Flash, Rocking on others Added value in DCM and CRT. C. Parsai Polyclinique des Fleurs France

Transcription

1 Flash, Rocking on others Added value in DCM and CRT C. Parsai Polyclinique des Fleurs France

2 Cleland JGF et al. (2007) Nat Clin Pract Cardiovasc Med 4: Predicting CRT Response Device Related Patient Related Events Related Criteria Related Timing Chance

3 12 Segment Model (LBBB) 290 ms 305 ms 220 ms 210 ms 215 ms 240 ms 230 ms 175 ms NS 210 ms 230 ms NS SD = 38 ms

4 Limitations TDI in Dilated Heart Globular shaped, thin-walled LV with excessive cardiac motion in chest Challenging acquisition of TDI and analysis Low velocities (approaching background noise)?several systolic peaks?rocking Heart AVO AVC RV Septum Which peak to use?? Lateral

5 ? Response to CRT 49 y-old DCM Normal coronaries NYHA III, QRS= 150 ms LVEF< 35%, LVEDD:71 mm Responder NO Mechanical Dyssynchrony SD 12 < 32.6 ms Septal- lateral < 60 ms 4 segments DI < 65 ms

6 State of current Dyssynchrony Parameters Current Echo Dyssynchrony Parameters are sub-optimal ( PROSPECT) PROSPECT - Chung, Circulation 117, 2008

7 Normal heart Rocking Hearts? 10 Velocity (m/s) Right Ventricle Velocity (m/s) 5 Septum 5 0 LW + influence RV -5 0 Lateral Wall M. Marciniak et al, Heart 2007 Mid-systolic notch in lateral wall velocity corresponds perfectly to the maximal RV velocity Septal velocity does not show a mid-systolic notch In normal hearts the RV long axis motion influences LV free wall motion

8 Mechanism Underlying Intra-ventricular Dyssynchrony due to LBBB Early activation of the septum Unloaded contraction Fast high velocities Pulls and stretches the opposite latent wall (lateral) Slowed down Late activation of lateral wall (still within isovolumic contraction) Against loosely bound septum Septal Cross-bridges break down inducing early relaxation Lower load to lateral wall Pulling and fast stretching of the septum Original speed Kerckhoffs et al,am J Physiol Heart Circ Physiol 289, 2005

9 Apical Rocking Pre-CRT Post-CRT re-remodelling of LV Good clinical result Only Apex rocks RV and apical lateral velocity perfectly mirrored in systole and early diastole Pre-CRT Basal lateral velocities are not

10 Whole Heart Rocking Pre-CRT Post-CRT little change in rocking Whole heart rocks RV and lateral velocity perfectly mirrored in systole and early diastole Post-CRT Septal velocities are not

11 average midwall circumferential strain RV pacing / LBBB and deformation / metabolism early activated late activated RV pacing/lbbb can induce a mechanical interaction of septum and lateral wall which results in unbalanced contributions to stroke work Oosterhout Circulation. 1998; Time [ms] 200 Kerckhoffs, Am J Physiol 2005 Nowak, J Am Coll Cardiol 41, 2003

12 Intra-ventricular Dyssynchrony: Septal Flash RV Septal Flash Septum Lateral Septum Septal Flash Septum R Wave Septal Flash Inferolateral Inferolateral

13 Radial Data The Septal Flash Radial velocity Radial strain Longitudinal Strain 2D strain DCM / LBBB Strain Rate Radial Displacement

14 Correction of Intra-ventricular Dyssynchrony after CRT Pre-CRT Post-CRT Septal Flash Resolution of Septal Flash

15 ?Rocking to Predict CRT Response TDI derived Apical Transverse Motion distinguishes Normals from LBBB Clockwise Rocking (apex swings laterally) associated with LVRR (mainly DCM patients) Counter-clockwise Rocking ( apex swings towards the septum) Poor Response (mainly IHD patients) Voigt et al, Eur H Journal 2009 Philips et al, JACC Imaging 2009 Visual assessment of Septal-to-Lateral shuffle predicts LV reverse remodelling Specificity 70%, Sensitivity 90% Jansen et al, Am J Cardiol 2007

16 ?Does Rocking Always mean Septal Flash 75 y-old NYHA III, QRS= 140 ms LVEF: 35% Coronary Angiogram: No significant coronary artery disease

17 Sub-endocardial Infarct inducing Rocking AVO AVC Septum Lateral Late Gadolinium Enhancement in Lateral wall Rocking but No Septal Flash

18 ?Does Septal Flash Always mean Rocking Septal Flash only present in the mid / apical septum Impaired RV function

19 Septal Flash - BUT - Long axis velocities synchronous! AVO AVC AVO

20 Conclusions LBBB is responsible for a typical abnormal short-lived Septal motion ( Septal Flash ) This can be easily identified in practice as a marker of Intra-ventricular Dyssynchrony: Grey-Scale M-mode (Colour) Velocities/ Deformation Presence of Septal Flash is highly suggestive of CRT response with LV remodelling if corrected

21 Septal flash can be associated with Rocking Rocking witnesses Unbalanced Contraction of Septal and Lateral wall Marker of Dyssynchrony (mainly in DCM patients) Preserved RV with impaired LV Lateral wall Infarction RV hypertrophy in PHT Conclusions Rocking motion alone is a sensitive tool but lacks specificity to select pre-crt patients Multiple Mechanisms underlie a CRT Response

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23 Septal flash?active Septal contraction or RV-LV interaction SF Present in LBBB Constant during a wide range of trans-septal pressure gradients Tightly coupled to septal electrical activation (occurring at a constant delay (~40ms) after septal activation) Regional Contraction involved in Septal Flash Gjesdal O et al, Circulation, Oct 2008; 118: S_618 - S_619.