Close Cardiovascular Monitoring during the Early Stages of Treatment for Patients Receiving Immune Checkpoint Inhibitors.

Background: There is an unmet medical need for the early detection of immune checkpoint inhibitor (ICI)-induced cardiovascular (CV) adverse events due to a lack of adequate biomarkers. This study aimed to provide insights on the incidence of troponin elevations and echocardiographic dynamics during ICI treatment in cancer patients and their role as potential biomarkers for submyocardial damage. In addition, it is the first study to compare hs-TnT and hs-TnI in ICI-treated patients and to evaluate their interchangeability in the context of screening. Results: Among 59 patients, the mean patient age was 68 years, and 76% were men. Overall, 25% of patients received combination therapy. Although 10.6% [95% CI: 5.0-22.5] of the patients developed troponin elevations, none experienced a CV event. No significant changes were found in 3D left ventricular (LV) ejection fraction nor in global longitudinal strain f (56 ± 6% vs. 56 ± 6%, p = 0.903 and -17.8% [-18.5; -14.2] vs. -17.0% [-18.8; -15.1], p = 0.663) at 3 months. There were also no significant changes in diastolic function and right ventricular function. In addition, there was poor agreement between hs-TnT and hs-TnI. Methods: Here, we present a preliminary analysis of the first 59 patients included in our ongoing prospective clinical trial (NCT05699915) during the first three months of treatment. All patients underwent electrocardiography and echocardiography along with blood sampling at standardized time intervals. This study aimed to investigate the incidence of elevated hs-TnT levels within the first three months of ICI treatment. Elevations were defined as hs-TnT above the upper limit of normal (ULN) if the baseline value was normal, or 1.5 ≥ times baseline if the baseline value was above the ULN. Conclusions: Hs-TnT elevations occurred in 10.6% of the patients. However, no significant changes were found on 3D echocardiography, nor did any of the patients develop a CV event. There were also no changes found in NT-proBNP. The study is still ongoing, but these preliminary findings do not show a promising role for cardiac troponins nor for echocardiographic dynamics in the prediction of CV events during the early stages of ICI treatment.

How to Conduct Clinical Research in Cardiovascular Imaging: A Primer for Clinical Cardiologists and Researchers. A Statement of the European Association of Cardiovascular Imaging (EACVI) of the ESC.

This statement from the European Association of Cardiovascular Imaging (EACVI) of the ESC aims to address the fundamental principles that guide clinical research in the field of cardiovascular imaging. It provides clinical researchers, cardiology fellows, and Ph.D. students with a condensed, updated, and practical reference document to support them in designing, implementing, and conducting imaging protocols for clinical trials. Although the present article cannot replace formal research training and mentoring, it is recommended reading for any professional interested in becoming acquainted with or participating in clinical trials involving cardiovascular imaging.

Impact of the initial clinical presentation on the outcome of patients with infective endocarditis.

BACKGROUND: Infective endocarditis (IE) is a life-threatening disease. Despite advancements in diagnostic methods, the initial clinical presentation of IE remains a valuable asset. Therefore, the impact of clinical presentation on outcomes and its association with microorganisms and IE localization were assessed herein. METHODS: This retrospective study included 183 patients (age 68.9 ± 14.2 years old, 68.9% men) with definite IE at two tertiary care hospitals in Belgium. Demographic data, medical history, clinical presentation, blood cultures, imaging data and outcomes were recorded. RESULTS: In-hospital mortality rate was 22.4%. Sixty (32.8%) patients developed embolism, 42 (23%) shock, and 103 (56.3%) underwent surgery during hospitalization. Shock at admission predicted embolism during hospitalization (odds ratio [OR] 2.631, 95% confidence interval [CI] 1.119-6.184, p = 0.027). A new cardiac murmur at admission predicted cardiac surgery (OR 1.949, 95% CI 1.007- -3.774, p = 0.048). Methicillin resistant Staphylococcus aureus predicted in-hospital mortality and shock (p = 0.005, OR 6.945, 95% CI 1.774-27.192 and p = 0.015, OR 4.691, 95% CI 1.348-16.322, respectively). Mitral valve and aortic valve IE predicted in-hospital death (p = 0.039, OR 2.258, 95% CI 1.043-4.888) and embolism (p = 0.017, OR 2.328, 95% CI 1.163-4.659), respectively. CONCLUSIONS: In this retrospective study, shock at admission independently predicted embolism during hospitalization in IE patients. Moreover, a new cardiac murmur at admission predicted the need for cardiac surgery. This emphasizes the importance of a comprehensive initial clinical evaluation in combination with imaging and microbiological data, in order to identify high-risk IE patients early.

