1. La selezione dei pazienti candidati alla Terapia Resincronizzante Cardiaca M Cristina Porciani Firenze “Incontri Pitagorici di Cardiologia 2010” “Πυθαγόρειοι κάνουμε συναντήσεις καρδιολογίας” VIIIa Edizione

2. It has been well established that CRT is able to improve clinical and hemodinamic parameters in patients with heart failure and LBBB

3. McAlister FA et al, Ann Intern Med. 2004;. CRT reduces HF hospitalizations

4. McAlister FA et al, Ann Intern Med. 2004;. CRT improves quality of life

5. Cleland JGF et al NEJM 2005 CRT reduces mortality

6. CRT reverses LV remodeling t Sutton MG Circulation 2003

7. Reverse remodeling induced by CRT Baseline 3 months 6months CRT

8. 1 Circulation 2002 Biventricular Stimulation in Patients With Medically Refractory Heart Failure NYHA III- IV, Idiopathic or Ischemic Cardiomyopathy, QRS  120 ms, and EF  35% Guidelines of ACC/AHA (2009)

9. RATIONALE OF CRT LBBB discordinate contraction ventricular dysfunction

10. Electrical asinchrony Mechanical asynchrony

11. Lecoq G et al Eur Heart J 2005 Reduction of QRS duration occurs only in responders

12. % Ghio S et al Eur Heart J 2004;25:571-578

13. Echocardiographic Data Before and After Cardiac Resynchronization Therapy Achilli A et al JACC 2003 QRS > 120ms QRS< 120ms

14. Leclerq C et al Circulation 2002 Electrical epicardial activation map of whole heart for 3 pacing modes Mechanical Resynchronization Does Not Require Electrical Synchrony in the Dilated Failing Heart With Left Bundle-Branch Block

15. Leclerq C et al Circulation 2002 Mechanical LV activation map of whole heart for 3 pacing modes Mechanical Resynchronization Does Not Require Electrical Synchrony in the Dilated Failing Heart With Left Bundle-Branch Block

16. it appears that Mechanical rather than electrical synchrony seems most important for functional improvement with CRT

17. Interventricular asynchrony

19. TDI is useful in recording the chronology and the entity of the velocity curves of miocardium segments

20. Ts-SD Cut-off 33ms the Standard Deviation of the 6 basal and the 6 mid LV segmental Ts as systolic asynchrony parameter Ts

21. septal to lateral delay cut-off 60 ms Bax et al. AM J Cardiol 2003;92:1238-40

22. Yu et al. JACC 2005; 45:677-84. TSI (Tissue Synchronization Imaging)

23. No single measure of mechanical dyssynchrony may be recommended to improve pt selection forCRT Methodology to determine mechanical dyssynchrony needs further elaboration QRS remains the selection criterium of dyssynchrony to identify for CRT Circulation 2008 Results of the PROSPECT study

24. From the initial focus on electrical markers, recent interest has shifted toward a more direct assessment of mechanical dyssynchrony by means of tissue Doppler imaging (TDI). From the initial focus on electrical markers, recent interest has shifted toward a more direct assessment of mechanical dyssynchrony by means of tissue Doppler imaging (TDI). from the direct assessment of mechanical dyssynchrony, attention again shifted toward QRS From the initial focus on electrical markers, interest shifted toward a more direct assessment of mechanical dyssynchrony by means of tissue Doppler imaging (TDI).

25. Porciani et al Echocardiography 2010 Electrical asynchrony + - + Mechanical asynchrony - + +

26. Porciani et al Echocardiography 2010

27. Since it is electrical activation that produces myocardial contraction that in turn is necessary for cardiac movement, why would they be any different? The question is

28. ► Problems with measuring electrical ayncrony ► Electromechanical interaction ► Complex nature of electrical and mechanical aynchrony The answer should be

29. Problems with measuring electrical synchrony Xiao Br Heart J 1994 Signal averaged electrocardiography detects potentials too low to appear on the standard 12 lead electrocardiogram

30. Di Donato et al Circulation 2004 Surgical Ventricular Restoration Improves Mechanical Intraventricular Dyssynchrony in Ischemic Cardiomyopathy Narrow QRS

31. Di Donato et al Circulation 2004 Surgical Ventricular Restoration Improves Mechanical Intraventricular Dyssynchrony in Ischemic Cardiomyopathy Narrow QRS

32. Tournoux F. JCE, 2007 Concordance Between Mechanical and Electrical Dyssynchrony in Heart Failure Patients: A Function of the Underlying Cardiomyopathy?

33. What’s about mechanichal dyssynchrony? Henein MY Heart 1999

34. Longitudinal asynchrony (TDI) Radial asynchrony (Speckle-tracking radial strain) Gorcsan J. JACC 2007 Combined Longitudinal and Radial Dyssynchrony Predicts Ventricular Response After Resynchronization Therapy

35. ) Gorcsan J. JACC 2007

36. Porciani et al PACE 2008

37. RV ejectionRV filling LV ejectionLV filling RV ejectionRV filling LV ejection LV filling IVCTIVRT IVCTIVRT Normal LBBB

38. a – b R-R Total isovolumic Time Index

39. Myocardial Performance Index (MPI)

40. Porciani et al J Card Med 2010

43. CONCLUSIONS Which is the best?