Mitral-Aortic Flow Reversal in Cardiac Resynchronization Therapy: Coupling With Ejection and Impact of Variations in...

Flow entering the left ventricle is reversed toward the outflow tract through rotating reversal flow around the mitral valve. This was thought to facilitate early ejection, but had not been proved to date. We hypothesized that perfect coupling between reversal and ejection flow would occur at optimal atrioventricular delay (AVD), contributing to its hemodynamic superiority, and evaluated its applicability for AVD optimization.

Forty consecutive patients with cardiac resynchronization therapy underwent intracardiac flow analysis and AVD optimization. Reversal and ejection flow curves were studied. The presence and duration of reversal-ejection discontinuity were assessed for all programmed AVD. Reproducibility of each optimization method was evaluated through interobserver variability. Discontinuity between reversal and ejection flow was observed in all patients with longer than optimal AVD, increasing linearly with excess duration in AVD (linear R²=0.976, P<0.001). Longer discontinuities implied progressive decreases in pre-ejection flow velocity in the left ventricular outflow tract, with consequent loss of flow momentum. The equation optimal AVD=programmed AVD-[1.2(discontinuity duration)]+4 accurately predicted optimal AVD. Short AVD systematically compromised reversal flow because of premature ejection. Agreement over optimal AVD was superior when assessed by flow reversal method (intraclass correlation coefficient =0.931; P<0.001) over both iterative and aortic velocity-time integral methods.

Perfect coupling between mitral-aortic flow reversal and ejection flow in the left ventricle occurs at optimal AVD. As a result, full blood momentum in the outflow tract is used to facilitate early ejection. This can be measured and provides a new method for AVD optimization.