Improvement in MR and in the dyssynchrony between the mid segments predict super responders in patients undergoing CRT


Background: Twenty to thirty percent of patients with left heart failure in randomized trials do not respond clinically to cardiac resynchronization therapy (CRT). The objectives of our work were to estimate the effec-tiveness of CRT in our routine practice, and to find predictors of favorable response to CRT. Methods: Retrospective analysis of consecutive patients who underwent CRT from 2003-2007. Results: Fifty six consecutive patients (73.2% men, age 66.3 ± 10.2 years) with left heart failure (LHF) (ischemic cardiomyopathy 60.7%) received CRT and were followed for a mean of 27 months. After the implantation: Mean NYHA improved by one class (p < 0.001), LHF admissions were reduced by 79% (p < 0.0001) and mean ejection fruction improved by 31% (19.5% vs 25.6%, p < 0.002). Significant improvement in severity of mitral regurgitation (MR) was an important predictor of high responsiveness (p = 0.004). Improvement of MR was associated with complete left bundle branch block (CLBBB) (p = 0.04) and lower total mortality (p = 0.005). Improvement in synchronization between the mid lateral and mid septal segments, as was calculated with longitudinal strain using echocardiography (105 ± 38 vs 20 ± 23 msec, p = 0.008) was predictor of super responsiveness and reduction in MR among patients with moderate to severe MR prior to implantation. Worsening the delay between the mid posterior and mid anterior septal segments (21 ± 27 vs 120 ± 0 msec, p = 0.006) was associated with absence of response and lack of improvement in MR. Conclusions: Patients who improve mid segments dyssynchrony in four chamber view, have more chance to improve MR and to become super responders.

Share and Cite:

