Analysis of ventricular synchrony: A complex puzzle

Journal of Nuclear Cardiology, Mar 2018

Guillermo Romero-Farina, Santiago Aguadé-Bruix

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Analysis of ventricular synchrony: A complex puzzle

Received Feb Analysis of ventricular synchrony: A complex puzzle Guillermo Romero-Farina 0 FASNC 0 1 2 Santiago Aguade´-Bruix 0 0 Reprint requests: Guillermo Romero-Farina MD , PhD, FESC, FASNC , Cardiology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Auto`noma de Barcelona , Paseo Vall d'Hebron 119-129, 08035, Barcelona , Spain; guir- 1 Department of Nuclear Medicine, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Auto`noma de Barcelona , Barcelona , Spain 2 Cardiology Department, Hospital Universitari Vall d'Hebron, Institut de Recerca (VHIR), Universitat Auto`noma de Barcelona , Barcelona , Spain - The following editorial was focused on the most relevant points of the article by Malik et al.:1 firstly, normal cut-off values of phase analysis parameters and different variables that influence in the ventricular synchrony analysis; secondly, the impact of the duration of type II diabetes mellitus on left ventricular mechanical synchrony analysis; thirdly, the repercussions on the cardiac function of the diseases associated with diabetes mellitus (DM), and its complications; and fourthly, a normal gated SPECT definition. In the last 13 years, we have a new tool in the area of nuclear cardiology called analysis of left ventricle synchrony. Since 2005, several articles2–20 have been published in relation to the normal cut-off values (Table 1), and diagnosis and prognosis (Table 2). From a physiological point of view, the study of the mechanical synchronization of the ventricles is very complex. Among the different publications, there is a general agreement between the average values and the cut-off values normality obtained; however, in spite of that they are not exactly concordant. This is due to the fact that these cut-off values depend on multiple variables, which are difficult to control in the statistical analysis (Figure 1). Until now, all the information provided by different groups of researchers have taught us that these influential variables can be grouped into four main categories (Figure 1): type of software, type of statistical methodology to find the appropriate cut-off values, the moment that images are acquired, and clinical patient data. But probably, as experimental studies show21, the most complex thing to control is the effect of the intrinsic myocardial properties on ventricular synchrony, which are specific to each patient. Through different mechanisms, patients with DM have high cardiovascular morbidity and mortality. The left ventricular diastolic dysfunction,22,23 systolic dysfunction,24 and left ventricular mechanical dyssynchrony (LVMD)1 are frequent. In this issue of Journal of Nuclear Cardiology, Malik et al. evaluated retrospectively 146 consecutive patients with normal gated SPECT-MPI.1 LVMD was determined by the cut-off values (mean ? 2 SD) observed for phase standard deviation (SD) and phase bandwidth (BW) from the control subjects. LVMD was detected in 24 (28%) DM patients with the pre-defined cut-off values for SD ([ 10.8) and BW ([ 35.6) derived from the controls. Hyperlipidemia, overweight/obesity, duration of DM, and its long-term complications were independently associated with LVMD, with long-term complications being the highest risk factor (OR 28.00; p \ 0.001). The authors concluded that the evolution time of the patients with type II DM affects the left ventricular mechanical synchrony. In this study, long-term type II diabetes complications (nephropathy, neuropathy, neuropathy, and/or retinopathy) were present in 27.9% (24/86) of patients, and 18 of them (18/24, 75%) had LVMD. Therefore, the cause and the degree of LVMD is not only due to the K – S – S 6 M s i s ly t- /s t o a s s s /n n s a Po tre re e Y s 2 2 ± ± s ) n t 4 s a ien ,n , irng (–0 ica tee eM s l ta ry o g , d o t d b . a , ifttrrcaenooo jtrssceuubpo l,traaTEPeSdCGm ii.tttsaPeebuhdow iiittrssvehhupoow i,ifrssccaaaeeddo iittrrrcayveennnoo iittrraaayhhnngom i()fftrssceeenudpo llitaanndoowm liittraaaybenngom Itr-sssTEPPSeCM litrceeennuddow ittsyeuhnd ifftrsscaeeenudpo lisssssaayvebeud iitttscaaavenunqd itseuhdwmm Biftrscaeh3oow it-seenngp17o5m li.ttrcaehudoomW isssaaeennddo iiiftrscaaenddoom .itrsayeehnnnpdo iitttrraayuhhhomW .saaeg5613±w issaxyenddBowm ..and62±522 l..frae72±722om ljftsscaaeebenudm litrscyveeep ir g o o C N N – 3 / 3 ( 9 3 6 3 b T C E – – – – – – – – – – ,D la ) o CA rm , ch f o G e o n EC (F 2 1 0 1 1 1 O O So SG FV ER TbC SG FV ER P P Q H c E Q H c d e u n i t o c . 