斑点追踪显像对慢性心力衰竭患者心脏再同步化治疗短期疗效的评价

目的 探讨超声斑点追踪显像(STI)技术对慢性心力衰竭患者心脏再同步化治疗(CRT)短期疗效的评价价值.方法 16例慢性心力衰竭患者,获取心尖长轴观测量各节段收缩期纵向应变达峰时间、径向应变达峰时间,胸骨旁短轴观测环向应变达峰时间,计算CRT术后1个月、术后3个月18节段纵向、径向、环向应变达峰时间标准差(LS-SD18、RS-SD18、CS-SD18),左室各节段收缩期纵向、径向、环向应变达峰时间最大差值(LS-dif、RS-dif、CS-dif)作为应变非同步指标.将术后3个月、1个月18节段纵向、径向、环向应变达峰时间标准差与术前的差值(△LS-SD18、△RS-SD18、ACS-SD18)与术后3个月、1个月左室收缩末容积减少百分比(△ESV%)进行相关性分析.结果 CRT后1个月、术后3个月LS-SD18、RS-SD18、CS-SD18及RS-dif较术前显著减少,差异有统计学意义(P<0.05);术后3个月△RS-SD18与术后3个月△ESV%具有明显的相关性(r=0.694).结论 应变非同步指标对评价短期CRT后机械非同步性具有重要意义.     

三维斑点追踪成像技术预测心脏再同步化治疗短期疗效的研究

目的探讨三维斑点追踪成像（3DT）技术评价左心室收缩同步性,预测心脏再同步化治疗（CRT）短期疗效的临床价值。方法接受CRT治疗的心力衰竭患者18例,于CRT术前及术后1个月用常规超声测量左心室舒张末期容积（LVEDV）、收缩末期容积（LVESV）及射血分数（LVEF）。采用3DT技术分析左心室16节段面积应变达峰时间最大差（A—Max-Ts）和标准差（A—Ts—sD）。将术后LVESV缩小≥15％定义为CRT短期治疗有效。18例患者中,CRT短期治疗有效组11例,CRT短期治疗无效组7例。结果与术前比较,有效组术后LVEDV和LVESV减小,LVEF增高,A—Max—Ts和A-Ts-SD缩短（P〈0．05）;无效组各参数比较差异均无统计学意义。有效组术前A—Max—Ts和A—Ts-SD大于无效组（P〈0．05）,其余参数比较差异均无统计学意义。有效组术后LVEDV和LVESV较无效组减小,LVEF增高,A—Max—Ts和A—Ts-SD缩短（P〈0．05）。A—Ts—SD是预测LVESV≥15％的独立因素,A—Ts-SD为48．2ms时预测CRT短期疗效的敏感性和特异性分别为100％和83．3％。结论CRT短期即可改善左心室收缩同步性。3DT技术能准确评价左心室收缩同步性,预测CRT短期疗效。     

Echo Doppler parameters predict response to cardiac resynchronization therapy

Background  Cardiac resynchronization therapy (CRT) has been shown to reduce heart failure related morbidity and mortality. However, approximately 30% of patients do not respond to CRT. We investigated the usefulness of Echo Doppler parameters to predict reverse remodelling, functional improvement and mortality following CRT.
Materials and methods  Our population consists of 200 consecutive heart failure patients evaluated for ventricular dyssynchrony by echocardiography between February 1999 and May 2007 who subsequently received CRT. Patients were reassessed for signs of reverse remodelling after a mean follow-up of 10 months. Information on vital status was obtained from local registration authorities.
Results  Three parameters significantly predicted reverse remodelling in the logistic regression analysis: the Q-to-E-wave-delay (QED) at a cutoff of 550 ms (odds ratio 4·5, P -value 0·001), the interventricular mechanical delay (IVMD) at a cutoff of 60 ms (odds ratio 2·4, P -value 0·02), and the aortic electromechanical delay (A-EMD) at a cutoff of 140 ms (odds ratio 2·9, P -value 0·004). Furthermore, the QED and the IVMD also predicted all-cause mortality (hazard ratio 0·36, P -value 0·02 and 0·21, P -value 0·004, respectively). Adjustment for confounders did not alter the results.
Conclusions  The QED and IVMD predict reverse remodelling and survival following CRT. These parameters are easy to obtain, provide valuable prognostic information, and should thus be measured in CRT candidates evaluated by echocardiography.     

