Search

Background: Global longitudinal strain (GLS) can predict cancer therapeutics-related cardiac dysfunction and guide initiation of cardioprotection (CPT)., Objectives: In this study, the authors sought to determine whether echocardiography GLS-guided CPT provides less cardiac dysfunction in survivors of potentially cardiotoxic chemotherapy, compared with usual care at 3 years., Methods: In this international multicenter prospective randomized controlled trial, patients were enrolled from 28 international sites. All patients treated with anthracyclines with another risk factor for heart failure were randomly allocated to GLS-guided (>12% relative reduction in GLS) or ejection fraction (EF)-guided (>10% absolute reduction of EF to <55%) CPT. The primary end point was the change in 3-dimensional (3D) EF (ΔEF) from baseline to 3 years., Results: Among 331 patients enrolled, 255 (77%, age 54 ± 12 years, 95% women) completed 3-year follow-up (123 in the EF-guided group and 132 in the GLS-guided group). Most had breast cancer (n = 236; 93%), and anthracycline followed by trastuzumab was the most common chemotherapy regimen (84%). Although 67 (26%) had hypertension and 32 (13%) had diabetes mellitus, left ventricular function was normal at baseline (EF: 59% ± 6%, GLS: 20.7% ± 2.3%). CPT was administered in 18 patients (14.6%) in the EF-guided group and 41 (31%) in the GLS-guided group (P = 0.03). Most patients showed recovery in EF and GLS after chemotherapy; 3-year ΔEF was -0.03% ± 7.9% in the EF-guided group and -0.02% ± 6.5% in the GLS-guided (P = 0.99) group; respective 3-year EFs were 58% ± 6% and 59% ± 5% (P = 0.06). At 3 years, 17 patients (5%) had cancer therapeutics-related cardiac dysfunction (11 in the EF-guided group and 6 in the GLS guided group; P = 0.16); 1 patient in each group was admitted for heart failure., Conclusions: Among patients taking potentially cardiotoxic chemotherapy for cancer, the 3-year data showed improvement of LV dysfunction compared with 1 year, with no difference in ΔEF between GLS- and EF-guided CPT. (Strain Surveillance of Chemotherapy for Improving Cardiovascular Outcomes [SUCCOUR]; ACTRN12614000341628)., Competing Interests: Funding Support and Author Disclosures This study was supported in part by a project grant (1119955) from the National Health and Medical Research Council, Canberra, Australia, and an unrestricted grant from General Electric Healthcare, Horten, Norway. At the CHU de Québec site, the study was funded by the Fondation du CHU de Québec. Dr Marwick is supported by an investigator grant (2008129) from the National Health and Medical Research Council, Canberra, Australia. Dr Thavendiranathan is supported by a Canadian Institutes of Health Research New Investigator Award (147814), an Ontario Early Research Award, and a Canada Research Chair in Cardio-oncology. Dr K. Negishi is supported by a fellowship (award reference no. 101868) from the National Heart Foundation of Australia. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: The left atrium (LA) has a pivotal role in cardiac performance and LA deformation is a well-known prognostic predictor in several clinical conditions including heart failure with reduced ejection fraction. The aim of this study is to investigate the effect of cardiac resynchronization therapy (CRT) on both LA morphology and function and to assess the impact of LA reservoir strain (LARS) on left ventricular (LV) systolic and diastolic remodelling after CRT., Methods and Results: Two hundred and twenty-one CRT-candidates were prospectively included in the study in four tertiary centres and underwent echocardiography before CRT-implantation and at 6-month follow-up (FU). CRT-response was defined by a 15% reduction in LV end-systolic volume. LV systolic and diastolic remodelling were defined as the percent reduction in LV end-systolic and end-diastolic volume at FU. Indexed LA volume (LAVI) and LV-global longitudinal (GLS) strain were the main parameters correlated with LARS, with LV-GLS being the strongest determinant of LARS (r = -0.59, P < 0.0001). CRT induced a significant improvement in LAVI and LARS in responders (both P < 0.0001). LARS was an independent predictor of both LV systolic and diastolic remodelling at follow-up (r = -0.14, P = 0.049 and r = -0.17, P = 0.002, respectively)., Conclusion: CRT induces a significant improvement in LAVI and LARS in responders. In CRT candidates, the evaluation of LARS before CRT delivery is an independent predictor of LV systolic and diastolic remodelling at FU., Competing Interests: Conflict of interest: none declared., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Myocardial