Nonechocardiographic imaging in evaluation for cardiac resynchronization therapy.
Nonechocardiographic imaging in evaluation for cardiac resynchronization therapy.
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DOI：
10.1161/circimaging.111.963504
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发表时间：
2011-05
期刊：
影响因子：
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通讯作者：
Marwick T
中科院分区：
文献类型：
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作者：
AlJaroudi W;Chen J;Jaber WA;Lloyd SG;Cerqueira MD;Marwick T
在心力衰竭和QRS持续时间延长的患者中，随机临床试验表明，心脏再同步化治疗（CRT）与生活质量改善、左心室重构和生存率相关。1-3这种改善被认为是由宽QRS存在时更有效的同步收缩介导的，但机械和电不同步并不等同。4,5尽管CRT反应的概念仍然存在问题，6根据电不同步标准（即QRS持续时间）接受CRT的患者中有20%至40%没有获得症状改善或表现出反向重构。7-10疤痕负担11 - 13和未能将左室起搏导联放置在最近开始收缩的部位14 - 17与不良反应有关。因此，CRT的最佳临床决策必须包括对所有这些因素的综合评估，以确定哪些心力衰竭患者将受益。左室机械非同步化的标准超声心动图参数已被广泛审查，18有600篇已发表的文章。这项工作大部分是使用组织多普勒成像完成的，最近的工作使用散斑跟踪，19,20 3D超声心动图，21超声心动图对比成像，22和心内超声心动图。23尽管组织多普勒成像具有高时间分辨率、单个中心的成功以及评估疤痕负荷影响和左室导联与最新激活位点一致性的能力等重要优势，但14组织多普勒成像的基本局限性包括无法测量足够数量的心动周期以克服搏动变化、图像质量差和测量误差。在唯一一项针对宽QRS患者的CRT随机试验中，12种不同的超声心动图非同步化参数未能改善结果，最有可能与观察者之间和观察者内部的较大变异性有关（分别为4%至24%和7%至72%）。超声心动图的这些局限性促使人们寻找非超声心动图成像技术来优化CRT前的决策（表1）。
In patients with heart failure and prolonged QRS duration, randomized clinical trials have shown that cardiac resynchronization therapy (CRT) is associated with improvement in quality of life, left ventricular (LV) remodeling, and survival. 1–3 The improvements are believed to be mediated by more effective synchronized contraction in the presence of a wide QRS, but mechanical and electrical dyssynchrony are not equivalent. 4, 5 Although the concept of CRT response remains problematic, 6 20% to 40% of patients who receive CRT based on electrical dyssynchrony criteria (ie, QRS duration) do not derive symptom improvement or demonstrate reverse remodeling. 7–10 Scar burden11–13 and failure to place the LV pacing lead at the site of latest onset of contraction14–17 have been linked to a poor response. Thus, optimal clinical decision-making for CRT must include a comprehensive evaluation of all these factors to identify patients with heart failure who will benefit. The standard echocardiographic parameters of LV mechanical dyssynchrony have been extensively reviewed, 18 with 600 published articles. Most of this work has been done using tissue Doppler imaging, with more recent work using speckle tracking, 19, 20 3D echocardiography, 21 echocardiographic contrast imaging, 22 and intracardiac echocardiography. 23 Despite the important benefits of high temporal resolution, success in individual centers, and ability to assess the impact of scar burden and concordance of LV lead with latest activation site, 14 fundamental limitations of tissue Doppler imaging include the inability to measure over a sufficient number of cardiac cycles to overcome beat-to-beat variation, poor image quality, and measurement error. 24 In the only randomized trial of CRT in patients with wide QRS, 25 the failure of 12 different echocardiographic dyssynchrony parameters to improve outcome was most likely related to the large interobserver and intraobserver variability (4% to 24% and 7% to 72%, respectively). These limitations of echocardiography have led to a search for nonechocardiographic imaging techniques to optimize decision-making before CRT (Table 1).