Combined flow-based imaging assessment of optimal cardiac resynchronization therapy pacing vector: a case report

Figures

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  Fig. 1. a Twelve-lead electrocardiogram showing the wide native QRS complex (145 ms) with first-degree atrioventricular block (PR 280 ms). b Two-dimensional color transthoracic echocardiogram apical four-chamber view. AV atrioventricular, CRT cardiac resynchronization therapy, ECG electrocardiogram, ICD implantable cardioverter defibrillator, LBBB left bundle branch block, M male, NO ISCH. DCM non-ischemic dilated cardiomyopathy, NYHA New York Heart Association, TTE transthoracic echocardiogram

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  Fig. 2. Left anterior oblique chest X-ray view displaying the left ventricular quadripolar lead (arrow)

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  Fig. 3. Quantitative analysis (to compare with the results of analysis represented in Fig. 7) by echo-particle imaging velocimetry of the orientation angle (φ) of the global hemodynamic forces exchanged between blood and surrounding tissues during acute study (post-cardiac resynchronization therapy 13-day follow-up). Left: Two-dimensional transthoracic echocardiogram high-temporal resolution contrast echocardiographies are performed by three-chamber apical view approach during acute study of different setting (a, b, c, d). Right: Changes in electrical activation settings modify the orientation of intraventricular forces during acute study. The intraventricular forces were predominantly transverse and not aligned along the LVaxis (a1) as quantified by the large value of their mean angle φ (φ = 55.6°). A first setting option (CRT ON, VV delay 0 ms) changed the orientation of intraventricular forces (b1) reducing the angle (φ = 45°), and increasing the delay (CRT ON, VV delay − 30 ms) improved the alignment (c1) reducing the angle (φ = 40.3°). The sequential biventricular activation with delay − 50 ms (d1) provided the best alignment of intraventricular forces (φ = 38.8°). CRT cardiac…

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  Fig. 4. Quantitative analysis (to compare with the results of analysis represented in Fig. 6), of functional mitral regurgitation by three-dimensional full-volume color Doppler transthoracic echocardiography: acute study (post-cardiac resynchronization therapy 13-day follow-up). Left: Setting cardiac resynchronization therapy OFF. Right: Setting cardiac resynchronization therapy ON with interventricular delay 0 ms. a, c Automated anatomy detection of the left ventricular endocardial border, mitral annulus, left ventricular outflow, and placement of three-dimensional hemispheric flow sampling planes in the mitral annulus (white arrow) and left ventricular outflow (yellow arrow). b, d Flow-time curve derived from automatic flow volume aggregation at each frame in the cardiac cycle and the automated calculation of the mitral (In SV), aortic (Out SV) stroke volume, regurgitant volume, regurgitation fraction (RF), and cardiac output (CO), with mean value, in three cardiac cycles, respectively. AVG mean value, CRT cardiac resynchronization therapy, F.U. follow-up, REG VOL regurgitant volume, TTE transthoracic echocardiogram, VV interventricular

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  Fig. 5. Left side: a Dilated left ventricle with an end-systolic volume of 380 ml, and an ejection fraction of 4.8% as was measured by the modified Simpson’s method pre-implant. b Pulsed wave Doppler mitral inflow pattern showing advanced diastolic dysfunction (deceleration time (DT) of early filling velocity, 165 ms). Right side: c Dilated left ventricle with reduced end-systolic volume of 288 ml and improved ejection fraction of 26.6% as was measured by the modified Simpson’s method post-implant at 6-month follow-up. d Pulsed wave Doppler mitral inflow pattern showing impaired relaxation. CRT cardiac resynchronization therapy, EF ejection fraction, ESV end-systolic volume, F.U. follow-up, LV left ventricle, PW pulsed wave

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  Fig. 6. Quantitative analysis (to compare with the results of analysis represented in Fig. 4), of functional mitral regurgitation by three-dimensional full-volume color Doppler transthoracic echocardiography: at 6-month follow-up setting cardiac resynchronization therapy ON interventricular delay − 50 ms. a Automated anatomy detection of the left ventricular endocardial border, mitral annulus, left ventricular outflow, and placement of three-dimensional hemispheric flow sampling planes in the mitral annulus (white arrow) and left ventricular outflow (yellow arrow). b Flow-time curve derived from automatic flow volume aggregation at each frame in the cardiac cycle and the automated calculation of the mitral (In SV), aortic (Out SV) stroke volume, regurgitant volume, regurgitation fraction (RF), and cardiac output (CO), with mean value, in three cardiac cycles, respectively. AVG mean value, CRT cardiac resynchronization therapy, F.U. follow-up, REG VOL regurgitant volume, VV interventricular

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  Fig. 7. Quantitative analysis (to compare with the results of analysis represented in Fig. 3), by echo-particle imaging velocimetry of the orientation angle (φ) of the global hemodynamic forces exchanged between blood and surrounding tissues during acute study (post-cardiac resynchronization therapy 6-month follow-up). a Two-dimensional transthoracic echocardiogram high-temporal resolution contrast echocardiography is performed by three-chamber apical view approach (see Additional file 10: Video S10 interventricular − 50 ms SONOVUE 6-month follow-up). b The polar histogram showed with setting interventricular delay − 50 ms the most aligned intraventricular forces that were partially dominated by the longitudinal path of pressure gradient (lower φ, value 43.1°). CRT cardiac resynchronization therapy, F.U. follow-up, PIV particle imaging velocimetry, TTE transthoracic echocardiogram, VV interventricular