Relation of left-ventricular dyssynchrony by phase analysis of gated SPECT images and cardiovascular events in patients with implantable cardiac defibrillators

doi:10.1007/s12350-009-9169-7

Journal of Nuclear Cardiology

Volume 17, Issue 3, June 2010, Pages 398-404

https://doi.org/10.1007/s12350-009-9169-7 Get rights and content

Abstract

Background

Left-ventricular (LV) dyssynchrony could be measured by gated SPECT myocardial perfusion imaging (MPI). This study examined the relation between the degree of dyssynchrony and outcome in patients with implantable cardiac defibrillators (ICDs).

Methods and Results

We studied 70 patients with ICD and LV ejection fraction (EF) <.40 by gated MPI (performed within 6 weeks of the device implantation). The images were re-processed using phase analysis to derive phase standard deviation (SD) and histogram bandwidth. All-cause mortality and appropriate ICD shocks were identified as the primary endpoint. There were 87% men, aged 62 ± 11 years. The EF was 26 ± 8% (range 12%-39%). The phase SD was 51° ± 20° (range 12°-99°) and the histogram bandwidth was 157° ± 72° (range 21°-327°). The SD and bandwidth were significantly greater than corresponding values in patients with normal EF (15.8 ± 11.8° and 42.0 ± 28.4°, respectively, P < .0001, each). At 1 year, 8 patients (11%) died or had shocks. The patients with events had higher phase SD than those without events (60 ± 5° vs 50 ± 21°, P = .002). The histogram bandwidth was also higher in those with events (185 ± 37 vs 154 ± 75, P = .07). All patients with event had a phase SD ≥ 50°, while none of the patients with a phase SD < 50° (N = 26) had an event (P = .02).

Conclusions

The severity of LV dyssynchrony by phase analysis in patients with LV dysfunction, and ICD is associated with increased risk of death and appropriate ICD shock; a phase SD < 50° was associated with no events at 1 year.

Introduction

In patients with left-ventricular (LV) dysfunction and reduced ejection fraction (EF), an implantable cardiac defibrillator (ICD) reduces mortality.¹^,² Also cardiac resynchronization therapy (CRT) has been shown to improve quality of life and survival in a select group of patients with heart failure.³^,⁴ Most of these patients have LV mechanical dyssynchrony, but the correlation between electrical (QRS duration) and mechanical dyssynchrony is only fair (r = .4-.5).⁵^,⁶ It is estimated that more than one-third of patients with CRT and two-third of patients with ICD do not benefit from the advanced therapy.7, 8, 9, 10, 11

Myocardial dyssynchrony can be quantitated with different imaging modalities but has more extensively been studied with echocardiography.¹²^,¹³ More recently, phase analysis of gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) has been used to assess LV dyssynchrony.14, 15, 16 Unlike echocardiography, the phase analysis is automated and reproducible.¹⁷ The phase standard deviation (SD) and bandwidth have been most useful in separating patients with and without dyssynchrony.14, 15, 16, 17, 18 The SD represents the LV phase distribution, and the bandwidth represents the phase range during which 95% of the LV is initiating contraction. Henneman et al reported that a SD of 43° best separated responders from nonresponders to CRT.¹⁹

This study examined the relationship of the degree of dyssynchrony, by phase analysis, in patients with ICD (implanted for clinical indications) to outcome (death or appropriate shocks).

Section snippets

Patient Selection

The study population was selected based on the following inclusion criteria: (1) Age > 18 years, (2) LVEF < .40, and (3) stress/rest-gated SPECT MPI (exercise or pharmacologic) within 6 weeks of the ICD implantation date and no revascularization procedure in between. Patients with hypertrophic obstructive cardiomyopathy, congenital heart disease, or patient with CRT plus ICD who had the MPI after the device implantation were excluded. Of the 290 patients in the database, 70 patients met the

Results

There were 70 patients (87% men) aged 62 ± 11 years. The pertinent data are listed in Table 1. One-third of the patients had CRT plus ICD. The LV volumes, EF, perfusion defects, and phase indices are listed in Table 2. The patients had dilated LV cavity, large perfusion defects (mostly fixed defects consistent with scar), and depressed EF. The mean phase SD was 51 ± 20° (range 12-99°) and the histogram bandwidth 157 ± 72° (range 21-327°). These values were significantly greater than those in

Discussion

The main conclusion of this study is that patients who had ICD for clinical indications and who have more severe degree of LV dyssynchrony, as measured by phase SD, are at higher risk of events (death or appropriate shocks). This study, despite the small number of patients and events, is the first to provide correlative outcome data to phase analysis by a method other than echocardiography.

Heart failure affects more than 5 million individuals in the United States and is one of the leading

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Among 1,310 patients with a median age of 64 years (interquartile range: 55 to 72 years), 69.7% were male and 2.6% had left bundle branch block. Overall, 241 (18.4%) and 238 (18.2%) patients had significant systolic and diastolic mechanical dyssynchrony, respectively, and 211 (16.1%) had both. After a median follow-up of 7.1 years, 543 deaths occurred. At 5 years, the mortality estimate was 21.2% among patients with a normal degree of diastolic left ventricular mechanical dyssynchrony (LVMD) and 41.7% among those with an abnormal degree of LVMD (p < 0.001). When added to clinical comorbidities, electrical dyssynchrony, and systolic LVMD, diastolic dyssynchrony was incrementally associated with cardiovascular mortality (global chi-square statistic of 211.9 vs. 222.8; 2 degrees of freedom; p = 0.004). In a model that also includes left ventricular ejection fraction, the addition of diastolic dyssynchrony to systolic dyssynchrony maintained an incremental prognostic benefit (global chi-square statistic of 234.8 vs. 241.8; p = 0.030). Adjustment for baseline ischemia and scar burden did not change this relationship.
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: See related editorial on doi:10.1007/s12350-010-9222-6.

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Original ArticleRelation of left-ventricular dyssynchrony by phase analysis of gated SPECT images and cardiovascular events in patients with implantable cardiac defibrillators

Abstract

Background

Methods and Results

Conclusions

Introduction

Section snippets

Patient Selection

Results

Discussion

J Nucl Cardiol

J Nucl Cardiol

Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Am Coll Cardiol

Am J Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Nucl Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol Img

Original Article
Relation of left-ventricular dyssynchrony by phase analysis of gated SPECT images and cardiovascular events in patients with implantable cardiac defibrillators