Tipos de juego y de juguetes asociados a roles de género

n ajmone marsan, G B Bleeker, C Ypenburg, R J van Bommel, S Ghio, N R van de

Veire, V Delgado, E R Holman, E E van der Wall, M J Schalij, and J J Bax

Heart Rhythm 2008;5:1257-64.

Chapter 9

170

abstract

objectives: Real-time 3-dimensional echocardiography (RT3DE) is a novel promis- ing technique for the assessment of left ventricular (LV) dyssynchrony. Aim of this study was to explore the value of RT3DE to assess LV and left atrium (LA) reverse remodeling and to predict response to cardiac resynchronization therapy (CRT).

methods: A total of 57 consecutive heart failure patients scheduled for CRT were included and RT3DE was performed before and 6 months after implantation. LV dys- synchrony was defined as the standard deviation of the time to reach the minimum systolic volume for 16 LV segments, expressed in percentage of cardiac cycle (systolic dyssynchrony index, SDI). Patients were divided in responders or non-responders, based on a reduction ≥15% in LV end-systolic volume after CRT.

results: Six patients (10%) were excluded from further analysis because of subopti- mal images. Out of the remaining 51 patients, 34 (67%) were classified as respond- ers. Baseline characteristics were similar between responders and non-responders, except for the SDI, which was larger in responders (9.7±3.6% vs. 5.1±1.8%, p <0.001). ROC curve analysis revealed that a cut-off value for SDI of 6.4% yielded a sensitivity of 88% with a specificity of 85% to predict response to CRT. In responders, RT3DE also demonstrated beneficial effects of CRT on LA: 1) significant LA reverse remodel- ing; 2) significant improvement in LA total emptying fraction and in LA conduit and reservoir function.

conclusions: RT3DE allows assessment of changes in LV and LA volumes and func- tion after CRT and it is highly predictive for response to CRT.

171 RT3DE predicts LV and LA reverse remodeling after CRT

IntroductIon

Cardiac resynchronization therapy (CRT) is considered an additional therapeutic option in

heart failure patients who remain highly symptomatic despite optimized medical treatment 1_.

Large studies have demonstrated a significant improvement in clinical and echocardiographic

endpoints 2_{. However, up to 30% of the patients do not respond to CRT when selection is}

based on the traditional clinical and electrocardiographic criteria 3_{. In the search for better}

selection criteria for CRT, it has been demonstrated that a direct echocardiographic assess-

ment of left ventricular (LV) dyssynchrony is highly predictive for response to CRT 4_{. A novel}

echocardiographic technique has emerged for the assessment of LV dyssynchrony based on the analysis of regional volumetric changes: real time three-dimensional echocardiography (RT3DE). Promising results for the assessment of LV dyssynchrony have been shown when RT3DE was applied in patients with varying degrees of LV dysfunction and in normal subjects

5_{. Furthermore, we have recently shown the value of RT3DE to predict acute echocardio-}

graphic response to CRT 6_{. Clinically more important however, is the response at long-term}

follow-up. In the current study, the value of RT3DE both to assess LV reverse remodeling and to predict echocardiographic response to CRT was evaluated at 6 months follow-up.

In addition, it has been recently demonstrated that RT3DE provides a highly accurate evaluation of left atrium (LA) size and function 7,8 _{that are established markers of adverse}

cardiovascular outcomes 9–11_{. Only few data are available about the effect of CRT on LA re-}

modeling and function 12_{. In the current study, it was hypothesized that a favorable response}

to CRT would also lead to an improvement in LA size and function.

methods

patient population and protocol

The study population consisted of 57 consecutive patients with heart failure scheduled for CRT implantation. Traditional selection criteria for CRT were applied: New York Heart Associa- tion (NYHA) functional class III-IV, LV ejection fraction (EF) ≤35%, and QRS duration >120ms. Patients with atrial fibrillation were excluded to allow a complete evaluation of LA function. Of

note, acute results after CRT in 42 of these patients have been reported recently 6_{. Before CRT}

implantation and at 6 months follow-up, clinical status (including NYHA class, 6-minute walk- ing distance and Minnesota quality-of-life score) was assessed and LV and LA size and func- tion were measured using RT3DE. Assessment of mitral regurgitation and LV filling pattern was performed using 2D Color-Doppler echocardiography. The echocardiographic analysis was performed by an experienced observer blinded to pre- and post-implantation data.

Chapter 9

172

real-time 3-dimensional echocardiography

Patients were imaged with a commercially available system (iE33, Philips Medical Systems, Bothell, Washington, USA) equipped with an X3, fully sampled matrix transducer. Apical full-volume data sets were obtained combining, within 1 breath-hold, 7 small real-time sub- volumes to provide a larger pyramidal volume. Frame rate ranged from 20 to 35 frames/sec. A 3D data set was considered unsuitable for analysis if >2 segments could not be visualized or if it contained visible translation artifacts. RT3DE data sets were stored digitally and quantitative analysis was performed off-line using a semi-automated contour tracing algorithm (Q-Lab, version 5.0, Philips Medical Systems); post-processing of the images required 5-7 minutes.