Abstract
Non-ischemic cardiomyopathy encompasses a heterogeneous group of diseases, with a generally unfavorable long-term prognosis. Cardiac resynchronization therapy (CRT) is a useful therapeutic option for patients with symptomatic heart failure, currently recommended by all available guidelines, with outstanding benefits, especially in non-ischemic dilated cardiomyopathy. Still, in spite of clear indications based on identifying a dyssynchronous pattern on the electrocardiogram (ECG,) a great proportion of patients are non-responders. The idea that multimodality cardiac imaging can play a role in refining the selection criteria and the implant technique and help with subsequent system optimization is promising. In this regard, predictors of CRT response, such as apical rocking and septal flash have been identified. Promising new data come from studies using cardiac magnetic resonance and nuclear imaging for showcasing myocardial dyssynchrony. Still, to date, no single imaging predictor has been included in the guidelines, probably due to lack of validation in large, multicenter cohorts. This review provides an up-to-date synthesis of the latest evidence of CRT use in non-ischemic cardiomyopathy and highlights the potential additional value of multimodality imaging for improving CRT response in this population. By incorporating all these findings into our clinical practice, we can aim toward obtaining a higher proportion of responders and improve the success rate of CRT.
Highlights
Non-ischemic cardiomyopathy encompasses a heterogeneous group of diseases, mostly with genetic determinism, with a generally unfavorable long-term prognosis due to the evolution to pump failure and sudden arrhythmic death, secondary to limited therapeutic options.Cardiac resynchronization therapy (CRT) is a useful therapeutic method for patients with heart failure, improving cardiovascular prognosis
The first set of evidence for the clinical benefits of CRT comes from the Multicenter InSync Randomized Clinical Evaluation (MIRACLE) trial, which showed a significant improvement in symptoms of patients with heart failure and left ventricle ejection fraction (LVEF) < 35%, with a QRS duration over 130 ms [1]
When discussing CRT response, it is important to distinguish between cardiac reverse remodeling, which is frequently assessed by imaging, and the net clinical benefit, with impact on hard endpoints such as all-cause death or hospitalization for heart failure
Summary
Non-ischemic cardiomyopathy encompasses a heterogeneous group of diseases, mostly with genetic determinism, with a generally unfavorable long-term prognosis due to the evolution to pump failure and sudden arrhythmic death, secondary to limited therapeutic options. When discussing CRT response, it is important to distinguish between cardiac reverse remodeling, which is frequently assessed by imaging, and the net clinical benefit, with impact on hard endpoints such as all-cause death or hospitalization for heart failure. In this regard, first reported in 2005 [5], the greater benefit of CRT on cardiac remodeling and clinical endpoints in non-ischemic patients was observed in sub-analyses of all major clinical trials: Multicenter InSync Randomized Clinical Evaluation (MIRACLE) [6], Cardiac. Future randomized control trials are needed in order to conclude if this approach can reduce costs and lead to a net clinical benefit
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