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Echocardiographic Phase Imaging to Predict Reverse Remodeling After Cardiac Resynchronization Therapy

Sebastian J. Buss, MD^_*,_*, Per M. Humpert, MD, Raffi Bekeredjian, MD^_*, Stefan E. Hardt, MD^_*, Christian Zugck, MD^_*, Dieter Schellberg, PhD^,, Alexander Bauer, MD^_*, Arthur Filusch, MD^_*, Helmut Kuecherer, MD^||, Hugo A. Katus, MD^_*, Grigorios Korosoglou, MD^_*

^_* Department of Cardiology, University of Heidelberg, Heidelberg, Germany
Department of Endocrinology, University of Heidelberg, Heidelberg, Germany
Department of Visceral and General Surgery, University of Heidelberg, Heidelberg, Germany
Department of Psychosomatic and General Internal Medicine, University of Heidelberg, Heidelberg, Germany
^|| Department of Cardiology, Kliniken im Naturpark Altmühltal, Eichstätt, Germany

^_* Reprint requests and correspondence: Dr. Sebastian J. Buss, University of Heidelberg, Department of Cardiology, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany (Email: sebastian.buss{at}med.uni-heidelberg.de).

Objectives: The aim of our study was to investigate whether echocardiographic phase imaging (EPI) can predict response in patients who are considered for cardiac resynchronization therapy (CRT).

Background: CRT improves quality of life, exercise capacity, and outcome in patients with bundle-branch block and advanced heart failure. Previous studies used QRS duration to select patients for CRT; the accuracy of this parameter to predict functional recovery, however, is controversial.

Methods: We examined 42 patients with advanced heart failure (New York Heart Association [NYHA] functional class III to IV, QRS duration >130 ms, and ejection fraction <35%) before and 6 to 8 months after CRT. Left ventricular (LV) dyssynchrony was estimated by calculating the SD of time to peak velocities (Ts-SD) by conventional tissue Doppler imaging (TDI), and the mean phase index (mean EPI-Index) was calculated by EPI in 12 mid-ventricular and basal segments. Patients who were alive and had significant relative decrease in end-systolic LV volume of ESV 15% at 6 to 8 months of follow-up were defined as responders. All others were classified as nonresponders.

Results: The Ts-SD and the mean EPI-Index were related to ESV (r = 0.43 for Ts-SD and r = 0.67 for mean EPI-Index, p < 0.01 for both), and both parameters yielded similar accuracy for the prediction of LV remodeling (area under the curve of 0.87 for TDI vs. 0.90 for EPI, difference between areas = 0.03, p = NS) and ejection fraction (EF) improvement (area under the curve of 0.87 for TDI vs. 0.93 for EPI, difference between areas = 0.06, p = NS). Furthermore, patients classified as responders by EPI (mean EPI-Index 59%) showed significant improvement in NYHA functional class and in 6-min walk test (409 ± 88 m at follow-up vs. 312 ± 86 m initially, p < 0.001).

Conclusion: Echocardiographic phase imaging can predict functional recovery, reverse LV remodeling, and clinical outcomes in patients who undergo CRT. EPI is a method that objectively and accurately quantifies LV dyssynchrony and seems to be noninferior to TDI for the prediction of reverse LV remodeling and functional recovery.

Key Words: cardiac resynchronization therapy • congestive heart failure • echocardiographic phase imaging • left ventricular dyssynchrony • tissue Doppler imaging

Abbreviations and Acronyms   CRT = cardiac resynchronization therapy   EF = ejection fraction   EPI = echocardiographic phase imaging   ESV = end-systolic volume   LV = left ventricle/ventricular   NYHA = New York Heart Association   TDI = tissue Doppler imaging   Ts-SD = SD of time to peak velocities

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