Joseph Kisslo

Duke University Medical Center, Durham, North Carolina, United States

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Publications (185)1326.26 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Calcific aortic stenosis (AS) is the most common underlying pathology in patients undergoing heart valve surgery, with an expected increasing prevalence among the aging population. We identified the temporal trends in referral patterns, disease severity, and associated surgical risk among patients with AS between January 1, 1995 and December 31, 2012 at the Duke University Hospital. A total of 6103 patients had a finding of mild (n = 3303), moderate (n = 1648), or severe AS (n = 1152) in a native aortic valve. Overall presence of severe AS increased significantly over time (P = 0.009) with the most substantial increase occurring from 2010 and onward. Median age upon referral (P < 0.001) and attendant predicted surgical risk (P < 0.001) increased significantly in the observation period among patients with a finding of severe AS. Among patients with a finding of severe AS, the proportion of patients aged older than 80 years increased to 51.0% in the most recent time period (2010-2012) compared with 32.6% in the preceding time period (P < 0.001 for overall time trend). Similarly, the proportion of patients with a logistic EuroSCORE greater than 20% increased to 21.3% (2010-2012) from 12.1% (pre-2010). Among patients referred for echocardiography to a high-volume tertiary hospital center, a significant increase in the prevalence of severe AS was observed over time. This trend occurred in parallel with increasing age and predicted surgical risk at referral. Health-care resource planning should account for an increasing number of patients in need of high-risk aortic valve replacements in the near future.
    Critical pathways in cardiology 09/2015; 14(3):103-109. DOI:10.1097/HPC.0000000000000048
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    ABSTRACT: Current guidelines suggest that patients with left bundle branch block (LBBB) be treated with cardiac resynchronization therapy (CRT); however, one-third do not have a significant activation delay, which can result in nonresponse. By identifying characteristic opposing wall contraction, 2-dimensional strain echocardiography (2DSE) may detect true LBBB activation. This study sought to investigate whether the absence of a typical LBBB mechanical activation pattern by 2DSE was associated with unfavorable long-term outcome and if this is additive to electrocardiographic (ECG) morphology and duration. From 2 centers, 208 CRT candidates (New York Heart Association classes II to IV, ejection fraction ≤35%, QRS duration ≥120 ms) with LBBB by ECG were prospectively included. Before CRT implantation, longitudinal strain in the apical 4-chamber view determined whether typical LBBB contraction was present. The pre-defined outcome was freedom from death, left ventricular assist device, or heart transplantation over 4 years. Two-thirds of patients (63%) had a typical LBBB contraction pattern. During 4 years, 48 patients (23%) reached the primary endpoint. Absence of a typical LBBB contraction was independently associated with increased risk of adverse outcome after adjustment for ischemic heart disease and QRS width (hazard ratio [HR]: 3.1; 95% CI: 1.64 to 5.88; p < 0.005). Adding pattern assessment to a risk prediction model including QRS duration and ischemic heart disease significantly improved the net reclassification index to 0.14 (p = 0.04) and improved the C-statistics (0.63 [95% CI: 0.54 to 0.72] vs. 0.71 [95% CI: 0.63 to 0.80]; p = 0.02). Use of strict LBBB ECG criteria was not independently associated with outcome in the multivariate model (HR: 1.72; 95% CI: 0.89 to 3.33; p = 0.11. Assessment of LBBB contraction pattern was superior to time-to-peak indexes of dyssynchrony (p < 0.01 for all). Contraction pattern assessment to identify true LBBB activation provided important prognostic information in CRT candidates. Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
    Journal of the American College of Cardiology 08/2015; 66(6):631-41. DOI:10.1016/j.jacc.2015.06.020 · 16.50 Impact Factor
  • Niels Risum · Joseph Kisslo · Galen Wagner
    Journal of electrocardiology 07/2015; 48(5). DOI:10.1016/j.jelectrocard.2015.07.020 · 1.36 Impact Factor
