Key result
CT-guided target BiV pacing is linked to a ~13-point greater acute hemodynamic response than non-target pacing.
Why the study?
No intraprocedural guidance is currently used to target optimal electrode placement while simultaneously guiding acoustic transmitter placement for leadless left ventricular pacing.
Does preprocedural cardiac CT perfusion and modeling with real-time fluoroscopic guidance improve acute hemodynamic response (dP/dtmax) during leadless LV endocardial pacing (WiSE-CRT) in heart failure patients?
Cohort (n=11)
Does preprocedural cardiac CT perfusion and modeling with real-time fluoroscopic guidance improve acute hemodynamic response (dP/dtmax) during leadless LV endocardial pacing (WiSE-CRT) in heart failure patients?
Preprocedural cardiac CT perfusion and acoustic/activation modeling with real-time fluoroscopic overlay can successfully guide leadless LV endocardial electrode and transmitter placement to achieve superior acute hemodynamic response and reliable biventricular pacing.
Answers are grounded in this paper and cite their sources.
CT-guided targeting was associated with superior acute response in leadless CRT; hypothesis-generating and should not yet change practice.
BACKGROUND: The WiSE-CRT System (EBR systems, Sunnyvale, CA) permits leadless left ventricular pacing. Currently, no intraprocedural guidance is used to target optimal electrode placement while simultaneously guiding acoustic transmitter placement in close proximity to the electrode to ensure adequate power delivery. OBJECTIVE: The purpose of this study was to assess the use of computed tomography (CT) anatomy, dynamic perfusion and mechanics, and predicted activation pattern to identify both the optimal electrode and transmitter locations. METHODS: A novel CT protocol was developed using preprocedural imaging and simulation to identify target segments (TSs) for electrode implantation, with late electrical and mechanical activation, with ≥5 mm wall thickness without perfusion defects. Modeling of the acoustic intensity from different transmitter implantation sites to the TSs was used to identify the optimal transmitter location. During implantation, TSs were overlaid on fluoroscopy to guide optimal electrode location that were evaluated by acute hemodynamic response (AHR) by measuring the maximal rate of left ventricular pressure rise with biventricular pacing. RESULTS: Ten patients underwent the implantation procedure. The transmitter could be implanted within the recommended site on the basis of preprocedural analysis in all patients. CT identified a mean of 4.8 ± 3.5 segments per patient with wall thickness < 5 mm. During electrode implantation, biventricular pacing within TSs resulted in a significant improvement in AHR vs non-TSs (25.5% ± 8.8% vs 12.9% ± 8.6%; P < .001). Pacing in CT-identified scar resulted in either failure to capture or minimal AHR improvement. The electrode was targeted to the TSs in all patients and was implanted in the TSs in 80%. CONCLUSION: Preprocedural imaging and modeling data with intraprocedural guidance can successfully guide WiSE-CRT electrode and transmitter implantation to allow optimal AHR and adequate power delivery.
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Sidhu et al. (2023) conducted a cohort in Heart failure with indication for cardiac resynchronization therapy (CRT) and WiSE-CRT implantation (n=11). Biventricular pacing within preprocedural CT- and modeling-defined target segments (TSs) using real-time fluoroscopic overlay during WiSE-CRT implantation vs. Biventricular pacing in non-target segments (non-TSs) was evaluated on Acute hemodynamic response (AHR), defined as percent change in maximal rate of left ventricular pressure rise (dP/dtmax) with biventricular pacing (p=<0.001). Biventricular pacing within CT-guided target segments significantly improved acute hemodynamic response compared to non-target segments (25.5% ± 8.8% vs 12.9% ± 8.6%; P < 0.001).
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