Outcomes of Cardiac Resynchronization Therapy with Image-Guided Left Ventricular Lead Placement at the Site of Latest Mechanical Activation: A Systematic Review and Meta-Analysis

Abstract

Aim. To assess evidence for an image-guided approach for cardiac resynchronization therapy (CRT) that targets left ventricular (LV) lead placement at the segment of latest mechanical activation. Methods. A systematic review of EMBASE and PubMed was performed for randomized controlled trials (RCTs) and prospective observational studies from October 2008 through October 2020 that compared an image-guided CRT approach with a non-image-guided approach for LV lead placement. Meta-analyses were performed to assess the association between the image-guided approach and NYHA class improvement or changes in end-systolic volume (LVESV), end-diastolic volume (LVEDV), and ejection fraction (LVEF). Results. From 5897 citations, 5 RCTs including 818 patients (426 image-guided and 392 non-image-guided) were identified. The mean age ranged from 66 to 71 years, 76% were male, and 53% had ischemic cardiomyopathy. Speckle tracking echocardiography was the primary image-guided method in all studies. LV lead placement within the segment of the latest mechanical activation (concordant) was achieved in the image-guided arm in 45% of the evaluable patients. There was a statistically significant improvement in the NYHA class at 6 months (odds ratio 1.66; 95% confidence interval (CI) [1.02, 2.69]) with the image-guided approach, but no statistically significant change in LVESV (MD −7.1%; 95% CI [−16.0, 1.8]), LVEDV (MD −5.2%; 95% CI [−15.8, 5.4]), or LVEF (MD 0.68; 95% CI [−4.36, 5.73]) versus the non-image-guided approach. Conclusion. The image-guided CRT approach was associated with improvement in the NYHA class but not echocardiographic measures, possibly due to the small sample size and a low rate of concordant LV lead placement despite using the image-guided approach. Therefore, our meta-analysis was not able to identify consistent improvement in CRT outcomes with an image-guided approach.

Targeted left ventricular lead positioning to the site of latest activation in cardiac resynchronization therapy: a systematic review and meta-analysis

“…The different study selection criteria applied by the different meta-analyses provide valuable complementory insights into the field. Another recent meta-analysis reported solely on echocardiographic parameters and NYHA functional class improvement, 21 one investigated exclusively imaging-guided strategy compared to routine positioning 20 and two 18 , 19 included non-randomized observational studies, 44–47 making them subject to risk of selection bias and residual confounding.…”

Combination of personalized computational modeling and machine-learning for optimization of left ventricular pacing site in cardiac resynchronization therapy

“…In mechanically guided implantation, the area of late mechanical activation derived from modern echocardiography imaging data was suggested as a target for LV lead placement (19). However, although a recent systematic study and a meta analysis of the randomized clinical studies using this approach confirmed improvements in the NYHA HF class in the patients, no improvements were found in the LV remodeling and ejection fraction (LV EF) (20). Recent studies using intra-operative evaluation of This is a provisional file, not the final typeset article 2 Dokuchaev et al…”