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    ABSTRACT: Left bundle branch block (LBBB) is a known complication of transcatheter aortic valve replacement (TAVR) and has been shown to predict worsened outcomes in TAVR patients. A regional longitudinal strain pattern, termed the "classic" pattern of left ventricular (LV) dyssynchrony, which is thought to be due to LBBB, is highly predictive of response to cardiac resynchronization therapy. Whether LBBB causes this "classic" pattern is not known. We retrospectively studied patients undergoing TAVR who also underwent pre- and post-TAVR strain analysis to determine if the "classic" pattern arose in those who developed TAVR-induced true LBBB. After removing patients with baseline conduction abnormalities or insufficient studies 9 patients had sufficient data for analysis. Six patients developed LBBB after TAVR and 3 patients did not develop LBBB after TAVR. ECGs were analyzed for the new onset of LBBB after TAVR. Global longitudinal strain (GLS) and regional longitudinal strain patterns were analyzed for changes between pre- and immediately post-TAVR examinations. Patients who did not develop LBBB showed no significant changes in their regional longitudinal strain pattern. Those patients who did develop LBBB showed significant increase in their difference of time-to-onset of contraction between the septal and lateral walls post-TAVR (22±14ms vs 111±49ms; p=0.003) and in their difference of time-to-peak contraction between the septal and lateral walls post-TAVR (63±56ms vs 133±46ms; p=0.002). Early lateral wall pre-stretch and delayed lateral wall peak contraction emerged in all patients with LBBB but early septal peak contraction meeting the established criteria was present in only one patient. The onset of LBBB led to acute, measurable changes in the regional longitudinal strain pattern consisting of early lateral wall pre-stretch and delayed lateral wall peak contraction. These represent 2 of the 3 findings in the "classic" pattern of LV dyssynchrony. Early termination of septal wall contraction meeting established criteria was not routinely found. Time and/or other factors may be required to develop the full "classic" pattern. Copyright © 2015. Published by Elsevier Inc.
    Journal of electrocardiology 05/2015; 48(4). DOI:10.1016/j.jelectrocard.2015.05.005 · 1.36 Impact Factor
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    ABSTRACT: New-onset left bundle branch block (LBBB) is a known complication during Transcatheter Aortic Valve Replacement (TAVR). This study evaluated the influence of pre-TAVR cardiac conditions on left ventricular functions in patients with new persistent LBBB post-TAVR. Only 11 patients qualified for this study because of the strict inclusion criteria. Pre-TAVR electrocardiograms were evaluated for Selvester QRS infarct score and QRS duration, and left ventricular end-systolic volume (LVESV) was used as outcome variable. There was a trend towards a positive correlation between QRS score and LVESV of r=0.59 (p=0.058), while there was no relationship between QRS duration and LVESV (r=-0.18 [p=0.59]). This study showed that patients with new LBBB and higher pre-TAVR QRS infarct score may have worse post-TAVR left ventricular function, however, pre-TAVR QRS duration has no such predictive value. Because of the small sample size these results should be interpreted with caution and assessed in a larger study population. Copyright © 2015. Published by Elsevier Inc.
    Journal of electrocardiology 05/2015; 48(4). DOI:10.1016/j.jelectrocard.2015.04.010 · 1.36 Impact Factor
  • Journal of the American College of Cardiology 03/2015; 65(10):A1982. DOI:10.1016/S0735-1097(15)61982-9 · 16.50 Impact Factor
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    ABSTRACT: Speckle-tracking strain is almost universally cited as being independent of angle of insonation, but there are minimal confirmatory studies, and this claim may not be consistent with the known limitations of ultrasound axial and lateral spatial resolution. The aim of this study was to assess the influence of angle and depth on longitudinal peak systolic strain (LPS). Thirty-four healthy pediatric subjects (age range, 6-18 years; 47% male) with normal cardiac anatomy and good image quality were prospectively imaged. Angular comparisons of LPS were investigated by examining interangle reproducibility on the basis of one standard and one alternative image acquisition relative to intraobserver reproducibility of two standard views of the same left ventricular segments. A single-window comparison was used to evaluated septal LPS: standard apical four-chamber versus right ventricular centered four-chamber. Two paired standard and alternative window comparisons were as follows: (1) four-chamber: standard apical versus subcostal; and (2) three-chamber: standard apical versus parasternal long-axis. The global LPS intraobserver difference using the paired standard and alternative window comparisons was lower than the interangle difference in global LPS (-1.0 ± 0.1% vs -2.1 ± 2.4%). Intraobserver reproducibility was significantly higher than interangle reproducibility (intraclass correlation coefficient = 0.9 vs 0.29, P < .001). Similar results were found