Scholarly article on topic 'Ventricular dyssynchrony; it is a dynamic phenomenon'

Ventricular dyssynchrony; it is a dynamic phenomenon Academic research paper on "Basic medicine"

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Journal of Cardiology
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{Dyssynchrony / Dobutamine / "Stress echocardiography" / "Congestive heart failure" / "Cardiac resynchronization therapy"}

Academic research paper on topic "Ventricular dyssynchrony; it is a dynamic phenomenon"

Journal of Cardiology 61 (2013) 309-311

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Ventricular dyssynchrony; it is a dynamic phenomenon




Stress echocardiography Congestive heart failure Cardiac resynchronization therapy

Ventricular dyssynchrony and heart failure

Since the 1990s, it has been well known that many adverse effects on hemodynamics are induced by ventricular dyssynchrony [1] and that it is related to prognosis in patients with congestive heart failure [2]. Cardiac resynchronization therapy (CRT) is an encouraging treatment for patients with congestive heart failure, especially for those showing wide QRS and ventricular dyssynchrony. Several clinical trials, such as MIRACLE trial, COMPANION trial, and Care-HF trial [3] demonstrated that CRT improves prognosis in patients with congestive heart failure. Therefore, the significance of evaluation of ventricular dyssynchrony in patients with congestive heart failure is widely recognized in clinical settings.

Evaluation of ventricular dyssynchrony

Many echocardiographic parameters have been proposed to predict responders to CRT, such as septal flash, septal-posterior wall motion delay by M mode, and the differences and its standard deviation of time to peak systolic velocity of each segment of the left ventricle by tissue Doppler imaging. The PROSPECT study [4] was designed to define echocardiographic parameters to

Table 1

Review of previous literature about dynamic dyssynchrony.

predict a beneficial effect of CRT, but no single echocardiographic parameter of dyssynchrony could improve patient selection for CRT beyond QRS width. Various potential causes related to the disappointing results of the PROSPECT study were suggested, such as patient selection, low detection rate, and low inter-observer repro-ducibility of echocardiographic parameters and variability of lead position. As well as these factors, evaluation only at rest is also a big issue in evaluation of ventricular dyssynchrony because it may vary depending on the conditions. In other words, ventricular dyssynchrony is a dynamic phenomenon [5].Therefore, exercise and dobutamine stress echocardiography may emerge as new tools for predicting the effects of CRT [6-8].

Dynamic ventricular dyssynchrony assessed by stress echocardiography

It has been reported that various conditions such as exercise, drug administration, and ischemia may influence the presence and degree of ventricular dyssnchrony.

Lancellotti et al. [9] were the first to show the dynamic characteristics in ventricular dyssynchrony (Table 1). They demonstrated using exercise stress echocardiography that dynamic changes of ventricular dyssynchrony varied substantially from patient to patient. Lafitte et al. [10] demonstrated that ventricular dyssynchrony was increased in 34%, remained stable in 37%, and decreased in 29% of the patients with congestive heart failure during exercise. It has been reported that dynamic changes in ventricular dyssynchrony during exercise influenced dynamic mitral regurgitation, cardiac output, and exercise tolerance [9-11]. Kang et al. [12] showed that dynamic dyssynchrony may be a predictor for reversal

Authors/year No. of patients Underlying heart disease Stress Evaluation of dyssynchrony

Lancellotti et al., 2005 [9] 35 ICM Exercise TDI

Lafitte et al., 2006 [10] 65 ICM+DCM Exercise TDI

D'Andrea et al., 2007 [11] 60 DCM Exercise TDI

Kangetal., 2008 [12] 41 DCM Exercise TDI

Rocchi et al., 2009 [7] 64 ICM+DCM Exercise TDI

Izumoet al., 2009 [14] 50 ICM+DCM Exercise 3D-echo

Chattopadhyay et al., 2008 [13] 77 ICM+DCM Dobutamine TDI

Parsai et al., 2009 [8] 52 ICM+DCM Dobutamine M-mode (septal flash)

Yagishita-Tagawa et al. [15] 33 DCM Dobutamine 3D-echo

ICM, ischemic cardiomyopathy; DCM, idiopathic dilated cardiomyopathy; TDI, tissue Doppler image; 3D-echo, three-dimensional echocardiography.

