Key result
Combining mechanical dyssynchrony and septal scarring improves CRT response prediction to an AUC of ~0.86.
Why the study?
Mechanical dyssynchrony predicts reverse remodelling after CRT while myocardial scar reduces CRT efficacy, prompting investigation of whether combined assessment of both markers reliably identifies responders.
Does the combined assessment of mechanical dyssynchrony and septal scarring improve the identification of CRT responders compared to mechanical dyssynchrony alone?
Cohort (n=170)
Outcome assessors blinded
Yes
Does the combined assessment of mechanical dyssynchrony and septal scarring improve the identification of CRT responders compared to mechanical dyssynchrony alone?
Effect estimate: AUC 0.86 (95% CI 0.79-0.91)
p-value: p=<0.01
Integrating CMR-based or clinical septal scarring data with echocardiographic indices of mechanical dyssynchrony substantially improves prediction of left ventricular reverse remodeling and long-term survival in CRT candidates.
Combined assessment may refine CRT responder identification beyond dyssynchrony alone; hypothesis-generating and requires prospective validation.
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.
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Duchenne et al. (2023) conducted a cohort in Heart failure with indication for CRT (n=170). Combined assessment of mechanical dyssynchrony and septal scarring vs. Mechanical dyssynchrony alone was evaluated on CRT response (defined as a ≥15% reduction in LV end-systolic volume 12 months after implantation) (AUC 0.86, 95% CI 0.79-0.91, p=<0.01). The combined assessment of mechanical dyssynchrony (septal flash or apical rocking) and septal scarring predicted CRT response with an AUC of 0.86, performing significantly better than mechanical dyssynchrony alone.
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