work is calculated from non-invasive left ventricular pressure and strain by speckle tracking echocardiography. Myocardial work provides diagnostic information beyond what is achieved from left ventricular ejection fraction and strain since it incorporates afterload, and provides a measure of myocardial efficiency. The method can be used to calculate global as well as segmental work. The work method was recently shown to be of clinical value in selection of patients for cardiac resynchronization therapy. Several other clinical applications are currently tested., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Background: In patients at risk of cancer therapy-related cardiac dysfunction (CTRCD), initiation of cardioprotective therapy (CPT) is constrained by the low sensitivity of ejection fraction (EF) for minor changes in left ventricular (LV) function. Global longitudinal strain (GLS) is a robust and sensitive marker of LV dysfunction, but existing observational data have been insufficient to support a routine GLS-guided strategy for CPT., Objectives: This study sought to identify whether GLS-guided CPT prevents reduction in LVEF and development of CTRCD in high-risk patients undergoing potentially cardiotoxic chemotherapy, compared with usual care., Methods: In this international, multicenter, prospective, randomized controlled trial, 331 anthracycline-treated patients with another heart failure risk factor were randomly allocated to CPT initiation guided by either ≥12% relative reduction in GLS (n = 166) or >10% absolute reduction of LVEF (n = 165). Patients were followed for EF and development of CTRCD (symptomatic EF reduction of >5% or >10% asymptomatic to <55%) over 1 year., Results: Of 331 randomized patients, 2 died, and 22 withdrew consent or were lost to follow-up. Among 307 patients (age: 54 ± 12 years; 94% women; baseline LVEF: 59 ± 6%; GLS: -20.6 ± 2.4%) with a median (interquartile range) follow-up of 1.02 years (0.98 to 1.07 years), most (n = 278) had breast cancer. Heart failure risk factors were prevalent: 29% had hypertension, and 13% had diabetes mellitus. At the 1-year follow-up, although the primary outcome of change in LVEF was not significantly different between the 2 arms, there was significantly greater use of CPT, and fewer patients met CTRCD criteria in the GLS-guided than the EF-guided arm (5.8% vs. 13.7%; p = 0.02), and the 1-year EF was 57 ± 6% versus 55 ± 7% (p = 0.05). Patients who received CPT in the EF-guided arm had a larger reduction in LVEF at follow-up than in the GLS-guided arm (9.1 ± 10.9% vs. 2.9 ± 7.4%; p = 0.03)., Conclusions: Although the change in LVEF was not different between the 2 arms as a whole, when patients who received CPT were compared, those in the GLS-guided arm had a significantly lower reduction in LVEF at 1 year follow-up. Furthermore, GLS-guided CPT significantly reduced a meaningful fall of LVEF to the abnormal range. The results support the use of GLS in surveillance for CTRCD. (Strain Surveillance of Chemotherapy for Improving Cardiovascular Outcomes [SUCCOUR]; ACTRN12614000341628)., Competing Interests: Author Disclosures This study was supported in part by a project grant (1119955) from the National Health and Medical Research Council, Canberra, Australia, and an unrestricted grant from General Electric Healthcare, Horten, Norway. At the Centre Hospitalier Universitaire (CHU) de Québec site, the study was funded by the Fondation du CHU de Québec. Dr. Thavendiranathan is supported by the Canadian Institutes of Health Research New Investigator Award (147814), the Ontario Early Research Award, and a Canada Research Chair in Cardio-oncology. Dr. Negishi is supported by a Fellowship (award reference no. 101868) from the National Heart Foundation of Australia. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: The present study sought to evaluate the correlation between indices of non-invasive myocardial work (MW) and left ventricle (LV) size, traditional and advanced parameters of LV systolic and diastolic function by 2D echocardiography (2DE)., Methods and Results: A total of 226 (85 men, mean age: 45 ± 13 years) healthy subjects were enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. Global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE) were estimated from LV pressure-strain loops using custom software. Peak LV pressure was estimated non-invasively from brachial artery cuff pressure. LV size, parameters of systolic and diastolic function and ventricular-arterial coupling were measured by echocardiography. As advanced indices of myocardial performance, global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) were