in the segmental strain analysis. Interangle reproducibility was significantly decreased compared with intraobserver reproducibility in the septal single-window comparison. Target depth assessment demonstrated a systematic bias between the near-field and far-field segments. Echocardiographically derived LPS values were modestly dependent on angle of insonation and target depth in this pediatric population. Normal strain ranges derived from standard apical images should not be applied to strain derived from sub-costal images, off-axis apical imaging, or applications in which a standard window cannot be defined. Copyright © 2015 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 02/2015; 28(5). DOI:10.1016/j.echo.2014.12.015 · 4.06 Impact Factor
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    ABSTRACT: Background: Recent studies have demonstrated that longitudinal septal deformation in patients with left ventricular (LV) dysfunction and left bundle branch block (LBBB) predict LV remodeling after CRT. However, the importance of septal deformation patterns for prediction of long-term survival is unknown. Methods: From 2 centers a total of 193 CRT candidates with LBBB (NYHA II-IV, EF≤35, and QRS≥120ms) underwent echocardiography before CRT. Longitudinal 2-D strain analysis in the apical four-chamber view identified four patterns based on previously defined criteria: double-peaked systolic pattern (type 1), early pre-ejection shortening peak followed by prominent systolic stretch (type 2), shortening with one systolic peak inside 70% of ejection phase (type 3) and normal septal peak timing outside early 70% (type 4) . Outcome was pre-defined as freedom from death, left ventricular assist device or heart transplantation over 4 years. Results: Thirty-six patients (19%) had early septal deformation pattern type 1, 49(25%) type 2, 44(23%) type 3 and 64(33%) pseudonormal septal contraction type 4. There were 35 deaths, 4 transplantations, and 6 left ventricular assist device implantations over 4 years. The event rate was 0.05% (2/36) for type 1, 14% (7/49) for type 2, 25% (11/44) for type 3, 39% (25/64) for type 4. Patients with type 1 and 2 patterns had a more favourable event-free survival HR 0.26, CI 0.09-0.81 (P=0.005) than type 3 HR 1.17, CI 0.06-2.2 (P=0.65). Patients with type 4 septal contraction showed poor event-free survival HR 2.8, CI 1.6-5.1 (<0.001). (Figure 1) Conclusions: In LBBB-patients, septal deformation strain patterns predict long-term survival after CRT. Pattern 1 and 2 are highly associated with long-term survival while patients with pattern 4 have a poor prognosis.
    European Heart Journal – Cardiovascular Imaging 12/2014; 15(suppl 2):ii161-ii164. DOI:10.1093/ehjci/jeu264 · 2.65 Impact Factor
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    ABSTRACT: We aimed to characterize the hemodynamic progression of aortic stenosis (AS) in a contemporary unselected cohort of patients with preserved left ventricular ejection fraction. Current guidelines recommend echocardiographic surveillance of hemodynamic progression. However, limited data exist on the expected rate of progression and whether clinical variables are associated with accelerated progression in contemporarily managed patients with AS. We conducted a retrospective analysis of patients presenting with AS and explored the trajectory of AS mean gradient over time using generalized estimating equations and fit a longitudinal linear regression model with adjustment for baseline clinical variables. A total of 1,558 patients (median age 72; interquartile range 65 to 79) having mild (n = 982), moderate (n = 363), or severe AS (n = 213) were included. In patients with mild AS at baseline (n = 983), 303 (31%) had progressed to moderate/severe AS/AVR within 5 years of the index echo. In patients with moderate AS, 159 of 363 (44%) had progressed to severe AS/AVR within 2 years of the index echo. The annual change in mean gradient was dependent on baseline AS severity. Average annual increases in mean gradient were 6.8% (95% confidence interval 6.0 to 7.6) and 7.1% (95% confidence interval 4.8 to 9.3) in patients with mild and moderate AS, respectively. In the subset of patients with mild AS at baseline, age (p = 0.0310) and gender (p = 0.0270) had significant interaction with change in mean gradient over time. In patients with moderate AS, age (p <0.0001), gender (p = 0.0346), renal dysfunction (p = 0.0036), and hyperlipidemia (p = 0.0010) demonstrated significant interaction with change in mean gradient over time. In conclusion, although average disease progression was slower than previously reported, a significant proportion of patients with mild and moderate AS progressed to higher grades within the currently recommended time windows for echocardiographic follow-up.