Prediction of response to cardiac resynchronization therapy using left ventricular pacing lead position and cardiovascular magnetic resonance derived wall motion patterns: a prospective cohort study

Background

Despite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately. Recently, a “U-shaped” (type II) wall motion pattern identified by cardiovascular magnetic resonance (CMR) has been associated with improved CRT response compared to a homogenous (type I) wall motion pattern. There is also evidence that a left ventricular (LV) lead localized to the latest contracting LV site predicts superior response, compared to an LV lead localized remotely from the latest contracting LV site.

Methods

We prospectively evaluated patients undergoing CRT with pre-procedural CMR to determine the presence of type I and type II wall motion patterns and pre-procedural echocardiography to determine end systolic volume (ESV). We assessed the final LV lead position on post-procedural fluoroscopic images to determine whether the lead was positioned concordant to or remote from the latest contracting LV site. CRT response was defined as a ≥ 15 % reduction in ESV on a 6 month follow-up echocardiogram.

Results

The study included 33 patients meeting conventional indications for CRT with a mean New York Heart Association class of 2.8 ± 0.4 and mean LV ejection fraction of 28 ± 9 %. Overall, 55 % of patients were echocardiographic responders by ESV criteria. Patients with both a type II pattern and an LV lead concordant to the latest contracting site (T2CL) had a response rate of 92 %, compared to a response rate of 33 % for those without T2CL (p = 0.003). T2CL was the only independent predictor of response on multivariate analysis (odds ratio 18, 95 % confidence interval 1.6-206; p = 0.018). T2CL resulted in significant incremental improvement in prediction of echocardiographic response (increase in the area under the receiver operator curve from 0.69 to 0.84; p = 0.038).

Conclusions

The presence of a type II wall motion pattern on CMR and a concordant LV lead predicts superior CRT response. Improving patient selection by evaluating wall motion pattern and targeting LV lead placement may ultimately improve the response rate to CRT.     

A prospective evaluation of cardiovascular magnetic resonance measures of dyssynchrony in the prediction of response to cardiac resynchronization therapy

Background

Many patients with electrical dyssynchrony who undergo cardiac resynchronization therapy (CRT) do not obtain substantial benefit. Assessing mechanical dyssynchrony may improve patient selection. Results from studies using echocardiographic imaging to measure dyssynchrony have ultimately proved disappointing. We sought to evaluate cardiac motion in patients with heart failure and electrical dyssynchrony using cardiovascular magnetic resonance (CMR). We developed a framework for comparing measures of myocardial mechanics and evaluated how well they predicted response to CRT.

Methods

CMR was performed at 1.5 Tesla prior to CRT. Steady-state free precession (SSFP) cine images and complementary modulation of magnetization (CSPAMM) tagged cine images were acquired. Images were processed using a novel framework to extract regional ventricular volume-change, thickening and deformation fields (strain). A systolic dyssynchrony index (SDI) for all parameters within a 16-segment model of the ventricle was computed with high SDI denoting more dyssynchrony. Once identified, the optimal measure was applied to a second patient population to determine its utility as a predictor of CRT response compared to current accepted predictors (QRS duration, LBBB morphology and scar burden).

Results

Forty-four patients were recruited in the first phase (91% male, 63.3 ± 14.1 years; 80% NYHA class III) with mean QRSd 154 ± 24 ms. Twenty-one out of 44 (48%) patients showed reverse remodelling (RR) with a decrease in end systolic volume (ESV) ≥ 15% at 6 months. Volume-change SDI was the strongest predictor of RR (PR 5.67; 95% CI 1.95-16.5; P = 0.003). SDI derived from myocardial strain was least predictive. Volume-change SDI was applied as a predictor of RR to a second population of 50 patients (70% male, mean age 68.6 ± 12.2 years, 76% NYHA class III) with mean QRSd 146 ± 21 ms. When compared to QRSd, LBBB morphology and scar burden, volume-change SDI was the only statistically significant predictor of RR in this group.

Conclusion

A systolic dyssynchrony index derived from volume-change is a highly reproducible measurement that can be derived from routinely acquired SSFP cine images and predicts RR following CRT whilst an SDI of regional strain does not.     