obtained. On multivariable analysis, GWI was significantly correlated with GLS (standardized beta-coefficient = -0.23, P < 0.001), ejection fraction (EF) (standardized beta-coefficient = 0.15, P = 0.02), systolic blood pressure (SBP) (standardized beta-coefficient = 0.56, P < 0.001) and GRS (standardized beta-coefficient = 0.19, P = 0.004), while GCW was correlated with GLS (standardized beta-coefficient = -0.55, P < 0.001), SBP (standardized beta-coefficient = 0.71, P < 0.001), GRS (standardized beta-coefficient = 0.11, P = 0.02), and GCS (standardized beta-coefficient = -0.10, P = 0.01). GWE was directly correlated with EF and inversely correlated with Tei index (standardized beta-coefficient = 0.18, P = 0.009 and standardized beta-coefficient = -0.20, P = 0.004, respectively), the opposite occurred for GWW (standardized beta-coefficient =--0.14, P = 0.03 and standardized beta-coefficient = 0.17, P = 0.01, respectively)., Conclusion: The non-invasive MW indices show a good correlation with traditional 2DE parameters of myocardial systolic function and myocardial strain., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Since the first report on biventricular pacing in 1994, cardiac resynchronization therapy (CRT) has become standard for patients with advanced heart failure (HF) and ventricular conduction delay. CRT improves myocardial function by resynchronizing myocardial contraction, which results in reverse left ventricular remodeling and improves symptoms and clinical outcomes. Despite the accelerated development of CRT device technology and its increased application in treating HF patients, almost one-third of these patients do not respond to the therapy or gain any clinical benefit from device implantation. Over the last decade, multiple cardiac imaging modalities have provided a deeper understanding of myocardial pathophysiology, thereby improving HF treatment management. However, the optimal strategy for improving the CRT response remains debatable. This article provides an updated overview of the electropathophysiology of myocardial dysfunction in ventricular conduction delay and the diagnostic approaches involving the use of multiple modalities., (© 2019 S. Karger AG, Basel.)

Objectives: The goal of this study was to compare echocardiographic measurements of global longitudinal strain (GLS) (using 3 apical views) with single-view longitudinal strain (LS, 4- or 2-chamber [4CV&#95;LS and 2CV&#95;LS, respectively]) for detection of cancer-therapy related cardiotoxicity., Background: GLS is useful for the detection of cardiotoxicity, but the need for repeated measurements poses a significant burden on busy echocardiography laboratories. A single-view LS measurement, possibly at point of care, could improve efficiency., Methods: Seventeen international centers prospectively recruited 108 patients (mean age 54 ± 13 years) at high risk for cardiotoxicity as part of the ongoing SUCCOUR (Strain Surveillance for Improving Cardiovascular Outcomes During Chemotherapy) randomized controlled trial. Echocardiography performed at baseline and follow-up were analyzed in a core laboratory setting blinded to clinical information. Peak systolic GLS and LS were measured from raw data. Cardiotoxicity was defined by reduction in left ventricular ejection fraction >0.10 to <0.55 or a relative drop in GLS by ≥12%., Results: Cardiotoxicity developed in 46 patients by either criteria. Baseline and follow-up 2-dimensional left ventricular ejection fraction were 61 ± 4% and 58 ± 5%, respectively (p < 0.001). The baseline GLS (-20.9 ± 2.4%) was not different from 4CV&#95;LS (-20.7 ± 2.5%; p = 0.09) or 2CV&#95;LS (-21.1 ± 3.1%; p = 0.25). The follow-up GLS (-19.5 ± 2.4%) was also similar to 4CV&#95;LS (-19.5 ± 2.6%; p = 0.80) and 2CV&#95;LS (-19.7 ± 3.1%; p = 0.19). There was good correlation between GLS and 4CV&#95;LS at baseline (r = 0.86; p < 0.001) and follow-up (r = 0.89; p < 0.001) and with 2CV&#95;LS at baseline (r = 0.87; p < 0.001) and follow-up (r = 0.88; p < 0.001). However, there was 15% to 22% disagreement between GLS and 4CV&#95;LS or 2CV&#95;LS for the detection of cardiotoxicity. The interobserver and intraobserver reproducibility was higher for GLS (intraclass correlation: 0.93 to 0.95; coefficient of variance: 2.9% to 3.7%) compared with either single-chamber-based LS measurement (intraclass correlation: 0.85 to 0.91; coefficient of variance: 4.1% to 4.8%)., Conclusions: Although there was good correlation between GLS and single-view LS measurements, single-view LS measurement led to disagreement in the diagnosis of cardiotoxicity in up to 22% of patients. GLS measurements were more reproducible than