Mechanical Dyssynchrony Combined with Septal Scarring Reliably Identifies Responders to Cardiac Resynchronization Therapy

Jürgen Duchenne; Camilla K Larsen; Marta Cvijic; Elena Galli; John M Aalen; Boudewijn Klop; Oana Mirea; Alexis Puvrez; Stéphanie Bézy; Laurine Wouters; Lennert Minten; Per A Sirnes; Faraz H Khan; Gabor Voros; Rik Willems; Martin Penicka; Erik Kongsgård; Einar Hopp; Jan Bogaert; Otto A Smiseth; Erwan Donal; Jens-Uwe Voigt

doi:10.3390/jcm12186108

Mechanical Dyssynchrony Combined with Septal Scarring Reliably Identifies Responders to Cardiac Resynchronization Therapy

J Clin Med. 2023 Sep 21;12(18):6108. doi: 10.3390/jcm12186108.

Authors

Jürgen Duchenne^{1

2}, Camilla K Larsen^{3

4

5}, Marta Cvijic^{1

2}, Elena Galli^{6

7}, John M Aalen^{3

4

5}, Boudewijn Klop^{1

2}, Oana Mirea^{1

2

8}, Alexis Puvrez^{1

2}, Stéphanie Bézy^{1

2}, Laurine Wouters^{1

2}, Lennert Minten^{1

2}, Per A Sirnes^{3

4

5}, Faraz H Khan^{3

4

5}, Gabor Voros^{1

2}, Rik Willems^{1

2}, Martin Penicka⁹, Erik Kongsgård^{3

4

5}, Einar Hopp¹⁰, Jan Bogaert^{11

12}, Otto A Smiseth^{3

4

5}, Erwan Donal^{6

7}, Jens-Uwe Voigt^{1

2}

Affiliations

¹ Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium.
² Department of Cardiovascular Diseases, University Hospitals Leuven, 3000 Leuven, Belgium.
³ Institute for Surgical Research, Oslo University Hospital and University of Oslo, 0450 Oslo, Norway.
⁴ Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway.
⁵ Department of Cardiology, Oslo University Hospital, 0379 Oslo, Norway.
⁶ Inserm, LTSI-UMR, 1099, 35042 Rennes, France.
⁷ Department of Cardiology, CHU Rennes, 35033 Rennes, France.
⁸ Department of Cardiology, University of Medicine and Pharmacy, 200349 Craiova, Romania.
⁹ Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium.
¹⁰ Division of Radiology and Nuclear Medicine, Oslo University Hospital, 0379 Oslo, Norway.
¹¹ Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium.
¹² Department of Radiology, University Hospitals Leuven, 3000 Leuven, Belgium.

Abstract

Background and aim: The presence of mechanical dyssynchrony on echocardiography is associated with reverse remodelling and decreased mortality after cardiac resynchronization therapy (CRT). Contrarily, myocardial scar reduces the effect of CRT. This study investigated how well a combined assessment of different markers of mechanical dyssynchrony and scarring identifies CRT responders. Methods: In a prospective multicentre study of 170 CRT recipients, septal flash (SF), apical rocking (ApRock), systolic stretch index (SSI), and lateral-to-septal (LW-S) work differences were assessed using echocardiography. Myocardial scarring was quantified using cardiac magnetic resonance imaging (CMR) or excluded based on a coronary angiogram and clinical history. The primary endpoint was a CRT response, defined as a ≥15% reduction in LV end-systolic volume 12 months after implantation. The secondary endpoint was time-to-death. Results: The combined assessment of mechanical dyssynchrony and septal scarring showed AUCs ranging between 0.81 (95%CI: 0.74-0.88) and 0.86 (95%CI: 0.79-0.91) for predicting a CRT response, without significant differences between the markers, but significantly higher than mechanical dyssynchrony alone. QRS morphology, QRS duration, and LV ejection fraction were not superior in their prediction. Predictive power was similar in the subgroups of patients with ischemic cardiomyopathy. The combined assessments significantly predicted all-cause mortality at 44 ± 13 months after CRT with a hazard ratio ranging from 0.28 (95%CI: 0.12-0.67) to 0.20 (95%CI: 0.08-0.49). Conclusions: The combined assessment of mechanical dyssynchrony and septal scarring identified CRT responders with high predictive power. Both visual and quantitative markers were highly feasible and demonstrated similar results. This work demonstrates the value of imaging LV mechanics and scarring in CRT candidates, which can already be achieved in a clinical routine.

Keywords: apical rocking; cardiac resynchronization therapy; dyssynchrony; myocardial scar; myocardial work; reverse remodelling; septal flash; systolic stretch index.

Grants and funding

This work was supported by a KU Leuven research grant (OT/12/084) and the Oslo Center for Cardiological Innovation. Individual research support came from the Research Foundation—Flanders (FWO) (J.D., R.W. and J.U.V.), the South-Eastern Norway Regional Health Authority (C.K.L.), and the Norwegian Health Association (J.M.A.), respectively.