P5679Utility of late iodine enhancement computed tomography with image subtraction in the evaluation of cardiac resynchronization therapy response

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
T Pezel ◽  
D Mika ◽  
J P Laissy ◽  
G Moubarak
Keyword(s):  
Computed Tomography ◽  
Cardiac Resynchronization Therapy ◽  
Wall Motion ◽  
Left Ventricular ◽  
Myocardial Scar ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Venous Anatomy ◽  
Image Subtraction ◽  
Late Iodine Enhancement

Abstract Background Despite the impressive results of the large CRT trials, it has been observed that, on an individual basis, about 30% of patients fail to respond to cardiac resynchronization therapy (CRT). The evaluation of left ventricular (LV) dyssynchrony, myocardial scar, and coronary venous anatomy by image subtraction in Late Iodine Enhancement Computed Tomography (LIE-CT) has the potential to comprehensively characterize non-responders. Purpose To assess the feasibility and the utility of image subtraction in LIE-CT in CRT patients and compare findings between responders and non-responders. Methods Monocentric prospective study of CRT patients at least 6 months after implantation who underwent post-procedural CT between March and October 2018. CRT-responders were defined as patients with an absolute increase in LV ejection fraction >5%. CT-derived residual global and segmental dyssynchrony metrics, extent and location of myocardial scar, coronary venous anatomy, and position of LV lead relative to scar and segment of latest mechanical contraction were analyzed. Results Among the 29 patients (mean age 71±12 years; 72% men), 18 were responders (62%). All CT metrics evaluating residual dyssynchrony such as wall motion indexand wall thickness indexwere worse in non-responders (p<0.0001 for both). In LIE-CT, predictive factors of CRT-non-response were an LV lead localized in an region of myocardial scar (p=0.0007), in a region with akinesia or dyskinesia (p=0.007), and with myocardial thickness <6mm (p=0.002). Percentage of fibrosis of the myocardial mass and the presence of fibrosis in postero-lateral region were not predictive of CRT-non-response (p=0.9 and p=0.3, respectively). Of the 11 non-responder patients, 8 (73%) had at least one other coronary venous branch visualized by CT; and among those, 3 (38%) were located in an non-akinetic area with late segmental contraction. Wall Motion and LIE-CT Conclusion Image subtraction in LIE-CT in patients who had CRT is feasible and allows better characterization of CRT-non-responders, who have a greater amount of residual dyssynchrony than responders. Distribution of fibrosis in relation to the LV lead and presence of alternative venous branches may help patient management.

Cardiac resynchronization therapy: selection of candidates

2015 ◽  
pp. 405-419
Author(s):  
Victoria Delgado ◽  
Jeroen J. Bax
Keyword(s):  
Cardiac Resynchronization Therapy ◽  
Left Ventricular ◽  
Myocardial Scar ◽  
Cardiac Resynchronization ◽  
Left Ventricular Ejection ◽  
Resynchronization Therapy ◽  
Venous Anatomy ◽  
Ventricular Ejection Fraction ◽  
Left Ventricular Mechanics ◽  
Selection Of

Cardiac resynchronization therapy (CRT) is an established treatment for heart failure patients who remain symptomatic despite optimal medical treatment, with left ventricular ejection fraction <35% and QRS complex with left bundle branch block morphology or duration ≥150 ms. Non-invasive imaging modalities contribute in the evaluation and selection of patients who are candidates for CRT. Evaluation of left ventricular mechanics and dyssynchrony, extent and location of myocardial scar and cardiac venous anatomy are important to estimate the likelihood of favourable response to CRT. This chapter will review the ‘why and how’ to assess cardiac dyssynchrony, myocardial scar, and cardiac venous anatomy, prior to CRT implantation.