single-view LS. GLS based on 3 apical views should remain the preferred technique for detection of cardiotoxicity. (Strain Surveillance for Improving Cardiovascular Outcomes During Chemotherapy [SUCCOUR]; ACTRN12614000341628)., (Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Aims: Clinical experience indicates that limited or no reverse left ventricular (LV) remodelling may not necessarily imply non-response to cardiac resynchronization therapy (CRT). We investigated the association of the extent of LV remodelling, mechanical dyssynchrony, and survival in patients undergoing CRT., Methods and Results: In 356 CRT candidates, three blinded readers visually assessed the presence of mechanical dyssynchrony (either apical rocking and/or septal flash) before device implantation and also its correction by CRT 12 ± 3 months post-implantation. To assess LV reverse remodelling, end-systolic volumes (ESV) were measured at the same time points. Patients were divided into four subgroups: no LV remodelling (ESV change 0 ± 5%), mild LV reverse remodelling (ESV reduction 5-15%), significant LV reverse remodelling (ESV reduction ≥15%), and LV volume expansion (ESV increase ≥5%). Patients were followed for all-cause mortality during the median follow-up of 36 months. Patients with LV remodelling as in the above defined groups showed 58, 54, and 84% reduction in all-cause mortality compared to patients with volume expansion. In multivariable analysis, LVESV change remained independently associated with survival, with an 8% reduction in mortality for every 10% decrease in LVESV (P = 0.0039), but an optimal cut-off point could not be established. In comparison, patients with corrected mechanical dyssynchrony showed 71% reduction in all-cause mortality (P < 0.001)., Conclusion: Volumetric response assessed at 1-year after CRT is strongly associated with long-term mortality. However, an optimal cut-off cannot be established. The association of the correction of mechanical dyssynchrony with survival was stronger than that of any volumetric cut-off., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.)

Aims: Cardiac resynchronization therapy (CRT) in heart failure is limited by many non-responders. This study explores whether degree of wasted left ventricular (LV) work identifies CRT responders., Methods and Results: Twenty-one patients who received CRT according to guidelines were studied before and after 8 ± 3 months. By definition, segments that shorten in systole perform positive work, whereas segments that lengthen do negative work. Work was calculated from non-invasive LV pressure and strain by speckle tracking echocardiography. For each myocardial segment and for the entire LV, wasted work was calculated as negative work in percentage of positive work. LV wall motion score index (WMSI) was assessed by echocardiography. Response to CRT was defined as ≥15% reduction in end-systolic volume (ESV). Responder rate to CRT was 71%. In responders, wasted work for septum was 117 ± 102%, indicating more negative than positive work, and decreased to 14 ± 12% with CRT (P < 0.01). In the LV free wall, wasted work was 19 ± 16% and showed no significant change. Global LV wasted work decreased from 39 ± 21 to 17 ± 7% with CRT (P < 0.01). In non-responders, there were no significant changes. In multiple linear regression analysis, septal wasted work and WMSI were the only significant predictors of ESV reduction (β = 0.14, P = 0.01; β = 1.25, P = 0.03). Septal wasted work together with WMSI showed an area under the curve of 0.86 (95% confidence interval 0.71-1.0) for CRT response prediction., Conclusion: Wasted work in the septum together with WMSI was a strong predictor of response to CRT. This novel principle should be studied in future larger studies., (© The Author 2016. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Apical rocking (ApRock) and septal flash (SF) are often observed phenomena in asynchronously contracting ventricles. We investigated the relationship of visually assessed ApRock and SF, reverse remodelling, and long-term survival in cardiac resynchronization therapy (CRT) candidates., Methods and Results: A total of 1060 patients eligible for CRT underwent echocardiographic examinations before and 12 ± 6 months after device implantation. Three blinded physicians were asked to visually assess the presence of ApRock and SF before device implantation and also their correction by CRT 12 ± 6 months post-implantation. Patients with a left ventricular (LV) end-systolic volume decrease of ≥15% during the first year of follow-up were regarded as responders. Patients were followed for a median period of 46 months (interquartile range: 27-65 months) for the occurrence of death of any cause. If corrected by CRT, visually assessed ApRock and SF were associated with reverse remodelling with a sensitivity of 84 and 79%, specificity of 79 and 74%, and accuracy of 82 and 77%, respectively. ApRock (hazard ratio [HR] 0.40, 95% confidence interval [CI] 0.30-0.53, P < 0.0001) and SF (HR 0.45 [CI 0.34-0.61], P < 0.001) were independently associated with lower all-cause mortality after CRT and had an incremental value over clinical variables and QRS width for identifying CRT responders. Both the absence of ApRock/SF and unsuccessful correction of ApRock/SF despite CRT were associated with a high risk for non-response and an unfavourable long-term survival., Conclusion: A specific LV mechanical dyssynchrony pattern, characterized by ApRock and SF, is associated with a more favourable long-term survival after CRT. Both parameters are also indicators of an effective therapy., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

To date, cardiac resynchronization therapy remains the only treatment that enhances systolic function while improving long-term outcome and survival. Dyssynchronous heart failure is characterized by profound global as well as regional cellular and molecular changes, many of which are not observed in synchronous heart failure. The beneficial effects of CRT on myofilament function, G protein-coupled receptor signaling, and adrenergic response are important components for restoring cardiac reserve and reducing arrhythmia, both major limitations in heart failure. Here, we review the molecular alterations associated with dyssynchronous heart failure and their reversibility induced by cardiac resynchronization therapy.

This case describes a middle-aged patient with normal ejection fraction (64%) and significant dyspnoea which could not be explained by results from routine examinations. A pressure-volume loop analysis revealed severe left ventricular (LV) dyssynchrony to be the underlying mechanism of heart failure. The patient underwent implantation of a biventricular pacemaker. Cardiac resynchronization therapy (CRT) was associated with an immediate reduction in LV dyssynchrony from 32 to 13%, decrease in LV end-diastolic pressure from 19 to 8 mmHg, and increased exercise tolerance during follow-up. Thus, CRT may be considered a causal therapy in selected patients with heart failure and preserved ejection fraction.

Objective: Myocardial viability and left ventricular dyssynchrony are important predictors of long-term outcomes in patients with ischemic left ventricular dysfunction. The objective of this study was to test the hypothesis that assessment of myocardial viability and left ventricular dyssynchrony will predict perioperative mortality in high-risk patients with ischemic left ventricular dysfunction having coronary artery bypass surgery., Methods: The study consisted of 79 consecutive patients with ischemic cardiomyopathy (age 65 +/- 9 years; 81% men; ejection fraction 30% +/- 6%) and logistic European system for cardiac operative risk evaluation > 10% having coronary artery bypass surgery. Myocardial viability was assessed by delayed contrast-enhanced magnetic resonance imaging. Left ventricular dyssynchrony was calculated using tissue Doppler from measurements of regional electromechanical coupling times in left ventricular basal segments before coronary artery bypass surgery., Results: Twenty (25.3%) patients died within 30 days following coronary artery bypass surgery. Survivors (n = 59) showed a larger extent of viable myocardium (6.9 +/- 3.6 viable segments vs 3.4 +/- 3.3 viable segments, P < .001) and smaller left ventricular dyssynchrony (75 +/- 5 ms vs 179 +/- 83 ms, P < .001) than nonsurvivors. The presence of significant dyssynchrony (>or=105 ms) and absence of myocardial viability (<5 viable segments) independently predicted 30-day mortality with hazard ratio 3.26, 95% confidence interval 1.61 to 8.33 (P < .01) and hazard ratio 1.72, 95% confidence interval 1.59 to 1.89 (P < .01), respectively. All but 2 patients (94.1%) with viable myocardium and without left ventricular dyssynchrony survived coronary artery bypass surgery as compared with only 12 (52.2%) patients with nonviable myocardium and severe dyssynchrony (P < .001)., Conclusions: In high-risk patients with ischemic left ventricular dysfunction having coronary artery bypass surgery, both myocardial viability and left ventricular dyssynchrony are important predictors of perioperative outcome. Assessment of myocardial viability and left ventricular dyssynchrony should be a routine part of the preoperative evaluation of these patients.

