Echocardiography-derived hemodynamic forces in cardiac resynchronization therapy: association with reverse remodeling and long-term outcomes

Journal of the American Society of Echocardiography

Abstract

BACKGROUND: Cardiac resynchronization therapy (CRT) improves survival and symptoms in patients with heart failure with reduced ejection fraction and electromechanical dyssynchrony, yet up to 30-40% do not respond despite guideline-based selection. Hemodynamic forces (HDF) quantify intraventricular pressure gradients and can be derived from routine echocardiographic images. The aim of this study was to assess the predictive and prognostic value of HDF parameters in patients undergoing CRT and to investigate changes in HDF after CRT implantation. METHODS: The following HDF parameters were assessed in 198 patients from the multicenter, prospective MARC study: (i) apical-basal force, (ii) latero-septal force (iii) their ratio (iv) force vector angle, (v) systolic apical-basal force, (vi) systolic angle. CRT response was defined as ≥15% reduction in left ventricular end-systolic volume (LVESV) at 6 months. The composite outcome of all-cause mortality or cardiovascular hospitalization was analyzed using Cox regression models with long-term follow-up. RESULTS: 120 patients (60.6%) demonstrated echocardiographic response to CRT at 6 months. The addition of baseline systolic angle to clinical, electrocardiographic, and conventional echocardiographic markers of dyssynchrony significantly improved model fit for CRT response, although discrimination was not significantly improved. Responders showed significant improvement in HDF parameters after CRT, whereas no significant changes were observed in non-responders. During a median follow-up of 9.3 years, baseline systolic angle was independently associated with the composite endpoint of all-cause mortality or cardiovascular hospitalization and significantly improved risk stratification when added to established prognostic markers. CONCLUSION: HDF parameters provide complementary descriptive insight into ventricular mechanics in patients undergoing CRT. Baseline systolic angle was independently associated with both reverse remodeling and long-term outcome, although discrimination was not significantly improved. While these findings suggest potential value for HDF assessment, further research is warranted to determine the clinical relevance in CRT patients.

Authors 23

1. Roberto Tarantini

   University Medical Center Utrecht

   Affiliation as printed

   Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: https://twitter.com/rotarantini

2. Willem Gerrits

   University Medical Center Utrecht

   Affiliation as printed

   Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands

3. Cheyenne S L Chiu

   University Medical Center Utrecht

   Affiliation as printed

   Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands

4. Leonie Smit

   University Medical Center Groningen · University of Groningen

   Affiliation as printed

   Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

5. Gilbert Heltzel

   Maastricht University

   Affiliation as printed

   Maastricht University, Maastricht, The Netherlands

6. Luuk H G A Hopman

   Amsterdam University Medical Centers

   Affiliation as printed

   Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands

7. Philippe C. Wouters

   University Medical Center Utrecht

   Affiliation as printed

   Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands

8. Maarten Jan Cramer

   University Medical Center Utrecht

   Affiliation as printed

   Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands

9. Frebus J. van Slochteren

   University Medical Center Utrecht

   Affiliation as printed

   Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands; CART-Tech BV, Utrecht, The Netherlands

10. René van Es

    University Medical Center Utrecht

    Affiliation as printed

    Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands

11. Alexander H. Maass

    University Medical Center Groningen · University of Groningen

    Affiliation as printed

    Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

12. Michiel Rienstra

    University Medical Center Groningen · University of Groningen

    Affiliation as printed

    Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

13. Cornelis P. Allaart

    Radboud University Nijmegen · Radboud University Medical Center · Amsterdam University Medical Centers

    Affiliation as printed

    Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands; Department of Cardiology, Radboud UMC, Nijmegen, the Netherlands

14. Kevin Vernooy

    Maastricht University Medical Centre · Maastricht University

    Affiliation as printed

    Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands

15. Antonius M W van Stipdonk

    Maastricht University Medical Centre · Maastricht University

    Affiliation as printed

    Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands

16. Frederik J. de Lange

    Amsterdam University Medical Centers

    Affiliation as printed

    Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands

17. Dorien Laenens Aachen

    Leiden University Medical Center · AZ Sint-Maarten

    Affiliation as printed

    Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, AZ Sint Maarten Hospital, Mechelen, Belgium

18. Philippe J. van Rosendael Aachen Department of Cardiology, Leiden University Medical Center

    Leiden University Medical Center

    Affiliation as printed

    Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands

19. Jeroen Joost Bax Aachen Department of Cardiology, Leiden University Medical Center

    Leiden University Medical Center

    Affiliation as printed

    Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands

20. Nina Ajmone Marsan Aachen Department of Cardiology, Leiden University Medical Center

    Leiden University Medical Center

    Affiliation as printed

    Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands

21. Mathias Meine

    University Medical Center Utrecht

    Affiliation as printed

    Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands

22. Robin Nijveldt

    University Medical Center Utrecht

    Affiliation as printed

    Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands

23. Marco Guglielmo

    Utrecht University · University Medical Center Utrecht

    Affiliation as printed

    Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Radiology, University Medical Center Utrecht, Utrecht, the Netherlands