Ventricular arrhythmia risk is associated with myocardial scar but not with response to cardiac resynchronization therapy

EP Europace ◽  
2020 ◽  
Vol 22 (9) ◽  
pp. 1391-1400
Author(s):  
Markus Linhart ◽  
Adelina Doltra ◽  
Juan Acosta ◽  
Roger Borràs ◽  
Beatriz Jáuregui ◽  
...  
Keyword(s):  
Ventricular Arrhythmia ◽  
Cardiac Resynchronization Therapy ◽  
Primary Outcome ◽  
Left Ventricular ◽  
Myocardial Scar ◽  
Cardiac Resynchronization ◽  
Left Ventricular Ejection ◽  
Resynchronization Therapy ◽  
Ischaemic Cardiomyopathy ◽  
Crt Response

Abstract Aims Sudden cardiac death (SCD) risk estimation in patients referred for cardiac resynchronization therapy (CRT) remains a challenge. By CRT-mediated improvement of left ventricular ejection fraction (LVEF), many patients loose indication for primary prevention implantable cardioverter-defibrillator (ICD). Increasing evidence shows the importance of myocardial scar for risk prediction. The aim of this study was to investigate the prognostic impact of myocardial scar depending on the echocardiographic response in patients undergoing CRT. Methods and results Patients with indication for CRT were prospectively enrolled. Decision about ICD or pacemaker implantation was based on clinical criteria. All patients underwent delayed-enhancement cardiac magnetic resonance imaging. Median follow-up duration was 45 (24–75) months. Primary outcome was a composite of sustained ventricular arrhythmia, appropriate ICD therapy, or SCD. A total of 218 patients with LVEF 25.5 ± 6.6% were analysed [158 (73%) male, 64.9 ± 10.7 years]. Myocardial scar was observed in 73 patients with ischaemic cardiomyopathy (ICM) (95% of ICM patients); in 62 with non-ischaemic cardiomyopathy (45% of these patients); and in all but 1 of 36 (17%) patients who reached the primary outcome. Myocardial scar was the only significant predictor of primary outcome [odds ratio 27.7 (3.8–202.7)], independent of echocardiographic CRT response. A total of 55 (25%) patients died from any cause or received heart transplant. For overall survival, only a combination of the absence of myocardial scar with CRT response was associated with favourable outcome. Conclusion Malignant arrhythmic events and SCD depend on the presence of myocardial scar but not on CRT response. All-cause mortality improved only with the combined absence of myocardial scar and CRT response.

scholarly journals Left ventricular wall thickness assessed by cardiac computed tomography and cardiac resynchronization therapy outcomes

EP Europace ◽  
2019 ◽  
Vol 22 (3) ◽  
pp. 401-411 ◽  
Author(s):  
Vincent Galand ◽  
Brian Ghoshhajra ◽  
Jackie Szymonifka ◽  
Saumya Das ◽  
Mary Orencole ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Cardiac Resynchronization Therapy ◽  
Wall Thickness ◽  
Response Rate ◽  
Positive Response ◽  
Cardiac Computed Tomography ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy ◽  
Positive Response Rate

Abstract Aims  Up to 30% of selected heart failure patients do not benefit clinically from cardiac resynchronization therapy (CRT). Left ventricular (LV) wall thickness (WT) analysed using computed tomography (CT) has rarely been evaluated in response to CRT and mitral regurgitation (MR) improvement. We examined the association of LVWT and the ability to reverse LV remodelling and MR improvement after CRT. Methods and results  Fifty-four patients scheduled for CRT underwent pre-procedural CT. Reduced LVWT was defined as WT &lt;6 mm and quantified as a percentage of total LV area. Endpoints were 6-month clinical and echocardiographic response to CRT [New York Heart Association (NYHA) class, LV ejection fraction (LVEF), LV end-diastolic volume (LVEDV), and LV end-systolic volume (LVESV)], MR improvement and 2-year major adverse cardiac events (MACE). Patients were divided into three groups according to the percentage of LVWT &lt;6 mm area: ≤20%, 20–50%, and ≥50%. At 6 months, 75%, 71%, and 42% of the patients experienced NYHA improvement in the ≤20%, 20–50%, and ≥50% group, respectively. Additionally, ≤20% group presented higher LVEF, LVEDV, and LVESV positive response rate (86%, 59%, and 83%, respectively). Both 20–50% and ≥50% groups exhibited a lower LVEF, LVEDV, and LVESV positive response rate (52% and 42%; 47% and 45%; and 53% and 45%, respectively). Additionally, ≥25% of LVWT &lt;6 mm inclusive of at least one papillary muscle insertion was the only predictor of lack of MR improvement. Lastly, ≥50% group experienced significantly lower 2-year MACE survival free probability. Conclusion  WT evaluated using CT could help to stratify the response to CRT and predict MR improvement and outcomes. Clinical trial registration NCT01097733.

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