"Hyper-response" evaluated by 3D echocardiography after cardiac resynchronization therapy

Abstracts

A terapia de ressincronização cardíaca consiste em tratamento promissor para pacientes com insuficiência cardíaca grave, porém cerca de 30% dos pacientes não apresentam melhora clínica com este tratamento. Por outro lado, aproximadamente 10% dos pacientes submetidos a essa terapia podem apresentar hiper resposta, e a ecocardiografia tridimensional pode oferecer uma opção interessante para a seleção e avaliação de tratamento desses pacientes.

Ecocardiografia tridimensional; insuficiência cardíaca; terapia de ressincronização cardíaca; remodelamento reverso ventricular esquerdo

La terapia de resincronización cardíaca consiste en un tratamiento promisorio para pacientes con insuficiencia cardíaca grave, sin embargo cerca de un 30% de los pacientes, no presentan una mejoría clínica con ese tratamiento. Por otro lado, aproximadamente un 10% de los pacientes sometidos a esa terapia pueden presentar hiperrespuesta, y la ecocardiografía tridimensional puede ser una opción interesante para la selección y la evaluación del tratamiento de esos pacientes.

Ecocardiografia tridimensional; insuficiência cardíaca; terapia de ressincronização cardíaca; remodelamento reverso ventricular esquerdo

CASE REPORT

^IInstituto do Coração (InCor) da Faculdade de Medicina da Universidade de São Paulo

^IIFleury Medicina e Saúde

^IIIHospital Israelita Albert Einstein, São Paulo, SP - Brazil

Mailing address

VIDEO 1

^{"Hyper-response" evaluated by 3D echocardiography after cardiac resynchronization therapy} (video_(1).wmv)

VIDEO 2

^{"Hyper-response" evaluated by 3D echocardiography after cardiac resynchronization therapy} (video_(2).wmv)

"Hiper-resposta" avaliada pelo eco 3D após terapia de ressincronização cardíaca

"Hyper-response" evaluated by 3D echocardiography after cardiac resynchronization therapy

"Hiperrespuesta" evaluada por el eco 3D después de la terapia de resincronización cardíaca

Viviane Tiemi Hotta; Marcelo Luiz Campos Vieira; Daniela do Carmo Rassi; Silvana Angelina D'orio Nishioka; Martino Martinelli Filho; Wilson Mathias Jr

Arq Bras Cardiol 2011; 96(6)

"Hiper-resposta" avaliada pelo eco 3D após terapia de ressincronização cardíaca

"Hyper-response" evaluated by 3D echocardiography after cardiac resynchronization therapy

"Hiperrespuesta" evaluada por el eco 3D después de la terapia de resincronización cardíaca

Viviane Tiemi Hotta; Marcelo Luiz Campos Vieira; Daniela do Carmo Rassi; Silvana Angelina D'orio Nishioka; Martino Martinelli Filho; Wilson Mathias Jr

Arq Bras Cardiol 2011; 96(6)

ABSTRACT

Cardiac resynchronization therapy consists of a promising treatment for patients with severe heart failure, but about 30% of patients do not exhibit clinical improvement with this procedure. However, approximately 10% of patients undergoing this therapy may have hyperresponsiveness, and three-dimensional echocardiography can provide an interesting option for the selection and evaluation of such patients.

Keywords: Echocardiography, three-dimensional; heart failure; left ventricular reverse remodeling; cardiomyopathy, dilated.

Introduction

Cardiac resynchronization therapy (CRT) has been used to treat patients with severe heart failure (left ventricular ejection fraction < 0.35), intraventricular conduction disturbance (QRS > 120 ms) and NYHA functional class III or IV despite an optimized medical treatment¹. CRT leads to a reduction of ventricular volumes and improvement of the diastolic pattern and left ventricular ejection fraction, reducing mitral regurgitation resulting in clinical and functional improvement. It also reduces mortality^2,3.

Three-dimensional echocardiography (3D Echo) has proven very useful in evaluating left ventricular volumes and ejection fraction (LVEF), and especially in the evaluation of cardiac dyssynchrony^4,5. This is the case of a patient treated with CRT who developed significant improvement of LVEF, reduction of left ventricular volumes and dyssynchrony indexes assessed by 3D echocardiography.

Case report

Female patient, 64 years old, diagnosed with heart failure five years ago has evolved with progressive worsening of symptoms (NYHA functional class III at baseline) despite regular use of optimized medication. She reports a history of hypertension and dyslipidemia under regular treatment. The patient was taking the following drugs: enalapril 20 mg 2x/day, carvedilol 25 mg 2x/day, spironolactone 25 mg/day, furosemide 40 mg/day and digoxin 0.25 mg ½ pill/day.

During the investigation, serology for Chagas (nonreactive) and cineangiocardiography (coronary arteries) were performed. On physical examination, the patient was in regular condition, eupneic at rest, BP 122 x 68 mmHg and HR of 68 bpm. It also found: two-stroke rhythmic sounds with mitral regurgitation murmur, lung auscultation with no abnormalities and edema + / 4 + in the legs.