斑点追踪显像对慢性心力衰竭患者心脏再同步化治疗短期疗效的评价

Objective To assess the short-term effect of cardiac resynchronization therapy (CRT) by speckle tracking strain imaging(STI). Methods Sixteen chronic heart failure patients(CHF) with CRT were enrolled. The time to peak systolic longitudinal strain and the time to peak systolic radial strain were derived from the LV apical views, and the time to peak systolic circumferential strain was derived from the parasternal short axis. The standard deviation for time to peak longitudinal, radial and circumferential strain in the 18 segments (LS-SD18, RS-SD18, CS-SD18) and the maximal temporal difference of any two segments(LS-dif, RS-dif, CS-dif) were calculated as a strain-derived dyssynchrony index. The difference of LS-SDIS, RS-SD18, CS-SD18 between 1 month,3 months after CRT and baseline (△LS-SD18, △RS-SD18, △CS-SD18) was calculated. The correlation between △LS-SD18,ARS-SD18,△CS-SD18 and the reduction of end-systolic volume at follow-up(△ESV%) were analyzed. Results The LS-SD18, RS-SD18,CS-SD18 and RS-dif were decreased significantly 1 month,3 months after CRT.△RS-SD18 was correlated with △ESV% 3 months after CRT(r = 0. 694). Conclusions The strain-derived dyssynchrony index is great significient for short-term effect of CRT.     

组织多普勒成像技术对心脏再同步化治疗的评价

目的探讨应用组织多普勒成像(TDI)技术评价心脏再同步化治疗(CRT)慢性心力衰竭患者的临床应用价值。方法选择拟行CRT的慢性心力衰竭患者31例,应用TDI测量收缩速度达峰时间判断左室收缩延迟部位,根据左室电极的位置是否与收缩延迟部位相符,将患者分为电极位置和收缩延迟部位符合者20例(A组)和不符合者11例(B组)。应用常规超声心动图及TDI技术观察两组术前及术后1,3,6个月左室收缩功能指标和心脏同步性参数的变化,评价CRT治疗效果。结果所有患者术前TDI技术评估均提示存在左室内收缩不同步,TDI技术能够指导左室电极植入理想靶静脉。术后1,3,6个月,患者的纽约心脏病协会心功能(NYHA)分级、6min步行距离、左室射血分数(LVEF)、左室舒张末期内径(LVEDd)、二尖瓣反流(MR)程度及室间机械延迟(IVMD)、左室12节段达峰时间标准差(Ts-SD)、左室内最晚收缩-最早收缩(Ts max-min)均较术前明显改善,术后6个月各参数改变最明显(P<0.05)。术后6个月,A,B组间NYHA分级、6min步行距离、LVEF、MR程度、IVMD、Tsmax-min及Ts-SD比较,差异均有统计学意义(均P<0.05)。结论 TDI技术可以用于慢性心力衰竭患者接受CRT的筛选,并能指导左室电极植入位置和评价疗效。     

实时三维超声和斑点追踪显像预测心脏再同步化治疗疗效的实验和临床研究

目的 应用实时三维超声心动图(RT-3DE)和斑点追踪显像(STI)评价左心室同步性,以探索检测心脏再同步化治疗(cardiac resynchronization therapy,CRT)疗效的有效方法。方法 动物实验对象为21条比格犬,随机分为A组(CRT组,10条),B组（心衰组,7条）和C组（对照组,4条）三组,临床研究对象为70例完成CRT术前及术后6个月随访的患者。以左室收缩末容积(LVESV)缩小15％为CRT治疗有效。评价同步性的超声参数包括RT-3DE评价左室16节段达最小收缩容积时间的标准差及其与心动周期的比值(Tmsv-16SD,SDI),STI评价犬左室乳头肌水平6节段QRS波起点至径向应变和圆周应变达峰时间的标准差与心动周期的比值(Trs-6SD、Tcs-6SD)。结果 动物实验的Tmsv-16SD、Trs-6SD、Tcs-6SD与左室射血分数(LVEF)呈负相关（r分别为-0.86、-0.75、-0.83,P均＜0.01）,Trs-6SD对CRT疗效最有预测价值,当Trs-6SD≥12.2％时,预测CRT有效的敏感性和特异性分别为83.3％和100％。临床研究显示,SDI最有预测价值,当其临界值为6.55％时,预测CRT有效的敏感性为80.0％,特异性为81.8％。结论 RT-3DE和STI能有效评价左室内不同步,有望成为预测CRT疗效的有效方法。     

