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Targeted left ventricular lead placement in biventricular pacing for heart failure: a national, multicentre, double-blind, randomised controlled trial in Denmark
Key result
Targeted LV lead placement fails to reduce death or HF hospitalization versus standard placement.
Why the trial?
A substantial share of patients do not respond to cardiac resynchronisation therapy. DANISH-CRT asked whether targeting the left ventricular lead to the latest activated myocardial segment improves response compared with conventional placement.
Does targeted left ventricular lead placement at the latest electrically activated site reduce death or unplanned heart failure hospitalization in patients with heart failure and wide QRS eligible for biventricular pacing?
Population
1,000 patients with heart failure and wide QRS on guideline-directed therapy
Comparison
LV lead at latest electrical activation site vs posterolateral non-apical placement
Design
National multicenter, double-blind, randomized superiority trial (5 Danish centres)
Follow-up
Median 45.8 months (IQR 28.5-65.7)
Authors
Discussion
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Key expert perspectives
Captured external expert commentary on this trial, strongest first. Original sources are linked where available.
DANISH-CRT randomised 1,000 heart failure patients with LBBB to electrically targeted left ventricular lead placement versus standard posterolateral non-apical placement for CRT. After a median 45.8 months, targeted placement did not reduce death or first unplanned heart failure hospitalisation (27.9% vs 25.5%; HR 1.10; p=0.45), with consistently neutral secondary endpoints and numerically more lead-related complications in the targeted group. The trial was presented as a Hot Line at ESC Congress 2026 with simultaneous publication in The Lancet.
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“While CRT improves symptoms, quality of life and survival in majority of patients, up to one-third do not experience any benefit. Observational data have shown that measuring a late electrical signal from the left ventricular lead is associated with better outcomes. However, whether a strategy of targeting placement of the left ventricular lead at the latest activated site improves outcomes has never been investigated in a large randomized controlled trial.”
Implication
Standard LV lead placement suffices for CRT; challenges observational data favoring electrically guided targeting.
Key Points
- To assess whether targeting left ventricular lead placement at the site of latest electrical activation improves clinical outcomes in patients undergoing biventricular pacing for heart failure.
- Conducted a national, multicenter, double-blind, randomized superiority trial (NCT03280862) across all five Danish university centers implanting devices.
- Enrolled 1001 patients with heart failure and prolonged QRS on guideline-directed medical therapy, randomly assigning 499 to intervention (latest electrical activation site) and 501 to control (posterolateral non-apical branch) in a modified intention-to-treat analysis over a median follow-up of 45.8 months.
- The primary composite outcome of time to death or first unplanned heart failure hospitalization occurred in 139 of 499 patients (28%) in the intervention group versus 128 of 501 (26%) in the control group (hazard ratio 1.10, 95% CI 0.86–1.39; p=0.45).
- Overall complication risk was 14% (71 of 499) in the intervention group versus 13% (64 of 501) in the control group, though lead-related complications were more frequent with targeted placement, along with one procedure-related death in the intervention arm.
Evidence details
What drove the result?
| Outcome | Targeted | Standard |
|---|---|---|
| Death or first unplanned heart-failure hospitalisation | 139/499 (27.9%) | 128/501 (25.5%) |
| Primary composite · HR 1.10 (95% CI 0.86-1.39); p=0.45 | ||
Limitations & tradeoffs
Safety
Overall complications occurred in 71/499 (14%) vs 64/501 (13%), including 1 procedure-related death vs 0.
Patient burden
Lead-related complications were more frequent with targeted placement (counts not reported).
Design limitations
Targeting achieved only a mean 9 ms later electrical activation at the LV lead, operating room personnel were not masked to allocation, and no secondary efficacy outcomes are reported in the record.
Structured PICO
Does targeted left ventricular lead placement at the latest electrically activated site reduce death or unplanned heart failure hospitalization in patients with heart failure and wide QRS eligible for biventricular pacing?
P
Population
1,000 patients with heart failure and left bundle branch block on guideline-directed medication, followed for a median of 45.8 months.
I
Intervention
Left ventricular lead placement at the latest electrically activated site within the coronary sinus branches.
C
Comparator
Left ventricular lead placement in a posterolateral non-apical branch (conventional placement).
O
Outcome
Composite of time to death or first unplanned heart failure hospitalisation.composite
Main Result
Hazard Ratio: 1.1 (95% CI 0.86–1.39)
Absolute Event Rate: 27.9% vs 25.5%
p-value: p=0.45
Targeted left ventricular lead placement at the site of latest electrical activation does not improve clinical outcomes compared to conventional posterolateral placement in patients with heart failure receiving biventricular pacing.
Coverage & sources
Journal, society, and media accounts. Useful signal, not independent expert judgment.
Cite This Study
Nielsen et al. (2026) conducted an RCT in Heart failure and left bundle branch block (n=1,000). Targeted left-ventricular lead placement vs. Standard posterolateral non-apical placement was evaluated on Death or first unplanned hospitalisation for heart failure (HR 1.10, 95% CI 0.86 to 1.39, p=0.45). Targeted left ventricular lead placement did not significantly reduce death or unplanned heart failure hospitalization compared to standard placement (27.9% vs 25.5%; HR 1.10; 95% CI 0.86-1.39; p=0.45).