Electrocardiogram (figure 1A) revealed sinus rhythm, first degree atrioventricular block, left anterior divisional block and left bundle branch block. Transthoracic echocardiogram revealed moderate dilation of the left chambers, severe reduction of LVEF reduced by a significant degree (LVEF estimated at 28% on 3D Echo, movie clip 1) at the expenses of diffuse hypokinesis and significant dyssynchrony assessed by 3D echocardiography (dyssynchrony index: 13.38% in the analysis of 16 segments; VN < 5%) (Figure 2A and 2B).

 

 

The patient received an atriobiventricular pacemaker for CRT, evolving to significant improvement in symptoms and clinical parameters. Six months after CRT, there was improvement in NYHA functional class and quality of life (assessed by the Minnesota Living with Heart Failure Questionnaire), and the electrocardiogram (EKG) of the patient (Figure 1B) revealed reduction of QRS duration in relation to preoperative findings. 3D Echo revealed a significant reduction in left ventricular diastolic and systolic volumes, significant increase in LVEF and improved dyssynchrony indexes (Figure 2C and 2D; movie clip 2).

Discussion

To date, clinical studies regarding the CRT reported rates around 30% of non-responders by assessing NYHA functional class. Considering echocardiographic parameters or imaging methods for assessment of ventricular volumes and LVEF, this rate increases, reaching up to 50%. There has been much discussion about the causes for the "non response" of these patients, but little is said about patients with "hyper-response", i.e., patients who have virtually normalization of LVEF after CRT.

In a recent study to assess the prevalence of hyper-responders after CRT, 13% of patients were found to present standardization (LVEF: 0.55 ± 2SD) in LVEF with CRT. In this study, the only factor associated with hyper-responsive patients was the etiology of cardiomyopathy. All hyper-responsive patients had nonischemic dilated cardiomyopathy. No patient with ischemic cardiomyopathy presented normalization of LVEF⁶.

This case illustrates an uncommon situation after CRT. The patient had significant improvement of LVEF, normalization of ventricular volumes and dyssynchrony indexes on 3D Echo after CRT. Such patient, probably had dilated cardiomyopathy secondary to hypertension, moderate dilation of the left ventricle, as well as preserved right ventricular systolic function and no signs of pulmonary hypertension. These features, besides a major intraventricular conduction disturbance (QRS > 150 ms) and a significant cardiac dyssynchrony evaluated by 3D echocardiography may be associated with this significant response after CRT.

Anyway, in light of current knowledge, the predictors of good response to CRT are still under discussion, and 3D Echo emerged as a promising and useful method to evaluate dyssynchrony in the setting of patients undergoing CRT, as well as an accurate method in assessing ventricular volumes and LVEF.

Potential Conflict of Interest

No potential conflict of interest relevant to this article was reported.

Sources of Funding

There were no external funding sources for this study.

Study Association

This article is part of the thesis of doctoral submitted by Viviane Tiemi Hotta, from Faculdade de Medicina da USP.

References

• 1. American College of Cardiology (ACC), American Heart Association (AHA). Heart faliure: 2009 focused update: ACC/AHA guidelines for the diagnosis and management of heart failure in adults heart failure focused update. J Am Coll Cardiol 2009;53:1343-82.
• 2. Cleland JGF, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, et al. Cardiac resynchronization - heart failure (CARE-HF) study investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352(15):1539-49.
• 3. Kapetanakis A, Kearney MT, Siva A, Gall N, Cooklin M, Monaghan MJ. Real-time three-dimensional echocardiogra¬phy: a novel technique to quantify global left ventricular mechanical dyssynchrony. Circulation. 2005;112(7):992-1000.
• 4. Sonne C, Sugeng L, Takeuchi M, Weinert L, Childers R, Watanabe N, et al. Real-time 3-dimensional echocardiographic assessment of left ventricular dyssynchrony: pitfalls in patients with dilated cardiomyopathy. JACC Cardiovasc Imaging. 2009;2(7):802-12.
• 5. Castellant P, Fatemi M, Bertault-Valls B. Cardiac resynchronization therapy: "nonresponders" and "hyperresponders". Heart Rhytm. 2008;5(2):193-7.

"Hyper-response" evaluated by 3D echocardiography after cardiac resynchronization therapy

Viviane Tiemi Hotta^I,II; Marcelo Luiz Campos Vieira^I,III; Daniela do Carmo Rassi^I; Silvana Angelina D'orio Nishioka^I; Martino Martinelli Filho^I; Wilson Mathias Jr^I

Publication Dates

• Publication in this collection
  03 Oct 2011
• Date of issue
  June 2011

History

• Reviewed
  26 Jan 2010
• Received
  06 Aug 2009
• Accepted
  25 Mar 2010