Extensive CArdioVAscular Characterization and Follow-Up of Patients Receiving Immune Checkpoint Inhibitors: A Prospective Multicenter Study.

BACKGROUND: The increasing use of immune checkpoint inhibitors (ICIs) in the treatment of both advanced and early stages of various malignancies has resulted in a substantial increase in the incidence of cardiovascular (CV) immune-related adverse events (irAEs). The current follow-up guidelines are based on anecdotal evidence and expert opinions, due to a lack of solid data and prospective studies. As many questions remain unanswered, cardiac monitoring, in patients receiving ICIs, is not always implemented by oncologists. Hence, an urgent need to investigate the possible short- and long-term CV effects of ICIs, as ICI approval is continuing to expand to the (neo)adjuvant setting. METHODS: We have initiated a prospective, multicenter study, i.e., the CAVACI trial, in which a minimum of 276 patients with a solid tumor, eligible for ICI treatment, will be enrolled. The study consists of routine investigations of blood parameters (troponin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, in particular) and a thorough CV follow-up (electrocardiograms, transthoracic echocardiograms, and coronary calcium scoring) at fixed time points for a total period of two years. The primary endpoint is the cumulative incidence of troponin elevation in the first three months of ICI treatment, compared to baseline levels. Furthermore, secondary endpoints include incidence above the upper limit of normal of both troponin and NT-proBNP levels, evolution in troponin and NT-proBNP levels, the incidence of CV abnormalities/major adverse cardiac events, evaluation of associations between patient characteristics/biochemical parameters and CV events, transthoracic echocardiography parameters, electrocardiography parameters, and progression of coronary atherosclerosis. Recruitment of patients started in January 2022. Enrolment is ongoing in AZ Maria Middelares, Antwerp University Hospital, AZ Sint-Vincentius Deinze, and AZ Sint-Elisabeth Zottegem. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05699915, registered 26 January 2023.

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.

BACKGROUND: The relative merits of left ventricular (LV) dyssynchrony, LV lead position, and myocardial scar to predict long-term outcome after cardiac resynchronization therapy remain unknown and were evaluated in the present study. METHODS AND RESULTS: In 397 ischemic heart failure patients, 2-dimensional speckle tracking imaging was performed, with comprehensive assessment of LV radial dyssynchrony, identification of the segment with latest mechanical activation, and detection of myocardial scar in the segment where the LV lead was positioned. For LV dyssynchrony, a cutoff value of 130 milliseconds was used. Segments with <16.5% radial strain in the region of the LV pacing lead were considered to have extensive myocardial scar (>50% transmurality, validated in a subgroup with contrast-enhanced magnetic resonance imaging). The LV lead position was derived from chest x-ray. Long-term follow-up included all-cause mortality and hospitalizations for heart failure. Mean baseline LV radial dyssynchrony was 133±98 milliseconds. In 271 patients (68%), the LV lead was placed at the latest activated segment (concordant LV lead position), and the mean value of peak radial strain at the targeted segment was 18.9±12.6%. Larger LV radial dyssynchrony at baseline was an independent predictor of superior long-term survival (hazard ratio, 0.995; P=0.001), whereas a discordant LV lead position (hazard ratio, 2.086; P=0.001) and myocardial scar in the segment targeted by the LV lead (hazard ratio, 2.913; P<0.001) were independent predictors of worse outcome. Addition of these 3 parameters yielded incremental prognostic value over the combination of clinical parameters. CONCLUSIONS: Baseline LV radial dyssynchrony, discordant LV lead position, and myocardial scar in the region of the LV pacing lead were independent determinants of long-term prognosis in ischemic heart failure patients treated with cardiac resynchronization therapy. Larger baseline LV dyssynchrony predicted superior long-term survival, whereas discordant LV lead position and myocardial scar predicted worse outcome.

