Large response to cardiac resynchronization therapy in a patient with segmental paradoxical systolic expansion identified by strain imaging.

An 84-year-old man with non-ischaemic cardiomyopathy underwent cardiac resynchronization therapy (CRT) based on the presence of drug-refractory heart failure, depressed left ventricular ejection fraction (25%), and wide QRS complex (160 ms). Longitudinal tissue velocity revealed no significant dyssynchrony (23 ms in Yu index and 35 ms in opposing wall delay). However, longitudinal tissue Doppler strain revealed unique appearances in apical four-chamber and long-axis views. The anterior and inferior septum at basal and mid-levels had reversed strain (becoming positive), indicating paradoxical systolic expansion. Ejection fraction dramatically improved from 26 to 50% the day following CRT, and this beneficial effect of CRT was sustained 12 months following CRT. The presence of the segmental reversed strain might have a potential to predict a large response to CRT in the assessment of longitudinal dyssynchrony.