Objectives: The objective of the present study was to assess the relationship between the presence of left ventricular (LV) dyssynchrony and clinical outcome in patients with moderate systolic heart failure undergoing coronary artery bypass graft (CABG) surgery., Background: The presence of LV dyssynchrony is associated with poor prognosis in patients with LV dysfunction., Methods: The study consisted of 215 consecutive patients with ischemic cardiomyopathy and dyspnea (age 65 +/- 9 years, 81% male) undergoing CABG. Dyssynchrony was calculated by tissue Doppler imaging from regional time intervals in basal LV segments before and 1 month after CABG. Myocardial viability was assessed using single-photon emission computed tomography (SPECT) before CABG., Results: Twenty-five patients (11.6%) died within 30 days (in-hospital mortality) of CABG. The presence of pre-CABG dyssynchrony > or =119 ms had the highest predictive accuracy for in-hospital mortality, with a sensitivity of 84% and a specificity of 71%. During the median follow-up period of 359 days (interquartile range 219 to 561), an additional 19 patients (10.3%) died and 34 patients (18.5%) were hospitalized for worsening heart failure. At Cox regression analysis, post-CABG dyssynchrony > or =72 ms and > or =5 viable segments were identified as independent predictors of clinical events, with a hazard ratio (HR) of 5.02, 95% confidence interval (CI) 2.57 to 10.02 (p < 0.001), and an HR of 0.63, 95% CI 0.55 to 0.75 (p < 0.001), respectively. Patients without post-CABG dyssynchrony and with viable myocardium had excellent prognosis compared with patients with severe post-CABG dyssynchrony and nonviable myocardium (event rate 3% vs. 64%; p < 0.001)., Conclusions: The presence of severe LV dyssynchrony is associated with poor clinical outcomes despite revascularization. These results advocate a routine assessment of both LV dyssynchrony and viability to predict outcome in systolic heart failure patients undergoing CABG surgery.

Aims: Exercise-induced mitral regurgitation (MR) bears a poor prognosis in patients with congestive heart failure (CHF). Cardiac resynchronization therapy (CRT) is associated with improved clinical outcome but its effects on exercise-induced MR remain undetermined. We investigated serial changes in functional MR in relation to left ventricular (LV) remodelling and cardiopulmonary performance after CRT., Methods and Results: Twenty-eight patients with CHF (LV ejection fraction 25 +/- 7%), broad QRS complex (171 +/- 27 ms), and at least mild MR [effective regurgitant orifice (ERO) 0.25 +/- 0.12 cm2] were studied with quantitative exercise echocardiography and cardiopulmonary exercise testing prior, within 1 week, and 3 months after CRT. Early after CRT, a decrease in LV dyssynchrony (from 54 +/- 21 to 19 +/- 7 ms, P < 0.001) and in MR at rest (ERO from 0.25 +/- 0.12 to 0.20 +/- 0.10 cm2, P = 0.047) was observed. However, no change in exercise-induced increase in MR was observed (ERO from 0.34 +/- 0.12 to 0.31 +/- 0.16 cm2, NS). Three months after CRT, a decrease in the mitral valve tenting area (from 3.3 +/- 1.2 to 2.0 +/- 0.6 cm2, P < 0.001) and an increase in LV sphericity index (from 1.5 +/- 0.3 to 1.8 +/- 0.5, P < 0.001) were paralleled by an attenuation of exercise-induced MR (ERO 0.19 +/- 0.06 cm(2), P = 0.001 vs. prior CRT). This was associated with an increase in LV ejection fraction (from 25 +/- 7 to 35 +/- 9%, P < 0.001), peak oxygen uptake (from 11.7 +/- 2.4 to 13.7 +/- 3.8 mL/kg/min, P = 0.001), and a decrease in Nt-pro-BNP (from 2777 +/- 1681 to 1963 +/- 1361 pg/mL, P = 0.067)., Conclusion: CRT is associated with acute decrease in resting MR but does not immediately attenuate exercise-induced MR. In contrast, only late, CRT-induced reversed LV remodelling and reduced mitral apparatus deformation are associated with a reduction in both resting and exercise-induced MR and with an improvement in cardiopulmonary performance.

