Key result
Image-guided LV lead placement boosts odds of NYHA class improvement ~66% in CRT.
Why the study?
Evidence needed to be assessed for an image-guided approach for cardiac resynchronization therapy that targets left ventricular lead placement at the segment of latest mechanical activation.
Does an image-guided approach for LV lead placement improve clinical and echocardiographic outcomes in patients receiving cardiac resynchronization therapy?
Meta-Analysis (n=818)
Double-blind
Does an image-guided approach for LV lead placement improve clinical and echocardiographic outcomes in patients receiving cardiac resynchronization therapy?
Odds Ratio: 1.66 (95% CI 1.02–2.69)
An image-guided approach for LV lead placement in CRT improves NYHA functional class but does not significantly enhance echocardiographic measures of reverse remodeling compared to standard placement.
May support image-guided LV lead placement to improve NYHA class in CRT; extends meta-analyses while leaving reverse remodeling unresolved.
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.
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LaPointe et al. (2022) conducted a meta-analysis in Heart failure requiring cardiac resynchronization therapy (n=818). Image-guided left ventricular lead placement vs. Non-image-guided approach was evaluated on ≥1 class improvement in NYHA class at 6 months (OR 1.66, 95% CI 1.02-2.69). Image-guided left ventricular lead placement during cardiac resynchronization therapy significantly increased the odds of NYHA class improvement at 6 months (OR 1.66) compared to standard placement.
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