DOI of original article:

0914-5087/$ - see front matter© 2013 Published by Elsevier Ltd on behalf of Japanese College of Cardiology.

Editorial / Journal of Cardiology 61 (2013) 309-311

remodeling with medical treatment for patients with dilated cardiomyopathy.

As well as exercise stress echocardiography, dobutamine stress echocardiography has also been used to evaluate dynamic changes in ventricular dyssynchrony [8,13]. Low-dose dobutamine stress echocardiography unmasks ventricular dyssynchrony, which can predict negative remodeling after CRT [8].

Dynamic dyssynchrony with stress echocardiography was evaluated by tissue Doppler imaging in most previous papers [7,9-13]. Izumo et al. [14] evaluated exercise-induced changes in the left ventricular shape and dyssynchrony using three-dimensional echocardiography. The left ventricular geometry and function, including dyssynchrony, is three dimensional. Three-dimensional echocardiography is an ideal method to evaluate ventricular dyssynchrony in that meaning if time and spatial resolution of this method improves.

The study by Yagishita-Tagawa et al. [15] evaluated dynamic ventricular dyssynchrony during dobutamine stress echocardiog-raphy in patients with idiopathic dilated cardiomyopathy, using three-dimensional echocardiography. The positive inotropic agent, dobutamine is sometimes needed for decompensated status of heart failure in patients with low ejection fraction. However, the effectiveness of dobutamine on systolic performance varies from patient to patient in clinical settings. The authors evaluated global

left ventricular stroke volume, sum of regional left ventricular stroke volume, and dyssynchrony index using three-dimensional echocardiography. Three-dimensional echocardiography makes it possible to simultaneously measure global and regional volumetric changes (Fig. 1). The discrepancy between increase in global left ventricular stroke volume and increase in sum of regional left ventricular stroke volume is a key point of this paper, which may result from dynamic dyssynchrony. Left ventricular dyssynchrony induced by dobutamine, as was shown in this paper, may be a cause of differences in effectiveness of dobutamine among patients. We should evaluate stroke volume, left ventricular geometry, and ventricular dyssynchrony after starting dobutamine, considering the possibility of adverse effects of dobutamine on left ventricular performance.


Ventricular dyssynchrony is not a stable status but a dynamic phenomenon. Evaluation of cardiac performance with stress echocardiography, including dynamic dyssynchrony, gives us additional information about pathophysiology, response to drug administration and prediction of prognosis in patients with congestive heart failure.

Fig. 1. Evaluation of dyssynchrony by three-dimensional echocardiography.

Editorial / Journal of Cardiology 61 (2013) 309-311


[1] Grines CL, Bashore TM, Boudoulas H, Olson S, Shafer P, Wooley CF. Functional abnormalities in isolated left bundle branch block. The effect of interventricular asynchrony. Circulation 1989;79:845-53.

[2] Baldasseroni S, OpasichC, Gorini M, Lucci D, Marchionni N, Marini M, Campana C, Perini G, Deorsola A, Masotti G, Tavazzi L, Maggioni AP, Italian Network on Congestive Heart Failure Investigators. Left bundle-branch block is associated with increased 1-year sudden and total mortality rate in 5517 outpatients with congestive heart failure: a report from the Italian network on congestive heart failure. Am Heart J 2002;143:398-405.

[3] Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, Tavazzi L, Cardiac Resynchronization-Heart Failure (CARE-HF) Study Investigators. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005;352:1539-49.

[4] Chung ES, Leon AR, Tavazzi L, Sun JP, Nihoyannopoulos P, Merlino J, Abraham WT, Ghio S, Leclercq C, BaxJJ, Yu CM, Gorcsan III J, St John Sutton M, De Sut-ter J, Murillo J. Results of the predictors of response to CRT (PROSPECT) trial. Circulation 2008;117:2608-16.

