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Background  In order to better understand the concept of mechanical dyssynchrony, a promising hallmark of cardiac resynchronization therapy (CRT) response, we investigated its effect on regional myocardial metabolism and myocardial blood flow (MBF) in non-ischemic CRT candidates.    Results  Thirty consecutive non-ischemic CRT eligible patients underwent static  18 F-FDG and resting dynamic  13 N-NH 3  PET/CT.  18 F-FDG uptake and MBF for septal and lateral wall were analysed and septal-to-lateral wall ratios (SLR) were calculated. Based on the presence of mechanical dyssynchrony (septal flash and/or apical rocking) on echocardiography, patients were divided into 2 groups, with ( n  = 23) and without ( n  = 7) mechanical dyssynchrony.  Patients with mechanical dyssynchrony had significantly lower  18 F-FDG SUVmean in the septum compared with the lateral wall (5.58 ± 2.65 vs 11.19 ± 4.10,  p  < 0.0001), while patients without mechanical dyssynchrony had a more homogeneous  18 F-FDG distribution (7.33 ± 2.88 vs 8.31 ± 2.50, respectively,  p  = 0.30). Similarly, MBF was significantly different between the septal and lateral wall in the dyssynchrony group (0.57 ± 0.11 ml/g/min vs 0.92 ± 0.23 ml/g/min, respectively,  p  < 0.0001), whereas no difference was observed in the non-dyssynchrony group (0.61 ± 0.23 ml/g/min vs 0.77 ± 0.21 ml/g/min, respectively,  p  = 0.16).  18 F-FDG SLR, but not MBF SLR, was associated with the presence of mechanical dyssynchrony and showed a significant inverse correlation with volumetric reverse remodeling after CRT ( r  = − 0.62,  p  = 0.001).    Conclusions  Non-ischemic heart failure patients with mechanical dyssynchrony demonstrate heterogeneous regional metabolism and MBF compared with patients without dyssynchrony. However, only  18 F-FDG SLR appeared to be highly associated with the presence of mechanical dyssynchrony.    Trial registration  Clinicaltrials,  NCT02537782 . Registered 2 September 2015.

Low septal to lateral wall 18F-FDG ratio is highly associated with mechanical dyssynchrony in non-ischemic CRT candidates