Predictive parameters of left ventricular reverse remodeling in response to cardiac resynchronization therapy in patients with severe congestive heart failure.

Abstract

Background: Cardiac resynchronization therapy (CRT) is useful for the treatment of severe congestive heart failure. Unfortunately up to 30% of patients could be non-responders. The aim of our study was to find parameters to predict responsiveness to CRT.

Methods: Fifteen patients (9 males, 6 females, mean age 67.3 +/- 7.8 years, range 52-83 years) with dilated cardiomyopathy, NYHA functional class III-IV, left ventricular (LV) ejection fraction < 35% and QRS > or = 110 ms, underwent CRT. All the patients had echocardiographic evidence of systolic dys-synchrony.

Results: One patient died of electromechanical dissociation. The remaining 14 patients maintained biventricular stimulation at 6 months; mean QRS width decreased from 156 to 132 ms (p < 0.001). Ten patients (71%) were considered responders because of a reduction in LV end-systolic volume > 15%. In non-responders (4 patients, 29%) LV end-systolic volume was stable in 3 patients and increased in 1. LV ejection fraction significantly increased only in responders (p < 0.001). Responders had more severe pre-pacing dyssynchrony than non-responders (p < 0.001). Inter- (p = 0.002) and intraventricular dyssynchrony (p = 0.003) did significantly reduce after CRT only in responders. On multiple regression analysis there were two independent predictors of reverse remodeling after pacing: the baseline mitral QS-tricuspid QS (QSm-QSt) time (B = -1.7, p = 0.005) and the intraventricular dyssynchrony index (B = -1.55, p = 0.007). Pre-implant QSm-QSt of 38 ms correctly identified the two groups: responders had a value > 38 ms and non-responders < 38 ms. The pre-implant intraventricular dyssynchrony index of 28 ms was the cut-off value: responders had an index > 28 ms, non-responders < 28 ms.

Conclusions: In the literature a tissue Doppler imaging index of intraventricular dyssynchrony evaluated before implantation is used to select responders to CRT. In our work we studied interventricular and intraventricular dyssynchrony, and both the QSm-QSt time and the standard deviation of the 12 LV segment QS time were correctly able to identify responders.