179-01: Integration of delayed enhancement cardiac magnetic resonance imaging with coronary venous electro-anatomic mapping for guidance of left ventricular lead positioning in CRT candidates

Abstract

Aim: Left ventricular (LV) lead placement in the region of maximal electrical delay free of scar is a potential determinant of response to cardiac resynchronization therapy (CRT). We investigated the feasibility of integrating delayed enhancement cardiac magnetic resonance imaging (DE-CMR) with coronary venous electro-anatomic mapping (EAM) to guide LV lead placement to the latest activated region free of scar. Methods: Eleven CRT candidates with ischemic cardiomyopathy and scar on prior DE-CMR were prospectively included. Ventricular structures were semi-automatically segmented pre-procedurally in DE-CMR images using CAAS MRV 3.4 (Pie Medical Imaging). Coronary venous EAM was performed intra-procedurally using NavX (St. Jude Medical) in combination with a mapping guidewire. The DE-CMR mesh was subsequently integrated with the EAM using NavX to guide LV lead placement. Results: Fusion of EAM and DE-CMR was achieved using 8.7 ± 2.4 fiducial points per patient. Image integration accuracy mean and standard deviation were 4.4 ± 1.3 mm and 3.0 ± 1.0 respectively and was measured at 20.7 ± 7.3 sites per patient. Maximal electrical delay ranged between 105–197 ms (72–113% of QRS duration) and was located anterolateral in 5 patients (basal n = 3; mid n = 2) and inferolateral in 6 (basal n = 4; mid n = 2). Scar was located inferoseptal (n = 3), septal (n = 1), anteroseptal (n = 2), and inferolateral (n = 5). LV lead placement in the latest activated region free of scar was achieved in 7 patients. In the other 4 patients, all target veins were located in scar area.