[5] Lancellotti P, Moonen M. Left ventricular dyssynchrony: a dynamic condition. Heart Fail Rev 2012;17:747-53.

[6] Moonen M, O'Connor K, Magne J, Lancellotti P, Pierard LA. Stress echocardiography for selecting potential responders to cardiac resynchronization therapy. Heart 2010;96:1142-6.

[7] Rocchi G, Bertini M, Biffi M, Ziacchi M, Biagini E, Gallelli I, Martignani C, Cervi E, Ferlito M, Rapezzi C, Branzi A, Boriani G. Exercise stress echocardiography is superiorto rest echocardiography in predicting left ventricular reverse remodeling and functional improvement after cardiac resynchronization therapy. Eur HeartJ 2009;30:89-97.

[8] Parsai C, Baltabaeva A, Anderson L, Chaparro M, Bijnens B, Sutherland GR. Low-dose dobutamine stress echo to quantify the degree of remodeling after cardiac resynchronization therapy. Eur Heart J 2009;30:950-8.

[9] Lancellotti P, Stainier PY, Lebois F, Pierard LA. Effect of dynamic left ventricular dyssynchrony on dynamic mitral regurgitation in patients with heart failure due to coronary artery disease. Am J Cardiol 2005;96: 1304-7.

[10] Lafitte S, Bordachar P, Lafitte M, Garrigue S, Reuter S, Reant P, Serri K, Lebouffos V, Berrhouet M, Jais P, Haissaguerre M, Clementy J, Roudaut R, DeMaria AN. Dynamic ventricular dyssynchrony. An exercise-echocardiography study. J Am Coll Cardiol 2006;47:2253-9.

[11] D'Andrea A, Caso P, Cuomo S, Scarafile R, Salerno G, Limongelli G, DiSalvo G, Severino S, Ascione L, Calabro P, Romano M, Romano G, Santangelo L, Maiello C, Cotrufo M, et al. Effect of dynamic myocardial dyssynchrony on mitral regurgitation during supine bicycle exercise stress echocardiography in patients with idiopathic dilated cardiomyopathy and 'narrow' QRS. Eur HeartJ 2007;28:1004-11.

[12] Kang SJ, Lim HS, Choi BJ, Choi SY, Yoon MH, Hwang GS, Shin JH, Tahk SJ. The impact of exercise-induced changes in intraventricular dyssynchrony on functional improvement in patients with nonischemic cardiomyopathy. J Am Soc Echocardiogr 2008;21:948-53.

[13] Chattopadhyay S, Alamgir MF, Nikitin NP, Fraser AG, Clark AL, Cleland JGF. The effect of pharmacological stress on intraventricular dyssynchrony in left ventricular systolic dysfunction. EurJ Heart Fail 2008;10:412-20.

[14] Izumo M, Lancellotti P, Suzuki K, Kou S, Shimozato T, Hayashi A, Akashi YJ, Osada N, Omiya K, Nobuoka S, Ohtaki E, Miyake F. Three-dimensional echocar-diographic assessments of exercise-induced changes in left ventricular shape and dyssynchrony in patients with dynamic functional mitral regurgitation. EurJ Echocardiogr 2009;10:961-7.

[15] Yagishita-Tagawa Y, Abe Y, Arai K, Yagishita D, Takagi A, Ashihara K, Shoda M, Naruko T, Itoh A, Haze K, Yoshikawa J, Hagiwara N. Low-dose dobutamine induces left ventricular mechanical dyssynchrony in patients with dilated car-diomyopathy and a narrow QRS: a study using real-time three-dimensional echocardiography. J Cardiol 2013;61:275-80.

Chisato Izumi (MD, FJCC) * Department of Cardiology, Tenri Hospital, Nara,

* Correspondence address: Department of Cardiology, Tenri Hospital, 200 Mishima-cho, Tenri-city, Nara, Japan. Tel.: +81 743 63 5611;

fax: +81 743 63 1530.

E-mail address:

15 January 2013 Available online 6 March 2013