Model-based navigation of left and right ventricular leads to optimal targets for cardiac resynchronization therapy: a single-center feasibility study (original) (raw)
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The Importance of Lead Positioning to Improve Clinical Outcomes in Cardiac Resynchronization Therapy
Cardiac Diseases in 21st Century [Working Title]
Left ventricular (LV) lead positioning is one of the main contributors to the cardiac resynchronization therapy (CRT) response. Conventional left ventricular (LV) lead implantation faces several difficulties, which may ultimately affect lead stability and performance. Several imaging techniques have been proposed to overcome all these obstacles including multimodality cardiac imaging to help in preprocedural or intraprocedural identification of the latest activated areas of the LV. Emerging pacing strategies like LV multisite and multipoint pacing may help deliver an enhanced response to CRT, but prospective trials are warranted to confirm the superiority of this approach.
Heart rhythm, 2017
Optimal lead positioning is an important determinant of cardiac resynchronization therapy (CRT) response. Evaluation of cardiac computed tomography (CT) selection of the optimal epicardial vein for LV lead placement by targeting regions of late mechanical activation (LMA) and avoiding myocardial scar. 18 patients undergoing CRT upgrade with existing pacing systems, underwent pre-implant ECG-gated cardiac CT to assess wall thickness, hypoperfusion, LMA and regions of myocardial scar by the derivation of the Stretch Quantifier of Endocardial Engraved Zones (SQUEEZ) algorithm. Cardiac venous anatomy was mapped to individualized AHA bulls-eye plots to identify the optimal venous target and compared with acute hemodynamic response (AHR) in each coronary venous target using an LV pressure wire. 15 datasets were evaluable. CT-SQUEEZ derived targets produced a similar mean AHR compared with the best achievable AHR (20.4±13.7% vs.24.9±11.1%, p=0.36). SQUEEZ derived guidance produced a positi...
Expert Review of Medical Devices, 2014
Cardiac resynchronization therapy (CRT) is a proven treatment adjunct for selected patients with heart failure and evidence of ventricular dyssynchrony. When applying most contemporary guidelines the accepted response rate has remained static with up to one-third of patients failing to respond. Empiric lateral/posterolateral lead positioning may not be the optimal strategy in all patients, particularly in those with extensive scar and there have been developments that suggest an approach whereby the latest mechanically activating segment is targeted for left ventricular (LV) lead placement may be of some benefit. Additionally, alternative means of delivering CRT, either by means of multi-site pacing or LV endocardial pacing, have similarly shown promise. At a time where novel predictors of response to CRT have proved disappointing in multi-center trials, a paradigm shift away from prediction towards better delivery of CRT may potentially be of most benefit to the significant minority who do not respond.
Analysis of LV Lead Position in Cardiac Resynchronization Therapy Using Different Imaging Modalities
JACC: Cardiovascular Imaging, 2010
This study sought to evaluate whether left ventricular (LV) lead position in cardiac resynchronization therapy (CRT) can be determined by myocardial deformation imaging during LV pacing and to compare imaging techniques for analysis of LV lead position. B A C K G R O U N D LV lead position has a significant impact on effectiveness of CRT, but clinically applicable methods to determine LV lead position are less defined. M E T H O D S In 56 patients (53 Ϯ 5 years, 34 men) undergoing CRT, fluoroscopy and 2 myocardial deformation imaging-based approaches were applied to determine the LV lead position. Myocardial deformation imaging-based techniques were used to determine 1) the segment with maximal temporal difference of peak circumferential strain before and while on biventricular CRT; and 2) the segment with earliest peak systolic circumferential strain during pure LV pacing. Twelve-month echocardiography was performed to determine LV remodeling and improvement in function. Optimal LV lead position was defined as concordance or immediate neighboring of the determined LV lead position to the segment with latest systolic strain prior to CRT. R E S U L T S LV lead position determined during LV pacing correlated to the position determined by fluoroscopy (kappa ϭ 0.761). Patients with optimal LV lead position had greater improvement in LV ejection fraction and decrease in end-diastolic volume than those with nonoptimal LV lead position (12 Ϯ 4% vs. 7 Ϯ 3%, p Ͻ 0.001, and 28 Ϯ 13 ml vs. 14 Ϯ 8 ml, p Ͻ 0.001, respectively). Determination of the LV lead position based on myocardial deformation imaging during LV pacing showed greater discriminatory power for improvement of ejection fraction (difference optimal vs. nonoptimal lead position group: 4.64 Ϯ 1.01 ml; p Ͻ 0.001) than deformation imaging with biventricular pacing (3.03 Ϯ 1.08 ml; p ϭ 0.007) and fluoroscopy (2.22 Ϯ 1.12 ml; p ϭ 0.053).
Trials, 2013
Background: Cardiac resynchronization therapy (CRT) is an established treatment in heart failure patients. However, a large proportion of patients remain nonresponsive to this pacing strategy. Left ventricular (LV) lead position is one of the main determinants of response to CRT. This study aims to clarify whether multimodality imaging guided LV lead placement improves clinical outcome after CRT. Methods/Design: The ImagingCRT study is a prospective, randomized, patient-and assessor-blinded, two-armed trial. The study is designed to investigate the effect of imaging guided left ventricular lead positioning on a clinical composite primary endpoint comprising all-cause mortality, hospitalization for heart failure, or unchanged or worsened functional capacity (no improvement in New York Heart Association class and <10% improvement in six-minute-walk test). Imaging guided LV lead positioning is targeted to the latest activated non-scarred myocardial region by speckle tracking echocardiography, single-photon emission computed tomography, and cardiac computed tomography. Secondary endpoints include changes in LV dimensions, ejection fraction and dyssynchrony. A total of 192 patients are included in the study.