常用超声指标不能预测心脏再同步化治疗的疗效

目的 比较和评价常用的M型超声、频谱多普勒和组织多普勒指标在预测心脏再同步化治疗(CRT)疗效中的价值.方法 29例完成随访的CRT患者,评价心脏同步性的常用超声心动图参数包括室间隔与左室后壁间的收缩延迟时间(SPWMD)、肺动脉射血前时间(PPEI)、主动脉射血前时间(APED、速度达峰时间的标准差(Ts-SD)、心室间机械延迟(IVMD).以CRT后6个月,左室收缩末容积较治疗前减小≥10%为治疗有效.结果 CRT的有效率为68.97%.术后CRT无效组的SPWMD、PPEI、APEI和Ts-SD均无显著改变(均P＞0.05),CRT有效组的SPWMD、APEI和Ts-SD显著缩短(P＜0.05或P＜0.001),SPWMD、PPEI、APEI、Ts-SD和IVMD预测CRT疗效的ROC曲线下面积在0.41～0.57之间,且差异均无统计学意义(均P＞0.05).结论 常用的M型超声、频谱多普勒和组织多普勒指标均不能预测CRT疗效,有必要进行实时三维超声和斑点追踪显像等新技术参数预测CRT疗效的研究.     

二维斑点追踪成像技术在心血管疾病中的应用进展

二维斑点追踪成像技术是超声医学领域内的一种新技术,无角度依赖性,能定量评价局部与整体心肌的运动情况,有利于对多种心血管疾病进行诊断、随访和判断预后。本文就其在心血管疾病中的应用进行综述。     

二维超声斑点追踪预测充血性心力衰竭患者心脏再同步化治疗的急性期反应

目的 观察二维超声斑点追踪(2D-STE)是否可预测充血性心力衰竭患者心脏再同步化治疗(CRT)的急性期反应.方法 24例充血性心力衰竭患者接受CRT治疗,术后7天分别在CRT关闭(OFF)和开启(ON)状态接受超声检查.将2D-STE测量的左心室短轴前间壁和后壁达峰值径向应变的时间差(T_(AS-POST))≥130 ms定义为左心室收缩不同步.将CRT-ON时左心室压力最大上升速率(LVdp/dt)的增长率Δdp/dt%>25%定义为急性反应有效.结果 15例患者(62.50%) CRT有反应,CRT-ON时左心室射血分数和LVdp/dt增大,T_(AS-POST) 缩短.T_(AS-POST) 是预测Δdp/dt%>25%的独立因素,T_(AS-POST)≥130 ms预测CRT急性反应的敏感度和特异度分别为86.24%和70.38%.结论 2D-STE技术能够有助于选择CRT最适病例,并预测其急性期反应.     

心肌组织速度成像对心脏再同步化治疗术后短期疗效的评价

目的 应用常规超声心动图和心肌组织速度成像技术对心脏同步化治疗(CRT)的短期疗效进行评价.方法 对18例心衰患者于三腔起搏器置入术前和术后1个月,应用Philips IE33分别测量左心室舒张末、收缩末的直径(LVDD、LVDS)、双平面Simpson's法测量左心室容积和射血分数(LVEF);心肌组织速度成像采集3个标准心尖切面图像,应用Q-lab分析软件测量左室基底部和中部12个节段收缩达峰时间的标准差(Ts-SD-12)及各节段心肌射血期峰值速度(Sm)、左室收缩后收缩(PSS)的峰值速度.结果 心脏同步化治疗后,左室收缩同步性改善,Ts-SD-12减低,从(48.4±17.87) ms下降到(35.16±19.4) ms(P＜0.05),左心室内径、容积缩小,收缩功能也有明显改善(P＜0.05),各节段Sm明显提高(P＜0.01)、PSS的峰值速度减低(P＜0.05).结论 心肌组织速度成像技术是目前评价心肌再同步化治疗的有效手段.     

