Ουδεµία σύγκρουση συµφερόντων
Καρδιακός ασυγχρονισµός και ηχωκαρδιογραφία Η αναζήτηση του Αγιου Δισκοπότηρου Αλέξανδρος Στεφανίδης, MD, FESC Καρδιολόγος, Α Καρδιολογικό τµήµα, Γ.Ν.Νίκαιας
Solvay conference, 1927, Brussels
Το λυκόφως της ηχωκαρδιογραφίας? J Am Coll Cardiol 2009;53:1944 59 J Am Coll Cardiol 2009;53:1960 4
All our science measured against reality, is primitive and childlike. and yet it is the most precious thing we have Einstein, 1956
ΦΥΣΗ Καρδιά Echo Ανθρωπος
Καθαρές κουβέντες για να συνεχίσουµε Αξίζει η αναζήτηση? Αναγνωρίζουµε τα λάθη µας? Είµαστε στο σωστό δρόµο? Πώς θα το αναγνωρίσουµε? Και µετά τι ακολουθεί?
Αξίζει η αναζήτηση? Fonarow et al. Eur Heart J 2011;32: 1631 9.
J Am Coll Cardiol 2014;64:1047 58
CRT Improves Quality of Life and NYHA Functional Class 0-4,5-9 Average Change in Score (MLWHF) 80% 60% NYHA: Proportion Improving 1 or More Class * * * -13,5 40% -18 * * * * MIRACLE MUSTIC SR CONTAK CD MIRACLE ICD 20% 0% MIRACLE MIRACLE ICD Control CRT Abraham et al., 2003 * P < 0.05 Control CRT 11
COMPANION Bristow et al, N Engl J Med 2004;350: 2140 50. A Boston Scientific pacemaker with CRT capabilities (CRT-P), in combination with OPT, reduced the risk of all-cause mortality or first hospitalization by 19% when compared with OPT alone. (p value: 0.015) A defibrillator with CRT capabilities (CRT-D), in combination with OPT, reduced the risk of all-cause mortality or first hospitalization by 20% when compared with OPT alone. (p value: 0.011) CRT-D, in combination with OPT, reduced the risk of all-cause mortality by 36% when compared with OPT alone. (p value: 0.004) Note: Alpha allocation: CRT-P = 0.02; CRT-D = 0.03. NO BENEFIT IN NYHA IV (Lindenfeld, et al. Circulation 2007;115: 204 12.
CARE-HF All-Cause Mortality N Engl J Med 2005; 352:1539-1549 1.00 HR 0.64 (95% CI 0.48 to 0.85) Event-free Survival 0.75 0.50 0.25 NO ICDs!!! CRT : 82pts (20%) P =.0019 Medical 120 pts Therapy (30%) 0.00 0 500 1000 1500 Days Number at risk CRT 409 376 351 213 89 8 Medical Therapy 404 365 321 192 71 5 13
Main Inclusion Criteria (cont d) QRS 120 ms Dyssynchrony confirmed by echo if QRS = 120-149 ms Aortic pre-ejection delay >140ms Inter-ventricular mechanical delay >40 ms Delayed activation of postero-lateral LV wall Main Exclusion Criteria Patients with chronic AF or requiring pacing excluded 14
Μάλλον ναι...αξίζει. Ενα αρκετά σαφές συµπέρασµα µεγάλης µελέτης επιβίωσης Μικρότερες µελέτες µε ευνοϊκά ως επί το πλείστον συµπεράσµατα Δεν διαπιστώνεται µηχανικός ασυγχρονισµός σε ανεπαρκούσες καρδιές στο 30% ασθενών µε ευρύ σύµπλεγµα QRS
Validation of an echocardiographic multiparametric strategy to increase responders patients after cardiac resynchronization: a multicentre study. Lafitte at el. European Heart Journal (2009) 30, 2880
Πρόβλεψη Ασθενείς µε 0 κριτήρια ήταν πρωτίστως µη ανταποκρινόµενοι (76%) σε CRT 4% των ανταποκρινόµενων είχαν 0 κριτήρια! European Heart Journal (2009) 30, 2880 2887
PROSPECT, eligibility criteria Class III or IV heart failure A left ventricular EF of 35% or less A QRS duration of >130 msec
Characteristics of heart failure patients associated with good and poor response to cardiac resynchronization therapy: a PROSPECT (Predictors of Response to CRT) sub-analysis. Bommel R et al. European Heart Journal (2009) 30, 2470 2477
Euro CRT Τι πήγε στραβά?
Euro CRT, eligibility criteria Class III or IV heart failure A left ventricular EF of 35% or less A QRS duration of <130 msec Echocardiographic evidence of left ventricular dyssynchrony
Echo methods 3 ch view : IVS vs posterior wall >80 ms 4 ch view: IVS vs lateral wall > 80 ms SAX view: radial strain ant IVS vs post> 130 m
Disappointing results
A second look
Considerations after Euro CRT and Prospect Pts with asynchrony (which parameter?) Does Echo direct the lead placement always? Asynchrony in ischemic heart disease? Reproducibility of measurements? Demand for new indices of asynchrony
Euro CRT study
Am Heart J 2007;154:1011-20
Inter-observer variability The newer the worse The inter-observer variability for dyssynchrony of the EchoCRT echocardiography core lab physicians in a sample of 50 randomly selected baseline echocardiograms had agreement as follows: TDI opposing wall delay apical 4-chamber view 96.2% (kappa coefficient 0.92), TDI opposing wall delay apical long-axis view 92.0% (kappa coefficient 0.84), and speckle tracking radial strain septal to posterior wall delay 90.5% (kappa coefficient 0.79).
Pairwise agreement between methods <0 Poor 0-20 Slight 0,21-0,40 Fair 0,41-0,60 Moderate 0,61-0,80 Substantial >0,80 Almost perfect
Ασυγχρονισµός και µόνο ή και κάτι άλλο? avo avc
Impact of Cardiac Resynchronization Therapy on Left Ventricular Mechanics: Understanding the Response through a New Quantitative Approach Based on Longitudinal Strain Integrals Anne Bernard, Erwan Donal, et al. J Am Soc Echocardiogr 2015;28:700-8.
Λεπτοµέρεια τάφου νεολιθικής εποχής 5000 πχ
560 πχ
Leonardo da Vinci
1 2 3 5 8 13,21,..
Am J Cardiol 2012;109:1197 1205
26% 27% 26% 27% Am J Cardiol 2012;109:1197 1205
Am J Cardiol 2012;109:1197 1205
J Am Coll Cardiol Img 2009;2:1425 35
ΚΑΡΔΙΑΚΟΣ ΑΣΥΓΧΡΟΝΙΣΜΟΣ Σηµαντική παράµετρος αποφάσεων στη διαχείριση ασθενών µε καρδιακή ανεπάρκεια Νέες µελέτες µε τριδιάστατη εκτίµηση του ασυγχρονισµού Πρέπει να υπενθυµίσουµε ότι αυτό που παρατηρούµε δεν είναι η φύση καθ εαυτή, αλλά η φύση σύµφωνα µε το αποτέλεσµα µιας έρευνας...
Werner Heisenberg (Nobel Φυσικής 1932) Physics and Philosophy: The Revolution in Modern Science (New York: Harper and Row, 1958). Lectures delivered at University of St. Andrews, Scotland, Winter 1955-56.