1 e l b a T K CAD;,itrchdoo Pl;,rcckabhno w b nd le a d B,b bun myocardial changes caused by diabetes directly, but also by the myocardial repercussion caused by the effects of DM on other organs (nephropathy, neuropathy, etc). Previously, From et al.22 evaluated the diastolic function in 486 patients with DM free of heart failure using tissue Doppler echocardiography, and concluded that a duration of DM of C 4 years is correlated with significant LV diastolic dysfunction. On the other hand, most of the asymptomatic diabetes patients with a 5- to 10-year duration of DM have ECG changes; 70% of patients with ECG changes have poor glycaemic control;24 and the most common abnormality observed is ST-T changes, left atrial enlargement, left ventricular hypertrophy, left bundle branch block, and right bundle branch block.24 In other study,23 1760 diabetic patients with a tissue Doppler echocardiographic assessment of diastolic function were identified; 411 patients (23%) had diastolic dysfunction. The cumulative probability of the development of heart failure at 5 years for diabetic patients with diastolic dysfunction was 36.9% compared to 16.8% for patients without diastolic dysfunction (p \ 0.001), and who had a significantly higher mortality compared to those without diastolic dysfunction. Also, these patients have an elevated risk for heart failure. The possible pathophysiological mechanisms between diabetes and heart failure may include a higher risk of atherosclerosis, microvascular dysfunction, and deposition of interstitial myocardial fibrosis, and specific neurohumoral deregulations.25 Ho¨ ke et al.25 studied 710 patients with diabetes with heart failure and cardiac resynchronization therapy. At the 6-month follow-up, they found a significant (p \ 0.001) improvement in diastolic and systolic function after cardiac resynchronization therapy. Therefore, the evolution time of the diabetes is very important, because the longer the exposure to diabetes, the higher the prevalences of myocardial involvement. Furthermore, another interesting aspect of Malik et al’s.1 work, is the association between diabetes, arterial hypertension, and ventricular hypertrophy. The left ventricular hypertrophy and remodeling is frequent in patients with type II DM; cardiac steatosis and impaired myocardial energetics can contribute to these changes.26 Interstitial fibrosis is implied in the pathogenesis of ventricular hypertrophy, and was identified in advanced stages of diabetic cardiomyopathy.26–28 DM per se is linked to significant cardiac steatosis, and there exists a correlation between myocardial triglyceride and the concentric ventricular remodeling. Also, the myocardial steatosis is a predictor of concentric LV remodeling and subclinical contractile dysfunction in patients with type II DM.26 All this explains how complex it is to study the ventricular dyssynchrony in DM patients. In future D B o r t e R u S 0 0 6 0 0 2 1 1 1 – – C – – – – – – 5 6 ± 8 1 ± 4 4 a P 1 1. l a 2 te 1l. a a r t o h l a t e s s o e h 5 1. l a t e g n a i h f o e c n r g e o in l l av ia e do rep rcad m e y e h h r t c se n ta r o r ve T la n e R u io c t rc rC itr llia ia te n r e b rd fa v fi a y r a H C 9 9 3 7 4 2 7 7 9 9 1 1 – 4 ro in [ f 0 6 27 37 35 49 77 SD SD 10 C6 .1 9 D 3 B 1 D y r a studies, to avoid these confounders (nephropathy, neuropathy, arterial hypertension, ventricular hypertrophy, etc.) in DM patients, it is very important to exclude patients with diabetic complications, but this requires a greater number of patients to be evaluated. Noteworthy, in the current issue of the journal,1 this study is titled ‘‘left ventricular mechanical dyssynchrony assessment in long-standing type II diabetes mellitus patients with normal gated SPECT-MPI.’’ All patients have a normal gated SPECT. To consider a normal gated SPECT, it is important to have a normal synchrony. Actually in our Nuclear Cardiology Department, we define a normal myocardial perfusion gated SPECT stress-rest as normal perfusion, motility and thickening (score 0), normal volumes, normal ejection fraction, normal transient ischemic dilation ratio, normal chape index, normal stress lung-heart ratio, normal synchrony, normal coronary flow, normal coronary reserve flow, normal ST, without angina, C 5 METs, normal heart rate recovery, normal % heart rate ([ 80%), normal reserve pulse pressure, and normal Duke treadmill score. According to these considerations, perhaps in future, research studies should use the same methodology and the same adjustment variables to obtain the normal cutoff values of phase parameters. Finally, we recognize the effort and enthusiasm of Dr. Malik and the rest of the authors in the preparation of this research work. Disclosures The authors report no potential conflict of interest relevant to this editorial. 1. Malik D , Mittal B , Sood A , Parmar M , Kaur G , Bahl A . Left ventricular mechanical dyssynchrony assessment in long-standing type II diabetes mellitus patients with normal gated SPECT-MPI . J Nucl Cardiol . 2018 . 2. Nakajima K , Okuda K , Matsuo S , Kiso K , Kinuya S , Garcia EV . Comparison of phase dyssynchrony analysis using gated myocardial perfusion imaging with four software programs: Based on the Japanese Society of Nuclear Medicine working group normal database . J Nucl Cardiol . 2017 ; 24 : 611 - 21 . 3. 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Guillermo Romero-Farina, Santiago Aguadé-Bruix. Analysis of ventricular synchrony: A complex puzzle, Journal of Nuclear Cardiology, 2018, 1-8, DOI: 10.1007/s12350-018-1252-5