超声心动图预测心脏再同步化治疗超反应的价值

目的探讨超声心动图预测心脏再同步化治疗(CRT)超反应的价值。方法对78例接受CRT术的慢性心力衰竭患者,分别于术前7天和术后1年行超声检查,测量左心室舒张末径(LVEDD)和射血分数(LVEF)、二尖瓣血流舒张早期(E)和舒张晚期速度(A),计算E/A和二尖瓣反流面积(MRA);以二维斑点追踪技术检测左心室收缩同步性(SI)。将CRT术后LVEF增加<5%定义为无反应组(CRT-NR),LVEF增加≥5%但LVEF<50%为CRT有反应组(CRT-R),LVEF≥50%为CRT超反应组(CRT-SR)。对3组间各参数进行统计学比较。结果术后12例为CRT-SR组(12/78,15.38%),其中扩张型心肌病(DCM)所占比例、左束支传导阻滞(LBBB)所占比例及其SI均大于CRT-NR组(19例,19/78,24.36%),MRA、E/A则小于CRT-NR组。CRT-SR组和CRT-R组(47例,47/78,60.26%)间DCM所占比例、LBBB所占比例、MRA和E/A差异有统计学意义。术前DCM所占比例、LBBB所占比例、MRA和E/A均与CRT超反应相关(r=0.51,0.40,-0.38,-0.32,P均<0.01)。结论CRT术前DCM合并LBBB、MRA较小和非限制型舒张功能减低患者术后更易出现超反应。     

组织同步显像技术在扩张型心肌病心脏同步化治疗的临床应用

目的 探讨常规超声心动图及组织同步显像（TSI）技术在扩张型心肌病心脏同步化治疗（CRT）前、后的临床应用价值.方法 53例CRT治疗的扩张型心肌病患者,于CRT术前3d、术后1周、3个月和6个月在超声心动图指导下进行个体化参数程控,观察CRT前后不同起搏参数时各指标变化.结果 CRT治疗后左心室发生逆重构,其中术后3个月及6个月左心室舒张末期内径、左心室舒张末期容积明显小于术前（P＜0.01,P＜0.05）,左心室舒张充盈时间增加,二尖瓣反流量减少,LVEF明显提高（P＜0.01）,重度延迟节段数减少,节段数量由术前的3.1±1.3减少至6个月的1.5±1.4（P ＜0.01）,左心室起搏电极所在节段的达峰时间有的回复到正常范围,收缩峰值速度亦有改善,但仍没有到正常水平,12节段达峰时间标准差（Ts-SD）由术前的（139±33）ms缩短至（110±40）ms,差异有统计学意义（P＜o.01）.结论 常规超声心动图和TSI技术是预测评价CRT疗效的临床应用最简便有效的方法,是参与CRT全程的一种无创、准确的检查手段.     

组织同步显像技术评价心脏同步治疗扩张型心肌病的疗效

目的应用组织同步显像(TSI)技术评价心脏同步治疗扩张型心肌病后的疗效。方法采用TSI技术，在心电图监测下采集7例扩张型心肌病患者的心尖四腔观、心尖二腔观及心尖长轴观的组织速度成像，其中5例扩张型心肌病伴有左束支阻滞患者在心脏同步治疗1d后再采集心尖四腔观、心尖二腔观及心尖长轴观的组织速度成像。结果3例扩张型心肌病患者在心脏同步治疗后，心室的不同步收缩改善明显，而2例在心脏同步治疗后心室的不同步收缩改善不明显。2例扩张型心肌病患者在心脏同步治疗前作TSI检查，1例因不存在心室不同步收缩，故未进行心脏同步治疗；1例下壁收缩活动延迟，但左室射血分数较高，为42％，故暂时不考虑进行心脏同步治疗。结论TSI在心脏同步治疗扩张型心肌病适应证选择及疗效评价方面有较大的应用价值。     

The incidence and outcomes of delayed response to cardiac resynchronization therapy

1 Background

The incidence and clinical outcomes of delayed response to cardiac resynchronization therapy (CRT) have not been well clarified. We aimed to observe the incidence and prognosis of delayed response and to identify its possible mechanisms.

2 Methods

A total of 115 CRT patients were retrospectively analyzed in our study. Patients who met the enrollment criteria were divided into two groups: group A, conventional responders who showed response at 1‐year follow‐up, and group B, delayed responders who showed response after 1‐year follow‐up. CRT response was defined as an absolute increase of ≥10% in left ventricular ejection fraction.

3 Results

Fifty‐two patients (61 ± 12 years, 37 male) experienced conventional response to CRT and 17 patients (63 ± 11 years, 10 male) experienced delayed response. The mean follow‐up time was 5.2 ± 2.4 years. The incidence of delayed response was 14.8% (17/115). All‐cause mortality and hospitalization rates for heart failure were similar for delayed and conventional responders. Multivariate logistic regression analysis revealed that scar burden > 35% was an independent predictor of CRT delayed response (odds ratio 8.794, P  =  0.038).

4 Conclusions

A significant proportion of patients demonstrated delayed response to CRT. The delayed responders had a good prognosis that was similar to that of conventional responders. More scar burden might be related to the incidence of delayed response.