Cardiac resynchronization therapy in paediatric and congenital heart disease patients.

The number of patients with congenital heart disease (CHD) has significantly increased over the last decades. The CHD population has a high prevalence of heart failure during late follow-up and this is a major cause of mortality. Cardiac resynchronization therapy (CRT) may be a promising therapy to improve the clinical outcome of CHD and paediatric patients with heart failure. However, the CHD and paediatric population is a highly heterogeneous group with different anatomical substrates that may influence the effects of CRT. Echocardiography is the mainstay imaging modality to evaluate CHD and paediatric patients with heart failure and novel echocardiographic tools permit a comprehensive assessment of cardiac dyssynchrony that may help selecting candidates for CRT. This article reviews the role of CRT in the CHD and paediatric population with heart failure. The current inclusion criteria for CRT as well as the outcomes of different anatomical subgroups are evaluated. Finally, echocardiographic assessment of mechanical dyssynchrony in the CHD and paediatric population and its role in predicting response to CRT is comprehensively discussed.

A rare cause of cardiac tamponade.

Cardiac tamponade is a life-threatening condition which must be quickly diagnosed and treated. This medical urgency can have several possible causes. We report the case of a 59-year-old patient presenting with a cardiac tamponade caused by extramedullary haematopoiesis due to myelofibrosis.

Transcatheter aortic valve implantation: role of multi-detector row computed tomography to evaluate prosthesis positioning and deployment in relation to valve function.

AIMS: Aortic regurgitation after transcatheter aortic valve implantation (TAVI) is one of the most frequent complications. However, the underlying mechanisms of this complication remain unclear. The present evaluation studied the anatomic and morphological features of the aortic valve annulus that may predict aortic regurgitation after TAVI. METHODS AND RESULTS: In 53 patients with severe aortic stenosis undergoing TAVI, multi-detector row computed tomography (MDCT) assessment of the aortic valve apparatus was performed. For aortic valve annulus sizing, two orthogonal diameters were measured (coronal and sagittal). In addition, the extent of valve calcifications was quantified. At 1-month follow-up after procedure, MDCT was repeated to evaluate and correlate the prosthesis deployment to the presence of aortic regurgitation. Successful procedure was achieved in 48 (91%) patients. At baseline, MDCT demonstrated an ellipsoid shape of the aortic valve annulus with significantly larger coronal diameter when compared with sagittal diameter (25.1 +/- 2.4 vs. 22.9 +/- 2.0 mm, P < 0.001). At follow-up, MDCT showed a non-circular deployment of the prosthesis in six (14%) patients. Moderate post-procedural aortic regurgitation was observed in five (11%) patients. These patients showed significantly larger aortic valve annulus (27.3 +/- 1.6 vs. 24.8 +/- 2.4 mm, P = 0.007) and more calcified native valves (4174 +/- 1604 vs. 2444 +/- 1237 HU, P = 0.005) at baseline and less favourable deployment of the prosthesis after TAVI. CONCLUSION: Multi-detector row computed tomography enables an accurate sizing of the aortic valve annulus and constitutes a valuable imaging tool to evaluate prosthesis location and deployment after TAVI. In addition, MDCT helps to understand the underlying mechanisms of post-procedural aortic regurgitation.

Time course of global left ventricular strain after acute myocardial infarction.