Blich, M. , Carasso, S. , Suleiman, M. , Marai, I. , Shwiri, T. , Gepstein, L. and Boulos, M. (2012) Improvement in MR and in the dyssynchrony between the mid segments predict super responders in patients undergoing CRT. World Journal of Cardiovascular Diseases, 2, 295-301. doi: 10.4236/wjcd.2012.24046.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Cazeau, S., Leclercq, C., Lavergne, T., Walker, S., Varma, C., Linde, C. and Garrigue, S. (2001) Multisite stimulation in cardiomyopathies (MUSTIC) study investigators: Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. The New England Journal of Medicine, 344, 873- 880. doi:10.1056/NEJM200103223441202
[2] Bradley, D.J., Bradley, E.A., Baughman, K.L., Berger, R.D., Calkins, H., Good-man, S.N, Kass, D.A., et al. (2003) Cardiac resynchronization and death from progressive heart failure: A Meta analysis of randomized controlled trials. JAMA, 289, 730-740. doi:10.1001/jama.289.6.730
[3] Cleland, J.G., Daubert, J.C., Erdmann, E., Freemantle, N., Gras, D., Kappenberger, L. and Tavazzi, L. (2005) The effect of cardiac resynchronization on morbidity and mortality in heart failure. The New England Journal of Medicine, 352, 1539-1549. doi:10.1056/NEJMoa050496
[4] Linde, C., Abraham, W.T., Gold, M.R., St John Sutton, M., Ghio, S. and Daubert, C. (2008) Randomized trial of cardiac resynchronization in mildly symptomatic heart failure patients and in asymptomatic patients with left ventricular dysfunction and previous heart failure symptoms. Journal of the American College of Cardiology, 52, 1834-1843. doi:10.1016/j.jacc.2008.08.027
[5] Abraham, W.T., Fisher, W.G., Smith, A.L., Hayes, D.L., Ellestad, M., Trupp, R.J., Underwood, J., et al. (2002) MIRA CLE study group. Multicenter insync randomized clinical evaluation: Cardiac resynchronization in chronic heart failure. The New England Journal of Medicine, 346, 1845-1853. doi:10.1056/NEJMoa013168
[6] Bristow, M.R., Saxon, L.A., Boehmer, J., Krueger, S., Kass, D.A., DeVries, D.W., Feldman, A.M. and Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure (COMPANION) Investigators (2004) Cardiac resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. The New England Journal of Medicine, 350, 2140-2150. doi:10.1056/NEJMoa032423
[7] Yu, C.M., Zhang, Q., Fung, J.W., Chan, H.C., Chan, Y.S., Yip, G.W., Kong, S.L., et al. (2005) A novel tool to assess systolic asynchrony and identify responders of cardiac resynchronization therapy by tissue synchronization imaging. Journal of the American College of Cardiology, 45, 677-684. doi:10.1016/j.jacc.2004.12.003
[8] Penicka, M., Bartunek, J., De Bruyne, B., Vanderheyden, M., Goethals, M., DeZutter, M., Brugada, P., et al. (2004) Improvement of left ventricular function after cardiac resynchronization therapy is predicted by tissue Doppler imaging echocardiography. Circulation, 109, 978-983. doi:10.1161/01.CIR.0000116765.43251.D7
[9] Bax, J.J., Bleeker, G.B., Marwick, T.H., Molhoek, S.G., Boersma, E., Steendijk, P., van der Wall, E.E., et al. (2004) Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. Journal of the American College of Cardiology, 44, 1834- 1840. doi:10.1016/j.jacc.2004.08.016
[10] Yu, C.M., Chau, E., Sanderson, J.E., Fan, K., Tang, M.O., Fung, W.H., Lin, H., et al. (2002) Tissue Doppler echocardiographic evidence of reverse remodeling and improved synchronicity by simultaneously delaying regional contraction after biventricular pacing therapy in heart failure. Circulation, 105, 438-445. doi:10.1161/hc0402.102623
[11] Chung, E.S., Leon, A.R., Tavazzi, L., Sun, J.P., Nihoyannopoulos, P., Merlino, J., Abraham, W.T., et al. (2008) Results of the predictors of response to CRT (PROSPECT) trial. Circulation, 117, 2608-2616. doi:10.1161/CIRCULATIONAHA.107.743120
[12] Suffoletto, M.S., Dohi, K., Cannesson, M., Saba, S. and Gorcsan, J. (2006) Novel speckle tracking radial strain from routine black and white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation, 113, 960-968. doi:10.1161/CIRCULATIONAHA.105.571455
[13] Robbins, J.D., Maniar, P.B., Cotts, W., Parker, M.A., Borow, R.O. and Gheorghiade, M. (2003) Prevalence and sevirity of mitral regurgitation in chronic systolic heart failure. Journal of the American College of Cardiology, 91, 360-362. doi:10.1016/S0002-9149(02)03172-7
[14] Grigioni, F., Enriquez-Sarano, M., Zehr, K.J., Bailey, K.R. and Tajik, A.J. (2001) Ischemic mitral regurgitation: Long term outcome and prognostic implication with quantitative doppler assessment. Circulation, 103, 1759-1764. doi:10.1161/01.CIR.103.13.1759
