Tissue Doppler velocity is superior to strain imaging in predicting long-term cardiovascular events after cardiac resynchronisation therapy.

OBJECTIVE: To examine the predictive value of systolic dyssynchrony measured by tissue Doppler velocity versus tissue Doppler strain imaging on long-term outcome after cardiac resynchronisation therapy (CRT). DESIGN: Cohort study. SETTING: Two university hospitals. PATIENTS: Two hundred and thirty-nine patients (65 (SD 12) years, 76% males) who underwent CRT. INTERVENTIONS: Baseline echocardiography with tissue Doppler imaging (TDI) and clinical follow-up for 37 (20) months. MAIN OUTCOME MEASURES: The time to peak systolic velocity during ejection phase (Ts) and the time to peak systolic strain (T(epsilon)) were assessed for dyssynchrony, that is the maximal delay in Ts and the maximal delay in T(epsilon) among the four left ventricular basal segments. Occurrence of cardiovascular endpoints between patients with and without dyssynchrony was compared by Kaplan-Meier curves, followed by Cox regression analysis for potential predictor(s). RESULTS: There were 78 (33%) deaths, with cardiovascular causes in 64 (27%) patients, while 136 (57%) patients were hospitalised for cardiovascular events, including decompensated heart failure in 87 (36%) patients. Patients with the maximal delay in Ts of > or =65 ms showed a lower event rate for cardiovascular mortality (19% vs 38%, logrank chi2 = 7.803, p = 0.005) and other prognostic endpoints. In Cox regression analysis, the maximal delay in Ts (hazard ratio (HR) 0.463, 95% CI 0.270 to 0.792, p = 0.005) and ischaemic aetiology (HR 2.716, 95% CI 1.505 to 4.901, p = 0.001) were independent predictors of cardiovascular mortality. In contrast, the maximal delay in T(epsilon) of > or =80 ms failed to predict any cardiovascular event. CONCLUSIONS: Echocardiographic evidence of prepacing systolic dyssynchrony measured by TDI velocity, but not TDI strain, predicted lower long-term cardiovascular events after CRT.

Imaging in cardiac resynchronisation therapy.

A substantial number of heart failure (HF) patients do not respond after cardiac resynchronisation therapy (CRT). Recent studies observed that assessment of intraventricular (LV) dyssynchrony may allow identification of potential responders to CRT. In addition, presence of scar tissue and venous anatomy may play a role in the selection of candidates. In this review, an extensive overview of the available LV dyssynchrony measurements is provided using different echocardiographic modalities. In addition, the value of other noninvasive techniques such as magnetic resonance imaging, nuclear imaging and computed tomography for the selection of potential candidates for CRT will be discussed. (Neth Heart J 2008;16(Suppl1):S36-S40.).

Triplane tissue Doppler imaging: a novel three-dimensional imaging modality that predicts reverse left ventricular remodelling after cardiac resynchronisation therapy.

BACKGROUND: Several two-dimensional (2-D) tissue Doppler imaging (TDI) echocardiographic techniques have proved useful to identify responders to cardiac resynchronisation therapy (CRT). Recently a 3-D probe allowing simultaneous acquisition of TDI data in three imaging planes became available. OBJECTIVE: To evaluate the value of triplane TDI to predict reverse left ventricular (LV) remodelling after CRT. METHODS: Sixty patients with heart failure, scheduled for CRT, underwent triplane echocardiography with simultaneous TDI acquisition before and 6 months after implantation. From the triplane dataset a 3-D LV volume was generated and LV volumes and ejection fraction were calculated. Intraventricular dyssynchrony was quantitatively analysed by evaluating time from onset of the QRS complex to peak myocardial systolic velocity in 12 LV segments from the triplane dataset and calculation of the standard deviation (Ts-SD-12). Clinical response was defined as an improvement of at least one New York Heart Association class. Reverse LV remodelling was defined as >/=15% decrease of LV end-systolic volume at 6 months' follow-up. RESULTS: Responders to CRT had significantly more LV dyssynchrony at baseline than non-responders (mean (SD) Ts-SD-12: 42 (14) vs 22 (12), p<0.001). A cut-off value of 33 ms for baseline Ts-SD-12, acquired from the triplane TDI dataset, yielded a sensitivity of 89% with a specificity of 82% to predict clinical response to CRT; sensitivity and specificity to predict reverse LV remodelling were 90% and 83%, respectively. CONCLUSION: Triplane TDI echocardiography predicts clinical response and reverse LV remodelling 6 months after CRT implantation.

[Infusion of inotropic agents at home in patients with severe heart failure: an important role for the nurse practitioner]. / Thuisinfusie van inotropica bij ernstig hartfalen; een belangrijke rol voor de 'nurse practitioner'.

Patients with severe heart failure commonly require intravenous inotropic agents to stabilise their haemodynamics and improve the clinical symptoms. Continuous intravenous inotropic agents in a home-based setting under the direction of specialised nurses has been introduced in patients waiting for cardiac transplantation and also as destination therapy. Since 1982, several case reports and case series have described the use of ambulatory intravenous dobutamine, but almost none of the available studies included a control group. Moreover, most trials were small and short in duration, and thus have not been able to provide reliable information about the effect of treatment on the risk of serious cardiac events. However, these data consistently demonstrate the feasibility of home infusion as well as an improved quality of life and reduced costs. Therefore, home infusion of dobutamine guided by a specialised nurse may be desirable in patients waiting for heart transplantation or as destination therapy in the last weeks of life.

[The practice guideline 'Heart failure' (first revision) from the Dutch College of General Practitioners; a response from the perspective of cardiology]. / De standaard 'Hartfalen' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de cardiologie.

The Dutch College of General Practitioners' practice guideline 'Heart failure' provides a clear insight into the history, diagnosis and treatment of patients with chronic heart failure. The revised guideline does however warrant some minor comments. It suggests that an elevated BNP value contributes towards the diagnosis of heart failure, however taking into account the high negative predictive value, BNP should, for the time being at least, only act as an 'instrument of exclusion' in the diagnosis of heart failure. The section on pharmacological treatment could have been expanded with the additional information that ACE-inhibitors should be replaced by angiotensin-II receptor blockers ifangioneurotic oedema appears. Another recommendation might be that early treatment with ACE-inhibitors and statins in high-risk patients reduces the incidence of heart failure. Furthermore, the guideline does not provide information about non-pharmacological treatment such as biventricular pacing and implantable cardioverter defibrillators. Prevention is not dealt with even though it is a task particularly suited to the GP. Lastly, it could have been more clearly pointed out that outpatient clinics providing special care for heart-failure patients are well-recognized support facilities for patients with heart failure. In conclusion, the first revision can be considered as an adequate and workable practice guideline for the GP.