AIMS: The purpose of the present study was to assess the evolution of left ventricular (LV) function after acute myocardial infarction (AMI) using global longitudinal peak systolic strain (GLPSS) during 1 year follow-up. In addition, patients were divided in groups with early, late, or no improvement of LV function and predictors of recovery of LV function were established. METHODS AND RESULTS: A total of 341 patients with AMI were evaluated. Two-dimensional echocardiography was performed at baseline, 3, 6, and 12 months. At baseline, LV function was assessed with traditional parameters and GLPSS. Global longitudinal peak systolic strain was re-assessed at 3, 6, and 12 months. Improvement of LV function was based on GLPSS and was observed in 72% of the patients. No differences were observed between patients with early and late improvement. The left anterior descending coronary artery as culprit vessel, peak cardiac troponin T level, diastolic function, and baseline GLPSS were identified as independent predictors of recovery of LV function. CONCLUSION: Improvement of LV systolic function occurred in the majority of patients during follow-up. Global longitudinal peak systolic strain, left anterior descending coronary artery as culprit vessel, peak cardiac troponin T level, and diastolic function were independent predictors of recovery of LV function. Quantification of GLPSS may be of important value for the prediction of recovery of LV function in patients after AMI.

Echocardiographic reference ranges for normal left ventricular layer-specific strain: results from the EACVI NORRE study.

AIMS: To obtain the normal range for 2D echocardiographic (2DE) measurements of left ventricular (LV) layer-specific strain from a large group of healthy volunteers of both genders over a wide range of ages. METHODS AND RESULTS: A total of 287 (109 men, mean age: 46 ± 14 years) healthy subjects were enrolled at 22 collaborating institutions of the EACVI Normal Reference Ranges for Echocardiography (NORRE) study. Layer-specific strain was analysed from the apical two-, three-, and four-chamber views using 2DE software. The lowest values of layer-specific strain calculated as ±1.96 standard deviations from the mean were -15.0% in men and -15.6% in women for epicardial strain, -16.8% and -17.7% for mid-myocardial strain, and -18.7% and -19.9% for endocardial strain, respectively. Basal-epicardial and mid-myocardial strain decreased with age in women (epicardial; P = 0.008, mid-myocardial; P = 0.003) and correlated with age (epicardial; r = -0.20, P = 0.007, mid-myocardial; r = -0.21, P = 0.006, endocardial; r = -0.23, P = 0.002), whereas apical-epicardial, mid-myocardial strain increased with the age in women (epicardial; P = 0.006, mid-myocardial; P = 0.03) and correlated with age (epicardial; r = 0.16, P = 0.04). End/Epi ratio at the apex was higher than at the middle and basal levels of LV in men (apex; 1.6 ± 0.2, middle; 1.2 ± 0.1, base 1.1 ± 0.1) and women (apex; 1.6 ± 0.1, middle; 1.1 ± 0.1, base 1.2 ± 0.1). CONCLUSION: The NORRE study provides useful 2DE reference ranges for novel indices of layer-specific strain.

Correlation between non-invasive myocardial work indices and main parameters of systolic and diastolic function: results from the EACVI NORRE study.

AIMS: The present study sought to evaluate the correlation between indices of non-invasive myocardial work (MW) and left ventricle (LV) size, traditional and advanced parameters of LV systolic and diastolic function by 2D echocardiography (2DE). METHODS AND RESULTS: A total of 226 (85 men, mean age: 45 ± 13 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. Global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE) were estimated from LV pressure-strain loops using custom software. Peak LV pressure was estimated non-invasively from brachial artery cuff pressure. LV size, parameters of systolic and diastolic function and ventricular-arterial coupling were measured by echocardiography. As advanced indices of myocardial performance, global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) were obtained. On multivariable analysis, GWI was significantly correlated with GLS (standardized beta-coefficient = -0.23, P < 0.001), ejection fraction (EF) (standardized beta-coefficient = 0.15, P = 0.02), systolic blood pressure (SBP) (standardized beta-coefficient = 0.56, P < 0.001) and GRS (standardized beta-coefficient = 0.19, P = 0.004), while GCW was correlated with GLS (standardized beta-coefficient = -0.55, P < 0.001), SBP (standardized beta-coefficient = 0.71, P < 0.001), GRS (standardized beta-coefficient = 0.11, P = 0.02), and GCS (standardized beta-coefficient = -0.10, P = 0.01). GWE was directly correlated with EF and inversely correlated with Tei index (standardized beta-coefficient = 0.18, P = 0.009 and standardized beta-coefficient = -0.20, P = 0.004, respectively), the opposite occurred for GWW (standardized beta-coefficient =--0.14, P = 0.03 and standardized beta-coefficient = 0.17, P = 0.01, respectively). CONCLUSION: The non-invasive MW indices show a good correlation with traditional 2DE parameters of myocardial systolic function and myocardial strain.