    The American Journal of Cardiology 10/2014; 115(1). DOI:10.1016/j.amjcard.2014.09.049 · 3.28 Impact Factor
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    ABSTRACT: Background Progressive heart failure leading to transplantation or death is common in pediatric dilated cardiomyopathy (DCM), and treatment options are limited. Select children with DCM have improved after cardiac resynchronization therapy (CRT), but predicting response is challenging. Nonetheless, considering the frequency of death or transplantation in this population, identifying any candidate would be valuable. Classic-pattern dyssynchrony (CPD) identifies mechanical dyssynchrony patterns consistent with underlying electrical activation delays and strongly predicts CRT response in adult DCM but has not been evaluated in pediatric DCM. The aim of this study was to test the hypothesis that CPD is present in a subgroup of patients with pediatric DCM and is associated with activation delays. Methods Fifty-nine subjects with pediatric DCM (left ventricular end-diastolic diameter Z score > 2 and left ventricular ejection fraction < 40%) who underwent echocardiography with a functional protocol with apical images optimized for two-dimensional speckle-tracking strain analysis (EchoPAC) were retrospectively analyzed for CPD. Electrocardiograms were evaluated for activation delays (prolonged QRS duration and strict criteria for left bundle branch block [LBBB]). Forty control subjects with no cardiac disease and good imaging widows were also analyzed. Results The mean age was 5.4 years (range, 1 day to 20 years); idiopathic DCM was most common (57%). Severe cardiomyopathy was present in 75% (end-diastolic diameter Z score > 4.6 and left ventricular ejection fraction < 32%). CPD was identified in seven subjects (12%), and prolonged QRS durations were present in 13 (22%), but only two subjects met strict criteria for LBBB. Six of seven subjects in the CPD group had prolonged QRS durations, and two of seven had LBBB. No control subjects had CPD. The CPD analysis was highly feasible and reproducible. Conclusions In this severely affected cohort, the small CPD subgroup is potentially important because their progressive disease may respond to CRT. CPD is associated with activation delays, although not necessarily strict LBBB. This has important potential implications for prospective evaluation of CRT in this disease.
    Journal of the American Society of Echocardiography 09/2014; 27(9). DOI:10.1016/j.echo.2014.06.014 · 4.06 Impact Factor
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    ABSTRACT: Background Right ventricular (RV) function is a strong predictor of mortality in pulmonary hypertension (PH), but two-dimensional (2D) echocardiography–derived assessments of RV function that could aid in risk assessment and management of patients with PH are of limited utility. RV longitudinal peak systolic strain (RVLS) derived from 2D speckle-tracking echocardiography is a relatively novel method for quantifying RV function but typically is derived from a single apical four-chamber view of the right ventricle and may have inherent limitations. The objective of this study was to determine the utility of regional and global RVLS calculated from multiple views of the right ventricle to comprehensively assess RV function in a cohort of patients with PH. Methods Regional and global RVLS were obtained from multiple views of the right ventricle (centered on the right ventricle–focused apical position) in 40 patients with PH, defined as a mean pulmonary artery pressure ≥ 25 mm Hg, most of whom also had pulmonary capillary wedge pressures ≤ 15 mm Hg and were thus defined as having pulmonary arterial hypertension. This was compared with other 2D echocardiography–derived parameters of RV function and functional parameters. Results Global RVLS calculated from multiple views had a superior correlation with 6-min walk distance compared with other parameters of RV function, including tricuspid annular plane systolic excursion, RV myocardial performance index, and fractional area change. Although global RVLS calculated from multiple views displayed a similar correlation with 6-min walk distance as global RVLS calculated from a single four-chamber view, analysis of regional strains provided by multiple views identified distinct patterns of RV dysfunction, consisting of global, free wall, or septal dysfunction, that were associated with specific clinical characteristics. Conclusions Global RVLS derived from multiple right ventricle–focused views yields a comprehensive quantitative assessment of regional and global RV function that correlates moderately with functional parameters and may be useful in the assessment of PH. Distinct patterns of regional RV dysfunction are associated with different clinical characteristics.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 06/2014; 27(6). DOI:10.1016/j.echo.2014.02.001 · 4.06 Impact Factor
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    Journal of the American College of Cardiology 04/2014; 63(12):A1129. DOI:10.1016/S0735-1097(14)61129-3 · 16.50 Impact Factor
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    Journal of the American College of Cardiology 04/2014; 63(12):A343. DOI:10.1016/S0735-1097(14)60343-0 · 16.50 Impact Factor
