Abstract
This study was performed to evaluate the feasibility of intra-procedural visualization of optimal pacing sites and image-guided left ventricular (LV) lead placement in cardiac resynchronization therapy (CRT). In fifteen patients (10 males, 68 ± 11 years, 7 with ischemic cardiomyopathy and ejection fraction of 26 ± 5%), optimal pacing sites were identified pre-procedurally using cardiac imaging. Cardiac magnetic resonance (CMR) derived scar and dyssynchrony maps were created for all patients. In six patients the anatomy of the left phrenic nerve (LPN) and coronary sinus ostium was assessed via a computed tomography (CT) scan. By overlaying the CMR and CT dataset onto live fluoroscopy, aforementioned structures were visualized during LV lead implantation. In the first nine patients, the platform was tested, yet, no real-time image-guidance was implemented. In the last six patients real-time image-guided LV lead placement was successfully executed. CRT implant and fluoroscopy times were similar to previous procedures and all leads were placed close to the target area but away from scarred myocardium and the LPN. Patients that received real-time image-guided LV lead implantation were paced closer to the target area compared to patients that did not receive real-time image-guidance (8 mm [IQR 0–22] vs 26 mm [IQR 17–46], p = 0.04), and displayed marked LV reverse remodeling at 6 months follow up with a mean LVESV change of −30 ± 10% and a mean LVEF improvement of 15 ± 5%. Real-time image-guided LV lead implantation is feasible and may prove useful for achieving the optimal LV lead position.
Highlights
Cardiac resynchronization therapy (CRT) has had a major beneficial effect on the treatment of patients with symptomatic heart failure, severe left ventricular (LV) dysfunction, and prolonged QRS duration
Cardiac magnetic resonance (CMR) imaging has been proposed as a promising tool for LV target area identification since it is able to assess myocardial scar tissue with late gadolinium enhancement (LGE) and mechanical dyssynchrony with feature tracking [6]
Image fusion took an average of 14 ± 4 min for merging of the computed tomography (CT)-scan, and 10 ± 6 min for merging the CMR scan
Summary
Cardiac resynchronization therapy (CRT) has had a major beneficial effect on the treatment of patients with symptomatic heart failure, severe left ventricular (LV) dysfunction, and prolonged QRS duration. Improving CRT response rate has been the main focus of many researchers in the field, whom have demonstrated that improved response can be achieved by targeting optimal pacing sites for LV stimulation [2,3,4]. LV lead placement in or near an area of myocardial scar worsens outcomes [4,5,6], while pacing in or near an area of latest mechanical contraction improves both response rate and prognosis after CRT [2, 3]. Cardiac magnetic resonance (CMR) imaging has been proposed as a promising tool for LV target area identification since it is able to assess myocardial scar tissue with late gadolinium enhancement (LGE) and mechanical dyssynchrony with feature tracking [6].
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