and has the potential to be widely used as a reliable complementary tool for guiding patient selection in clinical practice. Funding Acknowledgement Type of funding source: None

scholarly journals Septal scar predicts non-response to cardiac resynchronization therapy

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
C Kjellstad Larsen ◽  
J Duchenne ◽  
E Galli ◽  
JM Aalen ◽  
J Bogaert ◽  
...  
Keyword(s):  
Ejection Fraction ◽  
Cardiac Resynchronization Therapy ◽  
Characteristic Curve ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Scar Burden ◽  
Systolic Volume ◽  
The Impact ◽  
Crt Response

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): South-Eastern Norway Regional Health Authority Norwegian Health Association Background Scar in the left ventricular (LV) posterolateral wall is associated with poor response to cardiac resynchronization therapy (CRT). The impact of septal scar, however, has been less thoroughly investigated. As recovery of septal function seems to be an important effect of CRT, we hypothesized that CRT response depends on septal viability. Aim The aim of the present study was to investigate the association between septal scar and volumetric response to CRT, and to compare the impact of scar located in septum to scar located in the posterolateral wall. Methods 128 patients with symptomatic heart failure undergoing CRT implantation based on current guidelines (ejection fraction 30 ± 8%, QRS-width 164 ± 17 ms) were included in the study. Volumes and ejection fraction were measured by echocardiography using the biplane Simpson’s method at baseline and six months follow up. Non-response was defined as less than 15% reduction in end-systolic volume. Scar was assessed by late gadolinium enhancement cardiac magnetic resonance, and reported as percentage scar per regional myocardial volume. Numbers are given in [median ;10-90% percentile]. Results Scar was present in 62 patients (48%). Scar burden was equal in septum [0% ;0-34%] and the posterolateral wall [0% ;0-36%], p = 0.10. 31 patients (24%) did not respond to CRT. The non-responders had higher scar burden than the responders in both septum [16% ;0-57% vs 0% ;0-23%, p < 0.001] and the posterolateral wall [6% ;0-74% vs 0% ;0-22%, p < 0.001]. In univariate regression analysis both septal and posterolateral scars correlated with non-response to CRT (r = 0.51 and r = 0.33, respectively). However, combined in a multivariate model only septal scar remained a significant marker of non-response (p < 0.001), while posterolateral scar did not (p = 0.23). Septal scar ≥ 7.1% predicted non-response with a specificity of 81% and a sensitivity of 70% by receiver operating characteristic curve analyses. The area under the curve was 0.79 (95% confidence interval 0.70 – 0.89) (Figure). Conclusions Septal scar is more closely associated with volumetric non-response to CRT than posterolateral scar. Future studies should explore the correlation between regional scar burden and different functional parameters, and how they relate to CRT response. Abstract Figure. Septal scar predicts non-response to CRT

scholarly journals Regional contributions to left ventricular stroke volume determined by cardiac magnetic resonance imaging in cardiac resynchronization therapy

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Björn Östenson ◽  
Ellen Ostenfeld ◽  
Anna Werther-Evaldsson ◽  
Anders Roijer ◽  
Zoltan Bakos ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
Stroke Volume ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Reverse Remodeling ◽  
Resonance Imaging ◽  
Resynchronization Therapy

Abstract Background Cardiac resynchronization therapy (CRT) restores ventricular synchrony and induces left ventricular (LV) reverse remodeling in patients with heart failure (HF) and dyssynchrony. However, 30% of treated patients are non-responders despite all efforts. Cardiac magnetic resonance imaging (CMR) can be used to quantify regional contributions to stroke volume (SV) as potential CRT predictors. The aim of this study was to determine if LV longitudinal (SVlong%), lateral (SVlat%), and septal (SVsept%) contributions to SV differ from healthy controls and investigate if these parameters can predict CRT response. Methods Sixty-five patients (19 women, 67 ± 9 years) with symptomatic HF (LVEF ≤ 35%) and broadened QRS (≥ 120 ms) underwent CMR. SVlong% was calculated as the volume encompassed by the atrioventricular plane displacement (AVPD) from end diastole (ED) to end systole (ES) divided by total SV. SVlat%, and SVsept% were calculated as the volume encompassed by radial contraction from ED to ES. Twenty age- and sex-matched healthy volunteers were used as controls. The regional measures were compared to outcome response defined as ≥ 15% decrease in echocardiographic LV end-systolic volume (LVESV) from pre- to 6-months post CRT (delta, Δ). Results AVPD and SVlong% were lower in patients compared to controls (8.3 ± 3.2 mm vs 15.3 ± 1.6 mm, P < 0.001; and 53 ± 18% vs 64 ± 8%, P < 0.01). SVsept% was lower (0 ± 15% vs 10 ± 4%, P < 0.01) with a higher SVlat% in the patient group (42 ± 16% vs 29 ± 7%, P < 0.01). There were no differences between responders and non-responders in neither SVlong% (P = 0.87), SVlat% (P = 0.09), nor SVsept% (P = 0.65). In patients with septal net motion towards the right ventricle (n = 28) ΔLVESV was − 18 ± 22% and with septal net motion towards the LV (n = 37) ΔLVESV was − 19 ± 23% (P = 0.96). Conclusions Longitudinal function, expressed as AVPD and longitudinal contribution to SV, is decreased in patients with HF scheduled for CRT. A larger lateral contribution to SV compensates for the abnormal septal systolic net movement. However, LV reverse remodeling could not be predicted by these regional contributors to SV.

