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Hubungan Status Sinkronisitas Mekanis dengan Kapasitas Fungsional Pasca-Cardiac Resynchronization Therapy = Correlation of Mechanical Resynchronization and Functional Capacity after Cardiac Resynchronization Therapy.

Latar Belakang. Pada pasien gagal jantung refrakter yang disertai gangguan konduksi intraventrikular, Terapi Resinkronisasi Jantung (Cardiac resynchronization therapy,CRT) diketahui merupakan cara yang efektif dalam memperbaiki kelas fungsional, fraksi ejeksi ventrikel kiri, uji jalan 6 menit, kualitas hidup, dan mengurangi angka hospitalisasi gagal jantung, serta angka mortalitas karena berkurangnya progresivitas penyakit tersebut. Namun demikian persoalan nonresponder pasca-CRT masih merupakan masalah yang belum terselesaikan. Tujuan studi ini adalah untuk mengevaluasi ada atau tidaknya reverse remodeling yang ditunjukkan dengan disinkroni mekanis pasca-CRT dihubungkan dengan kapasitas fungsional pasien. Metodologi. Merupakan studi kroseksional dan retrospektif yang dilakukan di Pusat Jantung Nasional Harapan Kita, Jakarta. Semua pasien yang dilakukan pemasangan dari Januari 2008-Oktober 2012 dimasukkan dalam penelitian ini. Data pasien diambil dari data base rumahsakit, termasuk data klinis, EKG, ekokardiografi pra-pemasangan, dan data prosedur pemasangan. Disinkroni intraventrikular, interventrikular, dan atrioventrikular diukur melalui pemeriksaan ekokardiografi dengan Tissue Doppler Imaging (TDI). Kapasitas fungsional diukur melalui kelas fungsional NYHA serta uji jalan 6 menit. Pemeriksaan TDI, penilaian kelas fungsional NYHA dan uji jalan 6 menit dilakukan sedikitnya 6 bulan setelah pemasangan CRT. Hasil. Selama periode penelitian, sebanyak 32 pasien ikut dalam penelitian ini. Tidak ada komplikasi pemasangan. Rerata umur subjek adalah 60,3 + 13,5 tahun. Proporsi disinkroni yang masih terjadi pada subjek adalah 24 orang (75%) untuk disinkroni intraventrikular, 25 orang (78,1%) untuk disinkroni interventrikular, serta 11 orang (34,4%) pada disinkroni atrioventrikular. Rerata nilai Indeks Yu yang menggambarkan disinkroni intraventrikular berdasarkan kapasitas fungsional baik dan buruk secara berurutan adalah 39,04 + 10,69 vs 59,17 + 8,01 (p=0,001). Sedangkan untuk disinkroni interventrikular dan atrioventrikular sebesar 26,07 + 16,17 mdet vs 32,83 + 45,45 mdet (p=0,631) dan 42,76 + 8,65 vs 44,98 + 12,34 (p=0,485). Grafik korelasi linier menunjukkan bahwa adanya peningkatan disinkroni intraventrikular, berkorelasi kuat dengan penurunan kemampuan kapasitas fungsional yang ditunjukkan dalam uji jalan 6 menit (r=0,56;p=0,001). Kesimpulan. Disinkroni intraventrikular yang menetap pasca-pemasangan CRT berhubungan dengan kapasitas fungsional yang lebih buruk.
Kata Kunci : Cardiac Resynchronization Therapy, kapasitas fungsional, sinkronisitas mekanis, ekokardiografi tissue Doppler imaging


Background. Cardiac resynchronization therapy (CRT) is an effective method in management of refractory heart failure with intra-ventricular conduction delay. It will increase functional class, left ventricular ejection fraction (LVEF), six minute walk test, and quality of life, and also decrease hospitalization and mortality rate due to heart failure, and prevent the progression of the disease. However, nonresponder after CRT implantation is still a big problem. Aim of this study is to evaluate reverse remodeling after CRT implantation and the correlation with functional capacity of the patients. Method. This is a cross-sectional and retrospective study which was held in National Cardiovascular Center Harapan Kita, Jakarta. The subject are patients with diagnosis of refractory heart failure who performed CRT implantation between January 2008-October 2012. The data was recorded from medical record, include clinical data, electrocardiography, echocardiography pre-implantation, and implantation procedure. Intra-ventricular, inter-ventricular, and atrio-ventricular dyssynchrony was assessed by tissue Doppler imaging (TDI) echocardiography. Functional capacity was evaluated with New York Heart Association (NYHA) functional class and six minute walk test which performed at least 6 months after implantation. Results. A total of 32 patients were included in this study, with mean age of 60,3 + 13,5 years. Intra-ventricular dyssynchrony were persisted on 24 subjects (75%), meanwhile interventricular and atrioventricular dyssyncrony was 25 subjects and 11 subjects (78,1% and 34,4%). We found a significant correlation of intraventricular dyssynchrony, which was showed by Indeks Yu, in group with good and poor functional capacity with mean of 39,04 + 10,69 and 59,17 + 8,01, respectively (p=0,001). Meanwhile, mean inter-ventricular dyssynchrony in good functional capacity group and poor functional capacity were 26,07 + 16,17 mdet vs 32,83 + 45,45 mdet (p=0,631), and atrio-ventricular dyssynchrony were 42,76 + 8,65 vs 44,98 + 12,34 (p=0,485). Linear correlation graph showed increasing of intraventricular dyssynchrony will decrease the functional capacity assessed by six minute walk test. Conclusion. The presence of intraventricular dyssynchrony after CRT implantation correlates with poor functional capacity.
Keyword : Cardiac Resynchronization Therapy, functional capacity, mechanical resynchronization, tissue Doppler imaging echocardiography