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Volume 18 Supplement 1

19th Annual SCMR Scientific Sessions

  • Oral presentation
  • Open Access

Left ventricular kinetic energy as a marker of mechanical dyssynchrony in failing hearts with LBBB: a 4D flow CMR study

  • 1,
  • 1,
  • 1,
  • 1, 2,
  • 1,
  • 3 and
  • 1
Journal of Cardiovascular Magnetic Resonance201618 (Suppl 1) :O91

  • Published:


  • Direct Flow
  • Cardiac Resynchronization Therapy
  • Heart Failure Patient
  • Left Bundle Branch Block
  • Flow Component


Left bundle branch block (LBBB) leads to dyssynchronous left ventricular (LV) contraction and relaxation which may contribute to LV dysfunction and ultimately heart failure. LBBB-related mechanical dyssynchrony often responds to cardiac resynchronization therapy (CRT). However, this therapy is expensive and the number of non-responders remains significant. Reliable functional markers of dyssynchronous LV pumping that can predict response to CRT have proved elusive.

Almost all studies of LV mechanical dyssynchrony focus on wall motion properties rather than aspects of intraventricular flow. 4D flow CMR specific measures have recently emerged as markers of LV function in failing hearts. Reduced volume and kinetic energy (KE) of the portion of LV inflow which passes directly to outflow (Direct Flow) has been demonstrated in failing LVs compared to normal LVs. In this study we hypothesized that the volume and KE of Direct Flow would be further reduced in myopathic LVs with LBBB compared to similarly dysfunctional and remodeled LVs without LBBB.


22 heart failure patients were enrolled; 11 patients with LBBB and 11 patients without LBBB matched according to LV ejection fraction (EF), LV end-diastolic volume (EDV) index, heart rate, age and gender. In both groups, etiology of heart failure was dilated cardiomyopathy in 7, and ischemic cardiomyopathy in 4. 4D flow CMR and morphological images were acquired on a 3T Philips Ingenia. A previously validated method was used for flow analysis (Eriksson et al., JCMR 2010): Pathlines were emitted from the ED LV blood volume and traced forward and backward to the time of ES, thus encompassing one cardiac cycle. The traced ED blood volume was separated into 4 functional flow components. The kinetic energy (KE) of each flow component was computed over the cardiac cycle from the volume represented by each trace, its velocity and the density of blood.


There was no intergroup difference in LVEF, LVEDV-index, heart rate and age, whereas the QRS duration was longer (P < 0.001) in patients with LBBB (Table 1). The volume of the Direct Flow component was not significantly different between the groups (P = 0.17), but the KE at end diastole was lower among patients with LBBB (P = 0.018, Figure 1). When normalized to the Direct Flow volume, Direct Flow KE at ED was lower in patients with LBBB compared to matched patients without LBBB (P = 0.007, Table 1).
Table 1

Clinical characteristics and 4D flow CMR data of patients with and without LBBB


With LBBB (n = 11)

Without LBBB (n = 11)


Age (years)

61 ± 14

57 ± 15


Gender (female:male)




Heart rate (bpm)

71 ± 13

68 ± 10


LVEDV-index (ml/m2)

129 ± 48

115 ± 32


LVEF (%)

34 ± 9

36 ± 9


QRS duration (ms)

160 ± 20

104 ± 10

< 0.001

Volume (ml)


Direct flow

18.7 ± 10.5

25.7 ± 12.6


Retained inflow

54.5 ± 16.4

48.4 ± 16.6


Delayed ejection flow

48.7 ± 15.6

45.8 ± 11.6


Residual volume

119.7 ± 73.2

98.2 ± 63.3


KE/volume at ED (mJ/ml)


Direct flow

0.007 ± 0.003

0.013 ± 0.005


Retained inflow

0.008 ± 0.002

0.010 ± 0.004


Delayed ejection flow

0.010 ± 0.005

0.013 ± 0.005


Residual volume

0.004 ± 0.001

0.005 ± 0.002


Mean ± SD. ED, end diastole; EDV, end-diastolic volume; EF, ejection fraction; KE, kinetic energy; LV, left ventricle

Figure 1
Figure 1

Kinetic energy at end-diastole (mJ) for the 4 flow components in LBBB patients (grey) and matched patients without LBBB (white). mJ, millijoule. *P = 0.018 vs Direct Flow in patients without LBBB.


4D flow patterns and energetics in myopathic LVs with and without LBBB demonstrate reduced end-diastolic KE of Direct Flow in patients with LBBB compared to matched patients with normal conduction. This may reflect incremental impairment of diastolic function and less efficient ensuing ejection related to dyssynchrony in these failing ventricles. These intriguing preliminary findings suggest that 4D flow specific measures reflect LV mechanical dyssynchrony in heart failure patients, and could be investigated as predictors of response to CRT.

Authors’ Affiliations

Division of Cardiovascular Medicine, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
Department of Cardiology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
Department of Medicine, University of California San Francisco, San Francisco, CA, USA


© Zajac et al. 2016

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.