Aims: To assess the accuracy of tissue Doppler imaging-derived myocardial positive pre-ejection velocity (+Vic) in detecting myocardial viability defined by dobutamine stress echocardiography (DSE), fluorine-18 fluorodeoxyglucose positron emission tomography (PET), and contrast-enhanced magnetic resonance imaging (MRI), and in predicting recovery of left ventricular (LV) function after coronary artery bypass grafting (CABG) in patients with chronic ischaemic LV dysfunction., Methods and Results: +Vic in dysfunctional segments was recorded in 54 patients treated medically and 65 patients undergoing CABG [age 67 +/- 9 year; LV ejection fraction (EF) 30 +/- 6%]. A good agreement was observed between +Vic and detection of viable myocardium at DSE, PET, and MRI (kappa = 0.76). The presence of +Vic in greater than or equal to five dysfunctional segments had the highest sensitivity (93%) and specificity (60%) to identify patients (n = 28) with > or =10% increase in LV EF between baseline and 6-month echocardiogram. During follow-up (median 333 days, interquartile range 209-490 days), 13 cardiac events (6 deaths, 7 hospitalizations) occurred in 24 patients with small extent of viable myocardium (< 5 + Vic), whereas only four hospitalizations in 39 patients with > or =5 + Vic (54% vs. 10%; P < 0.001)., Conclusion: The extent of +Vic in dysfunctional segments accurately predicts extent of viable myocardium and bears a clinical prognostic value in patients with ischaemic LV dysfunction considered for CABG.

Background: Cardiac resynchronization therapy was shown to reverse left ventricular (LV) remodeling in patients with congestive heart failure (CHF). However, the prediction of benefit is controversial. We aimed to investigate predictive factors of LV functional recovery and reversed remodeling after biventricular pacing., Methods and Results: Forty-nine consecutive patients with CHF and a wide QRS complex (182+/-32 ms) were studied by echocardiography before resynchronization. Intraventricular and interventricular asynchrony and their combination were assessed by pulsed-wave tissue Doppler imaging from measurements of regional electromechanical coupling times in basal segments of the right and left ventricle. At 6-month follow-up, responders were defined by a relative increase in LV ejection fraction > or =25% compared with baseline (n=27). Receiver operating curve analysis revealed the degree of intraventricular asynchrony (area under the curve=0.77), interventricular asynchrony (area under the curve=0.69), and their combination (area under the curve=0.84) as the best predictors of functional recovery after resynchronization. In addition, the degree of intraventricular and interventricular asynchrony correlated significantly with the improvement of LV ejection fraction (r=0.73, P<0.0001), end-diastolic diameter (r=-0.59, P<0.0001), and end-systolic diameter (r=-0.48, P<0.001) at follow-up. QRS duration and conventional echo-Doppler indices were not predictive of reversed LV remodeling., Conclusions: In patients with CHF, the degree of intraventricular and interventricular asynchrony and their combination are the best predictive factors of LV functional recovery and reversed remodeling after cardiac resynchronization therapy.