Echocardiographic Predictors of Reverse Remodeling After Cardiac Resynchronization Therapy and Subsequent Events

Abstract

Background-Studies of echocardiographic predictors of response after cardiac resynchronization therapy (CRT) have largely involved single parameters. We hypothesized that combining parameters would be more robust and sought to develop a multiparametric echocardiographic score for predicting CRT response. Methods and Results-Global longitudinal strain of left ventricle was added to standard echocardiographic measurements in 334 consecutive patients (224 men; mean, 65±12 years) who underwent baseline echocardiography before CRT and underwent follow-up echocardiograms at 1 year. Regression analysis was performed to create an echocardiographic score for prediction of LV reverse remodeling (defined as ≥15% reduction in the LV end-systolic volume). Cox proportional hazards models were used to identify the association of the score with death, transplantation or LV assist device implantation, and heart failure hospitalization during 57±22 months of follow-up. LV reverse remodeling (n=161; 48%) was associated with pre-CRT LV end-diastolic dimension index <3.1 cm/m 2 , global longitudinal strain of left ventricle <-7%, left atrial area <26 cm 2 , right ventricular end-diastolic area index <10.0 cm 2 /m 2 , right atrial area <20 cm 2 , and right ventricular fractional area change ≥35%. Combination of these into an echocardiographic score allowed prediction of LV reverse remodeling with a sensitivity of 84% and a specificity of 79%. During follow-up, there were 134 deaths, 18 heart transplantations/LV assist device implantations, and 93 heart failure admissions. The score was associated with heart failure admission, heart transplantation/LV assist device, or death (hazard ratio, 0.97; 95% confidence interval, 0.95-0.98; P<0.001) and all-cause death (hazard ratio, 0.97; 95% confidence interval, 0.96-0.98; P<0.001), independent of age, sex, ischemic cause, and initial functional class. Conclusions-A multiparametric echocardiographic score is helpful in selecting patients likely to undergo reverse remodeling after CRT and predicts clinical outcomes. (Circ Cardiovasc Imaging. 2013;6:864-872.)

Incremental Value of Speckle Tracking Echocardiography to Predict Cardiac Resynchronization Therapy (CRT) Responders

“…As well, the START score may be more useful compared to the MADIT score. The present results were consistent with a study that evaluated the usefulness of a multiparametric echocardiographic score method for CRT responders . In addition, we found that the START score was an independent predictor of clinical outcomes, which supports the finding in previous studies that patients with reverse remodeling have more‐favorable long‐term survival than those without reverse remodeling post‐RT …”

“…Because the main subjects in the MADIT‐CRT study were patients classified as NYHA class I or II, it is unknown whether the MADIT scoring system can be used to make extrapolations in patients classified as NYHA class III or IV . Park et al reported that the echocardiographic score more accurately predicted LV reverse remodeling with CRT, and, compared to the MADIT score, it predicts clinical outcomes in 90% of patients classified as NYHA class III or IV. However, the echocardiographic score of these patients does not even include LBBB, which is the established clinical parameter.…”

Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction

“…115,116 In addition, in patients requiring CRT, an increase in GLS after implantation, in addition to the standard echocardiographic measurements, has been shown to predict responders and all-cause mortality at 1-year follow-up. 117 Although LV dyssynchrony is reported even in patients with HFpEF, 118,119 CRT has not been shown to result in any benefit when LVEF is >35% and, therefore, not recommended in these patients. 57 Instead, some studies have suggested that HFpEF patients often have interatrial dyssynchrony, which may contribute to their symptoms.…”

The Role of Echocardiography in Heart Failure

“…Although several echocardiographic measurements, particularly involving tissue Doppler, have proven difficult outside major centers, the use of myocardial strain to document the site of maximal delay has now been shown in more than one randomized trial to benefit the outcome of cardiac resynchronization therapy (46,47). In addition, echocardiographic assessment of candidates for cardiac resynchronization therapy can predict nonresponse on the basis of nonsynchrony markers, including the severity of ventricular enlargement, RV involvement, and hemodynamic evaluation (48).…”