[15] Capomolla, S., Febo, O., Gnemmi, M., Riccardi, G., Opasich, C., Caporotondi, A., Morata, A., et al. (2000) Beta blockade therapy in chronic heart failure: Diastolic function and mitral regurgitation improvement by carvedilol. American Heart Journal, 139, 596-608. doi:10.1016/S0002-8703(00)90036-X
[16] Haan, C.K., Cabral, C.I., Conetta, D.A., Coombs, L.P. and Edwards, F.H. (2004) Selecting patients with mitral regurgitation and left ventricular dysfunction for isolated mitral valve surgery. The Annals of Thoracic Surgery, 78, 820-825. doi:10.1016/j.athoracsur.2004.04.003
[17] Linde, C., Leclercq, C., Rex, S., Garrigue, S., Lavergne, T., Cazeau, S., McKenna, W., et al. (2002) Long term benefits of biventricular pacing in congestive heart failure: Results from the Multisite Stimulation in Cardiomyopathy (MUSTIC) study. Journal of the American College of Cardiology, 40, 111-118. doi:10.1016/S0735-1097(02)01932-0
[18] St John Sutton, M.G., Plappert, T., Abraham, W.T., Smith, A.L., DeLurgio, D.B., Leon, A.R., Loh, E., Multicenter InSync Randomized Clinical Evaluation (MIRACLE) Study Group, et al. (2003) Effect of cardiac resynchronization therapy on left ventricular size and function in chronic heart failure. Circulation, 107, 1985-1990. doi:10.1161/01.CIR.0000065226.24159.E9
[19] Zanon, F., Aggio, S., Baracca, E., Bilato, C., Corbucci, G., Rigatelli, G. and Zonzin, P. (2004) Reduced mitral regurgitation in heart failure patients submitted to cardiac resynchronization therapy: A short term prospective study. Italian Heart Journal, 111, 826-830.
[20] Breithardt, O.A., Sinha, A.M., Schwammenthal, E., Bidaoui, N., Markus, K.U., Franke, A. and Stellbrink, C. (2003) Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure. Journal of the American College of Cardiology, 41, 765-767. doi:10.1016/S0735-1097(02)02937-6
[21] Castellant, P., Fatemi, M., Bertault-Valls, V., Etienne, Y. and Blanc, J.J. (2008) Cardiac resynchronization therapy: “Nonresponders” and “hyperresponders”. Heart Rhythm, 5, 193-197. doi:10.1016/j.hrthm.2007.09.023
[22] Gasparini, M., Regoli, F., Ceriotti, C., Galimberti, P., Bragato, R., De Vita, S., Pini, D., et al. (2008) Remission of left ventricular systolic dysfunction and of heart failure symptoms after cardiac resynchronization therapy: Temporal pattern and clinical predictors. American Heart Journal, 155, 507-514. doi:10.1016/j.ahj.2007.10.028
[23] Lai, D.T., Tibayan, F.A., Myrmel, T., Timek, T.A., Dagum, P., Daughters, G.T., Liang, D., et al. (2002) Mechanistic insights into posterior leaflet inter scallop malcoaptation during acute ischemic mitral regurgitation. Circulation, 106, 140-145.
[24] Otsuji, Y., Handschumacher, M.D., Schwammenthal, E., Jiang, L., Song, J.K., Guerrero, J.L., Vlahakes, G.J., et al. (1997) Insights from three dimentional echocardiography into the mechanism of functional mitral regurgitation: Direct in vivo demonstration of altered leaflet thethering geometry. Circulation, 96, 1999-2008. doi:10.1161/01.CIR.96.6.1999
[25] Kanzaki, H., Bazaz, R., Schwartzman, D., Dohi, K., Sade, L..E, Gorcsan, J. 3rd. (2004) A mechanism for immediate reduction in mitral regurgitation after cardiac resynchronization therapy: Insights from mechanical activation strain mapping. Journal of the American College of Cardiology, 44, 1619-1625. doi:10.1016/j.jacc.2004.07.036
[26] Agricola, E., Oppizzi, M., Galdersi, M., Pisani, M., Meris, A., Pappone, C. and Margonato, A. (2006) Role of regional mechanical dyssynchrony as a determinant of functional mitral regurgitation in patients with left ventricular systolic dysfunction. Heart, 92, 1390-1395. doi:10.1136/hrt.2005.082115
[27] Naqvi, T.Z., Rafique, A.M., Swerdlow, C., Verma, S., Siegel, R.J., Tolstrup, K., Kerwin, W., et al., (2008) Predictors of reduction in mitral regurgitation in patients undergoing cardiac resynchronization treatment. Heart, 94, 1580-1588. doi:10.1136/hrt.2007.118356
[28] Brandt, R.R., Reiner, C., Arnold, R., Sperzel, J., Pitschner, H.F. and Hamm, C.W. (2006) Contractile response and mitral regurgitation after temporary interruption of long term cardiac resynchronization therapy. European Heart Journal, 27, 187-192. doi:10.1093/eurheartj/ehi558

Copyright © 2023 by authors and Scientific Research Publishing Inc.

Creative Commons License

This work and the related PDF file are licensed under a Creative Commons Attribution 4.0 International License.