Why, how and when do we need to optimize the setting of cardiac resynchronization therapy?

Current cardiac resynchronization therapy (CRT) devices allow manipulation of the atrioventricular (AV) and interventricular (VV) timings in order to maximize the left ventricular (LV) performance. Multiple echocardiographic and non-echocardiographic methods have been proposed to optimize AV and VV intervals but no consensus has been reached on which methodology should preferably be used. Furthermore, different physiologic conditions, such as rest and exercise, may markedly change LV loading conditions, and therefore an optimal setting determined at rest may be different during exercise. The present article reviews current methodologies to optimize AV and VV interval and discuss why, when and how optimization of these delays may be performed based on current evidence. Moreover, an overview of the results of the multicenter trials on AV and VV intervals optimization is provided.

The role of non-invasive imaging in patient selection.

Cardiac resynchronization therapy (CRT) is an established therapy for patients with advanced heart failure, depressed left ventricular (LV) function and wide QRS complex. A substantial amount of patients do not respond to CRT. Recent studies suggest that assessment of mechanical dyssynchrony may allow identification of potential CRT responders. In addition, presence of scar tissue and venous anatomy may play a role in the selection of candidates. This article summarizes the role of non-invasive cardiac imaging modalities addressing these issues in the selection of CRT candidates.

Echocardiographic reference ranges for normal non-invasive myocardial work indices: results from the EACVI NORRE study.

AIMS: To obtain the normal ranges for 2D echocardiographic (2DE) indices of myocardial work (MW) from a large group of healthy volunteers over a wide range of ages and gender. METHODS AND RESULTS: A total of 226 (85 men, mean age: 45 ± 13 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. Global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE) were estimated from left ventricle (LV) pressure-strain loops. Peak LV systolic pressure was non-invasively derived from brachial artery cuff pressure. The lowest values of MW indices in men and women were 1270 mmHg% and 1310 mmHg% for GWI, 1650 mmHg% and 1544 mmHg% for GCW, and 90% and 91% for GWE, respectively. The highest value for GWW was 238 mmHg% in men and 239 mmHg% in women. Men had significant lower values of GWE and higher values of GWW. GWI and GCW significantly increased with age in women. CONCLUSION: The NORRE study provides useful 2DE reference ranges for novel indices of non-invasive MW.

Left ventricular resynchronization is mandatory for response to cardiac resynchronization therapy: analysis in patients with echocardiographic evidence of left ventricular dyssynchrony at baseline.

BACKGROUND: Recent studies have demonstrated that a positive response to cardiac resynchronization therapy (CRT) is related to the presence of preimplantation left ventricular (LV) dyssynchrony. The time course and the extent of LV resynchronization after CRT implantation and their relationship to response are currently unknown. METHODS AND RESULTS: One hundred consecutive patients scheduled for implantation of a CRT device were prospectively included if they met the following criteria: New York Heart Association class III to IV, LV ejection fraction < or = 35%, QRS duration > 120 ms, and LV dyssynchrony (> or = 65 ms) on color-coded tissue Doppler imaging. Immediately after CRT implantation, LV dyssynchrony was reduced from 114+/-36 to 40+/-33 ms (P<0.001), which persisted at the 6-month follow-up (35+/-31 ms; P<0.001 versus baseline; P=0.14 versus immediately after implantation). At the 6-month follow-up, 85% of patients were classified as responders to CRT (defined as > 10% reduction in LV end-systolic volume). Immediately after implantation, the responders to CRT demonstrated a significant reduction in LV dyssynchrony from 115+/-37 to 32+/-23 ms (P<0.001). The nonresponders, however, did not show a significant reduction in LV dyssynchrony (106+/-29 versus 79+/-44 ms; P=0.08). If the extent of acute LV resynchronization was < 20%, response to CRT at the 6-month follow-up was never observed. Conversely, 93% of patients with LV resynchronization > or = 20% responded to CRT. CONCLUSIONS: LV resynchronization after CRT is an acute phenomenon and predicts response to CRT at 6-month follow-up in patients with echocardiographic evidence of LV dyssynchrony at baseline.