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    ABSTRACT: Background Although quantitative right ventricular (RV) strain analysis may be useful in congenital and acquired heart disease populations with RV failure, a comprehensive, standardized approach is lacking. An 18-segment RV strain analysis obtained from three standardized RV apical echocardiographic images was used to determine the feasibility, normal values, and reproducibility of the method in normal adults. Methods Forty healthy, prospectively enrolled volunteers with no cardiac histories and normal QRS durations underwent echocardiography optimized for strain analysis including three RV apical views. Two-dimensional speckle-tracking longitudinal strain analysis was performed using EchoPAC software. Eleven retrospectively identified subjects with RV disease were included as a pilot population. All had been imaged using the same protocol including the three RV apical views. Results All control subjects had normal anatomic morphology and function by echocardiography. Feasibility of the RV strain analysis was good (adequate tracking in 696 of 720 segments [97%]). RV global peak systolic strain was −23 ± 2%. Peak strain was highest in the RV free wall and lowest in the septum. Dyssynchrony indices demonstrated no dyssynchrony using left ventricular criteria. Reproducibility of most strain measures was acceptable. This methodology identified important disease not seen in the four-chamber apical view alone in the pilot population of 11 patients with RV disease. Strain patterns and values were different from those in the control population, indicating that differences do exist from normal. Conclusions Eighteen-segment RV strain analysis is feasible, with strain measures falling into discrete ranges in this normal population. Those with RV disease illustrate the potential utility of this approach. These data indicate that this model can be used for more detailed studies evaluating abnormal RV populations, in which its full potential can be assessed.
    Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 04/2014; 27(4). DOI:10.1016/j.echo.2013.12.018 · 4.06 Impact Factor
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    Journal of the American College of Cardiology 04/2014; 63(12):A123. DOI:10.1016/S0735-1097(14)60123-6 · 16.50 Impact Factor
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    Journal of the American College of Cardiology 04/2014; 63(12):A2022. DOI:10.1016/S0735-1097(14)62025-8 · 16.50 Impact Factor
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    ABSTRACT: The authors present a patient with symptomatic chronic MR in the setting of severe LV dyssynchrony. This is a distinct entity, with a complex pathophysiology and mechanism of MR. This case highlights the need for a comprehensive preoperative analysis of the mechanism of MR in all patients with sympto- matic MR, given its multiple etiologies and distinct therapeutic options. A multidisciplinary approach that includes preoperative strain analysis and clinical consideration of patient candidacy for CRT should preferably be taken prior to surgery in deciding the best therapy in order to ensure the best outcomes.
    Journal of cardiothoracic and vascular anesthesia 09/2013; 27(6). DOI:10.1053/j.jvca.2013.06.025 · 1.46 Impact Factor
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    ABSTRACT: Perioperative transesophageal echocardiography is essential for decision-making for mitral valve surgery. While two-dimensional transesophageal echocardiography represents the standard of care, tracking of dynamic changes using three-dimensional imaging permits assessment of morphologic and functional characteristics of the mitral valve. The authors hypothesized that quantitative three-dimensional analysis would reveal distinct differences among diseased, repaired, and normal mitral valves. Case-control observational clinical study. Tertiary care hospital. Using novel mitral valve quantification software, the authors retrospectively analyzed 80 datasets of cardiac surgery patients who underwent intraoperative transesophageal echocardiographic imaging. Twenty patients with degenerative mitral regurgitation were evaluated before and after mitral valve repair. Twenty patients had functional mitral regurgitation, and 20 patients had no mitral valve disease. Primary outcome measures of dynamic mitral valve function were: 1) three-dimensional annulus area, 2) annular displacement distance, 3) annular displacement velocity, and 4) annular area fraction. Other mitral annular tracking indices, in addition to intraobserver reliability and interobserver agreement, also were reported. Annulus area was enlarged in degenerative and functional mitral regurgitation. Annular displacement distance was decreased in functional mitral regurgitation and repaired valves. Annular displacement velocity was decreased in functional mitral regurgitation. Annular area fraction was decreased in functional mitral regurgitation and repaired valves. Intraobserver reliability and interobserver agreement were high for all 4 analyzed indices. Normal, functional regurgitant, degenerative, and repaired mitral valves have distinctly different dynamic signatures of anatomy and function as reliably determined by perioperative echocardiographic tracking.