scholarly journals Using Machine-Learning for Prediction of the Response to Cardiac Resynchronization Therapy: the SMART-AV Study

2020 ◽  
Author(s):  
Stacey Howell ◽  
Tim Stivland ◽  
Kenneth Stein ◽  
Kenneth Ellenbogen ◽  
Larisa Tereshchenko
Keyword(s):  
Machine Learning ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Adaptive Lasso ◽  
Volume Index ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Systolic Volume ◽  
End Systolic Volume ◽  
Crt Response

Introduction—We aimed to apply machine learning (ML) to develop a prediction model for cardiac resynchronization therapy (CRT) response. Methods and Results—Participants from the SmartDelay Determined AV Optimization (SMART-AV) trial (n=741; age, 66 ±11 yrs; 33% female; 100% NYHA III-IV; 100% EF≤35%) were randomly split into training & testing (80%; n=593), and validation (20%; n=148) samples. Baseline clinical, ECG, echocardiographic and biomarker characteristics, and left ventricular (LV) lead position (43 variables) were included in 6 ML models (random forests, convolutional neural network, lasso, adaptive lasso, plugin lasso, elastic net, ridge, and logistic regression). A composite of freedom from death and heart failure hospitalization and a >15% reduction in LV end-systolic volume index at 6-months post-CRT was the endpoint. The primary endpoint was met by 337 patients (45.5%). The adaptive lasso model was more accurate than class I ACC/AHA guidelines criteria (AUC 0.759; 95%CI 0.678-0.840 versus 0.639; 95%CI 0.554-0.722; P<0.0001), well-calibrated, and parsimonious (19 predictors; nearly half are potentially modifiable). The model predicted CRT response with 70% accuracy, 70% sensitivity, and 70% specificity, and should be further validated in prospective studies. Conclusions—ML predicts short-term CRT response and thus may help with CRT procedure planning.

scholarly journals Using Machine-Learning for Prediction of the Response to Cardiac Resynchronization Therapy: the SMART-AV Study

2020 ◽  
Author(s):  
Stacey Howell ◽  
Tim Stivland ◽  
Kenneth Stein ◽  
Kenneth Ellenbogen ◽  
Larisa G Tereshchenko
Keyword(s):  
Machine Learning ◽  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Adaptive Lasso ◽  
Volume Index ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Systolic Volume ◽  
End Systolic Volume ◽  
Crt Response

Background: There is a controversy whether the response of both sexes to cardiac resynchronization therapy (CRT) is similar. Optimal CRT delivery requires procedure planning. Objective: To apply machine learning (ML) to develop a prediction model for CRT response. Methods: Participants from the SmartDelay Determined AV Optimization (SMART-AV) trial (n=741; age, 66 ± 11 yrs; 33% female; 100% NYHA III-IV; 100% EF≤35%) were randomly split into training & testing (80%; n=593), and validation (20%; n=148) samples. The entropy balancing procedure was used to match for the means of 30 covariates in male and female groups. Baseline clinical, ECG, echocardiographic and biomarker characteristics, and left ventricular (LV) lead position (43 variables) were included in 6 ML models (random forests, convolutional neural network, lasso, adaptive lasso, plugin lasso, elastic net, ridge, and logistic regression). A composite of freedom from death and heart failure hospitalization and a >15% reduction in LV end-systolic volume index at 6-months post-CRT was the endpoint. Results: The primary endpoint was met by 337 patients (45.5%). Weighting resulted in a perfect balance of means of covariates in men and women. After reweighting, CRT response for women versus men was similar (OR 1.53; 95%CI 0.88-2.65; P=0.131). The adaptive lasso model was more accurate than class I ACC/AHA guidelines criteria (AUC 0.759; 95%CI 0.678-0.840 versus 0.639; 95%CI 0.554-0.722; P<0.0001), well-calibrated, and parsimonious (19 predictors; nearly half are potentially modifiable). Conclusions: After balancing for covariates, both sexes similarly benefit from CRT. ML predicts short-term CRT response and thus may help with CRT procedure planning.

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