Noninvasive evaluation of coronary sinus anatomy and its relation to the mitral valve annulus: implications for percutaneous mitral annuloplasty.

BACKGROUND: Percutaneous mitral annuloplasty has been proposed as an alternative to surgical annuloplasty. In this respect, evaluation of the coronary sinus (CS) and its relation with the mitral valve annulus (MVA) and the coronary arteries is relevant. The feasibility of evaluating these issues noninvasively with multislice computed tomography was determined. METHODS AND RESULTS: In 105 patients (72 men, age 59+/-11 years), 64-slice multislice computed tomography was performed for noninvasive evaluation of coronary artery disease. Thirty-four patients with heart failure and/or severe mitral regurgitation were included. Three-dimensional reconstructions and standard orthogonal planes were used to assess CS anatomy and its relation with the MVA and circumflex artery. In 71 patients (68%), the circumflex artery coursed between the CS and the MVA with a minimal distance between the CS and the circumflex artery of 1.3+/-1.0 mm. The CS was located along the left atrial wall, rather than along the MVA, in the majority of the patients (ranging from 90% at the level of the MVA to 14% at the level of the distal CS). The minimal distance between the CS and MVA was 5.1+/-2.9 mm. In patients with severe mitral regurgitation, the minimal distance between the CS and the MVA was significantly greater as compared with patients without severe mitral regurgitation (mean 7.3+/-3.9 mm versus 4.8+/-2.5 mm, P<0.05). CONCLUSIONS: In the majority of the patients, the CS courses superiorly to the MVA. In 68% of the patients, the circumflex artery courses between the CS and the mitral annulus. Multislice computed tomography may provide useful information for the selection of potential candidates for percutaneous mitral annuloplasty.

Comparison of left atrial volumes and function by real-time three-dimensional echocardiography in patients having catheter ablation for atrial fibrillation with persistence of sinus rhythm versus recurrent atrial fibrillation three months later.

Real-time 3-dimensional echocardiography (RT3DE) can provide a unique combination of accurate left atrial (LA) volume quantification and rapid, automatic assessment of LA function. The aim of the study was to evaluate the changes in LA volumes and function in patients with atrial fibrillation (AF) undergoing radiofrequency catheter ablation (RFCA) using RT3DE; 57 consecutive patients referred for RFCA were studied. Paroxysmal AF was present in 43 patients (75%) and persistent AF in 14 (25%). After a mean follow-up of 7.9 +/- 2.7 months, patients were divided into 2 groups: successful RFCA (SR group) and recurrence of AF (AF group). RT3DE was performed before, within 3 days, and 3 months after RFCA to assess LA volumes (maximum, minimum, and preA) and LA functions (passive, active, and reservoir). A total of 38 patients (67%) had successful RFCA (SR group). Immediately after RFCA, no significant changes in LA volumes and function were observed. After 3 months, a significant reduction in LA volumes (maximum: 26 +/- 8 to 23 +/- 7 ml/m(2), p <0.01) was noted only in the SR group, with a significant improvement in LA active (22 +/- 8% to 33 +/- 9%, p <0.01) and reservoir functions (116 +/- 45% to 152 +/- 54%, p <0.01). Conversely, the AF group showed a trend towards a deterioration of LA volumes and function. In conclusion, in patients who maintain sinus rhythm after RFCA, a significant reverse remodeling and functional improvement of the left atrium is observed using RT3DE.