    Journal of cardiothoracic and vascular anesthesia 09/2013; 28(1). DOI:10.1053/j.jvca.2013.03.024 · 1.46 Impact Factor
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    ABSTRACT: Short-lag spatial coherence (SLSC) imaging is a novel beamforming technique that reduces acoustic clutter in ultrasound images. A clinical study was conducted to investigate clutter reduction and endocardial border detection in cardiac SLSC images. Individual channel echo data were acquired from the left ventricle of 14 volunteers, after informed consent and institutional review board approval. Paired B-mode and SLSC images were created from these data. Contrast, contrast-to-noise, and signal-to-noise ratios were measured in paired images, and these metrics were improved with SLSC imaging in most cases. Three cardiology fellows rated the visibility of endocardial segments in randomly ordered B-mode and SLSC cine loops. SLSC imaging offered 22%-33% improvement (p < 0.05) in endocardial border visibility when B-mode image quality was poor (i.e., 80% or more of the endocardial segments could not be visualized by the three reviewers). The percentage of volunteers with poor-quality images was decreased from 21% to 7% with the SLSC beamformer. Results suggest that SLSC imaging has the potential to improve clinical cardiac assessments that are challenged by clutter.
    Ultrasound in medicine & biology 08/2013; 39(10). DOI:10.1016/j.ultrasmedbio.2013.03.029 · 2.21 Impact Factor
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    ABSTRACT: The relationship between myocardial electrical activation by electrocardiogram (ECG) and mechanical contraction by echocardiography in left bundle-branch block (LBBB) has never been clearly demonstrated. New strict criteria for LBBB based on a fundamental understanding of physiology have recently been independently published for both ECG and echocardiography. The relationship between the 2 modalities and the relation to cardiac resynchronization therapy (CRT) response was investigated. Sixty-six patients with LBBB by conventional criteria had a standard 12-lead ECG and 2-dimensional strain echocardiography performed before CRT implantation. Criteria for LBBB by echocardiography included early termination of contraction in one wall and prestretch and late contraction in opposing wall(s). New strict criteria by ECG included QRS duration ≥140 ms (men) or 130 ms (women), QS or rS in leads V1 and V2, and mid-QRS notching or slurring in ≥2 of leads V1, V2, V5, V6, I, and aVL. Response was defined as >15% decrease in left ventricular end-systolic volume after 6 months. In 64 of 66 patients, ECG analysis was possible. Echo and ECG readings for LBBB presence were concordant in 54 (84%) of 64. Thirty-seven (82%) of 45 patients with LBBB by strict ECG criteria responded to CRT, whereas only 4 (21%) of the 19 patients without LBBB responded (sensitivity 90% and specificity 65%). Thirty-six (95%) of 38 patients with concordance for the presence of LBBB responded to CRT. In patients with concordance for the absence of LBBB, 15 (94%) of 16 did not respond. For the first time, a close relation has been demonstrated between electrical activation by ECG and mechanical contraction by echocardiography. These findings may help identify CRT candidates.
    American heart journal 08/2013; 166(2):340-8. DOI:10.1016/j.ahj.2013.04.005 · 4.46 Impact Factor

Publication Stats

4k Citations
1,326.26 Total Impact Points


  • 1976–2015
    • Duke University Medical Center
      • • Division of Cardiology
      • • Department of Surgery
      • • Department of Medicine
      • • Department of Radiology
      Durham, North Carolina, United States
  • 1976–2014
    • Duke University
      • • Department of Biomedical Engineering (BME)
      • • Department of Surgery
      Durham, North Carolina, United States
  • 2001
    • Mazda Hospital, Fuchu
      Фучу, Hiroshima, Japan
  • 1998
    • National Heart, Lung, and Blood Institute
      베서스다, Maryland, United States
  • 1984
    • California State University, Sacramento
      Sacramento, California, United States