Model-Based Navigation of Left and Right Ventricular Leads to Optimal Targets for Cardiac Resynchronization Therapy

Abstract

Background-Left ventricular (LV) and right ventricular pacing site characteristics have been shown to influence response to cardiac resynchronization therapy (CRT). This study aimed to determine the clinical feasibility of image-guided lead delivery using a 3-dimensional navigational model displaying both LV and right ventricular (RV) pacing targets. Serial echocardiographic measures of clinical response and procedural metrics were evaluated. Methods and Results-Thirty-one consecutive patients underwent preimplant cardiac MRI with the generation of a 3-dimensional navigational model depicting optimal segmental targets for LV and RV leads. Lead delivery was guided by the model in matched views to intraprocedural fluoroscopy. Blinded assessment of final lead tip location was performed from postprocedural cardiac computed tomography. Clinical and LV remodeling response criteria were assessed at baseline, 3 months, and 6 months using a 6-minute hall walk, quality of life questionnaire, and echocardiography. Mean age and LV ejection fraction was 66±8 years and 26±8%, respectively. LV leads were successfully delivered to a target or adjacent segment in 30 of 31 patients (97%), 68% being nonposterolateral. RV leads were delivered to a target or adjacent segment in 30 of 31 patients (97%), 26% being nonapical. Twenty-three patients (74%) met standard criteria for response (LV end-systolic volume reduction ≥15%), 18 patients (58%) for super-response (LV end-systolic volume reduction ≥30%). LV ejection fraction improved at 6 months (31±8 versus 26±8%, P=0.04). Conclusions-This study demonstrates clinical feasibility of dual cardiac resynchronization therapy lead delivery to optimal targets using a 3-dimensional navigational model. High procedural success, acceptable procedural times, and a low rate of early procedural complications were observed. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01640769.

Comprehensive use of cardiac computed tomography to guide left ventricular lead placement in cardiac resynchronization therapy

“…We previously demonstrated that CMR-derived scar and dyssynchrony can guide LV lead implantation 18 with excellent CRT response if pacing in a CMR target in keeping with the present findings. Similarly, Laksman et al 19 used CMR-derived scar and dyssynchrony-guided lead placement with echocardiographic super-response in 58% of patients. Currently there are limited clinical data describing the use of cardiac CT LV lead guidance.…”

Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy

“…The optimal location for the RV lead tip was assigned first followed by the preferential LV pacing site. At follow-up, 74% of patients met the predefined echocardiographic criteria of a responder despite the fact that lead implantation was informed purely by fluoroscopy and visual assessment of the 3D models, and real-time guidance was used [137]. …”

An image fusion tool for echo‐guided left ventricular lead placement in cardiac resynchronization therapy: Performance and workflow integration analysis

“…LV regional function was estimated in accordance with the 17-Segment American Heart Association (AHA) model. 24 The apical segments (ie, segments [13][14][15][16][17] and the septal segments (ie, segments 2, 3, 8, and 9) were not considered as possible targets for lead placement, 4,25 and therefore were not included in the model. Following the procedure outlined by the STARTER 11 trial, strain curves were analyzed for the remaining 8 free wall segments imaged using short-axis views at mitral valve and papillary muscle level.…”

“…Cardiac resynchronization therapy implantation is performed under X‐ray guidance which provides an excellent visualization of catheters and pacing leads but lacks detailed information on cardiac function and structure. Studies have demonstrated that multimodality image fusion could be used to overcome these limitations. However, they rely on techniques and imaging modalities which are not part of the clinical routine for CRT candidates.…”

“…[9][10][11][12][13] Cardiac resynchronization therapy implantation is performed under X-ray guidance which provides an excellent visualization of catheters and pacing leads but lacks detailed information on cardiac function and structure. Studies 8,12,[14][15][16][17][18][19][20] have demonstrated that multimodality image fusion could be used to overcome these limitations.…”