Noninvasive imaging of cardiac venous anatomy with 64-slice multi-slice computed tomography and noninvasive assessment of left ventricular dyssynchrony by 3-dimensional tissue synchronization imaging in patients with heart failure scheduled for cardiac resynchronization therapy.

Objectives of this study were to perform a prospective head-to-head comparison between multi-slice computed tomography (MSCT) venography and invasive venography in cardiac resynchronization therapy (CRT) candidates as well as to evaluate the relation between left ventricular (LV) lead position and effect on LV dyssynchrony and immediate response to CRT. Twenty-one consecutive heart failure patients scheduled for CRT implantation were prospectively enrolled to undergo 64-slice MSCT to visualize the venous system, invasive venography during device implantation, and tri-plane tissue synchronization imaging (TSI) before and after implantation. Excellent agreement between MSCT and invasive venography was noted. No significant differences were observed between both techniques regarding vessel diameters. In 12 patients, a match was observed between the area of latest mechanical activation (on TSI) and LV lead position. These patients showed a significant decrease in LV dyssynchrony (43 +/- 7 ms to 11 +/- 9 ms, p <0.0001) with acute reduction in LV end-systolic volume (188 +/- 54 ml to 162 +/- 48 ml, p <0.01) and improvement in LV ejection fraction (22% +/- 9% to 34% +/- 9%, p <0.01). Patients with a mismatch between area of latest activation and LV lead position remained dyssynchronous without improvement in LV function. In conclusion, visualization of major tributaries of the coronary sinus was comparable between invasive venography and MSCT venography. Optimal LV lead positioning in a vein draining the area of latest mechanical activation (determined from tri-plane TSI) resulted in acute improvement of LV dyssynchrony and systolic function after CRT implantation.

Real-time three-dimensional echocardiography permits quantification of left ventricular mechanical dyssynchrony and predicts acute response to cardiac resynchronization therapy.

OBJECTIVE: To evaluate the value of real-time three-dimensional echocardiography (RT3DE) to predict acute response to cardiac resynchronization therapy (CRT). METHODS: Sixty consecutive heart failure patients scheduled for CRT were included. RT3DE was performed before and within 48 hours after pacemaker implantation to calculate both left ventricular (LV) volumes and LV dyssynchrony. LV dyssynchrony was defined as the standard deviation of the time taken to reach the minimum systolic volume for 16 LV segments (referred to as the systolic dyssynchrony index, SDI). Patients were subsequently divided into acute responders or nonresponders, based on a reduction > or = 15% in LV end-systolic volume immediately after CRT. RESULTS: Four patients (7%) were excluded from further analysis because of either suboptimal apical acquisitions or significant translation artifacts. Out of the remaining 56 patients, 35 patients (63%) were classified as acute responders. Baseline characteristics were similar between responders and nonresponders, except for the SDI, which was larger in responders. Moreover, responders demonstrated a significant reduction of SDI immediately after CRT (from 9.7 +/- 4.1% to 3.6 +/- 1.8%, P < 0.0001), whereas SDI did not change in nonresponders (3.4 +/- 1.8% vs 3.1 +/- 1.1%, NS). ROC curve analysis revealed that a cut-off value for SDI of 5.6% yielded a sensitivity of 88% with a specificity of 86% to predict acute echocardiographic response to CRT (AUC 0.96). CONCLUSION: RT3DE is highly predictive for acute response to CRT (sensitivity 88% and specificity 86%). In addition, RT3DE allows assessment of changes in LV volumes and LV ejection fraction before and after CRT implantation.

Magnetic resonance imaging and computed tomography in assessing cardiac veins and scar tissue.

The success of cardiac resynchronization therapy is influenced by several issues including cardiac venous anatomy and myocardial scar tissue. This article discusses non-invasive imaging modalities that could contribute significantly to the selection process of cardiac resynchronization therapy (CRT) candidates: multi-slice computed tomography to depict the coronary sinus tributaries and magnetic resonance imaging to identify scar tissue.