Abstract

BackgroundDespite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately. Recently, a “U-shaped” (type II) wall motion pattern identified by cardiovascular magnetic resonance (CMR) has been associated with improved CRT response compared to a homogenous (type I) wall motion pattern. There is also evidence that a left ventricular (LV) lead localized to the latest contracting LV site predicts superior response, compared to an LV lead localized remotely from the latest contracting LV site.MethodsWe prospectively evaluated patients undergoing CRT with pre-procedural CMR to determine the presence of type I and type II wall motion patterns and pre-procedural echocardiography to determine end systolic volume (ESV). We assessed the final LV lead position on post-procedural fluoroscopic images to determine whether the lead was positioned concordant to or remote from the latest contracting LV site. CRT response was defined as a ≥ 15 % reduction in ESV on a 6 month follow-up echocardiogram.ResultsThe study included 33 patients meeting conventional indications for CRT with a mean New York Heart Association class of 2.8 ± 0.4 and mean LV ejection fraction of 28 ± 9 %. Overall, 55 % of patients were echocardiographic responders by ESV criteria. Patients with both a type II pattern and an LV lead concordant to the latest contracting site (T2CL) had a response rate of 92 %, compared to a response rate of 33 % for those without T2CL (p = 0.003). T2CL was the only independent predictor of response on multivariate analysis (odds ratio 18, 95 % confidence interval 1.6-206; p = 0.018). T2CL resulted in significant incremental improvement in prediction of echocardiographic response (increase in the area under the receiver operator curve from 0.69 to 0.84; p = 0.038).ConclusionsThe presence of a type II wall motion pattern on CMR and a concordant LV lead predicts superior CRT response. Improving patient selection by evaluating wall motion pattern and targeting LV lead placement may ultimately improve the response rate to CRT.

Highlights

  • Despite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately

  • Favorable electrocardiographic criteria associated with improved response are a left bundle branch block (LBBB) morphology and a QRS duration greater than 150 ms [4,5,6]

  • We investigated how cardiovascular magnetic resonance (CMR)-derived wall motion patterns interact with left ventricular (LV) lead location to influence response to CRT

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Summary

Introduction

Despite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately. Favorable electrocardiographic criteria associated with improved response are a left bundle branch block (LBBB) morphology and a QRS duration greater than 150 ms [4,5,6] To better refine these clinical criteria, an evolving understanding of the electrical and mechanical substrate within the myocardium is needed [7,8,9,10,11,12,13,14,15]. A “U-shaped” (type II) LV wall motion pattern, suggestive of electrical conduction block, can be demonstrated with cardiovascular magnetic resonance (CMR), and has been associated with a superior CRT response compared to a more homogenous (type I) pattern [12]. CRT guided by such methods has yielded results superior to conventional implantation in randomized controlled trials [8, 9]

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