Key result
CMR-guided LV lead placement for CRT achieves a ~36% mean reduction in LVESV.
Why the study?
Image guidance to assist LV lead placement may improve CRT outcomes, but previous approaches varied greatly and multicenter feasibility was lacking.
Is on-screen CMR-guided left ventricular lead placement using periprocedural fluoroscopy image fusion feasible and effective in reducing LV end-systolic volume at 6 months in patients undergoing de novo CRT implantation?
Cohort (n=30)
Final LV lead positions were determined by 2 observers blinded to targets, patient characteristics, and outcome
Yes
Is on-screen CMR-guided left ventricular lead placement using periprocedural fluoroscopy image fusion feasible and effective in reducing LV end-systolic volume at 6 months in patients undergoing de novo CRT implantation?
This multicenter feasibility study demonstrates that fusing preprocedural CMR-derived 36-segment scar and strain models with live fluoroscopy during CRT implantation is clinically practical, alters operator lead placement in 38% of cases, and yields an 86% echocardiographic response rate.
Answers are grounded in this paper and cite their sources.
Supports feasibility of CMR-fluoroscopy fusion for CRT; leaves open whether randomized trials confirm outcome benefit over standard placement.
Background: Image guidance to assist left ventricular (LV) lead placement may improve outcome after cardiac resynchronization therapy (CRT), but previous approaches and results varied greatly, and multicenter feasibility is lacking altogether. Objective: We sought to investigate the multicenter feasibility of image guidance for periprocedural assistance of LV lead placement for CRT. Methods: In 30 patients from 3 hospitals, cardiac magnetic resonance imaging was performed within 3 months prior to CRT to identify myocardial scar and late mechanical activation (LMA). LMA was determined using radial strain, plotted over time. Segments without scar but clear LMA were classified as optimal for LV lead placement, according to an accurate 36-segment model of the whole heart. LV leads were navigated using image overlay with periprocedural fluoroscopy. After 6 months, volumetric response and super-response were defined as ≥15% or ≥30% reduction in LV end-systolic volume, respectively. Results: Periprocedural image guidance was successfully performed in all CRT patients (age 66 ± 10 years; 59% men, 62% with nonischemic cardiomyopathy, 69% with left bundle branch block). LV leads were placed as follows: within (14%), adjacent (62%), or remote (24%) from the predefined target. According to the conventional 18-segment model, a remote position occurred only once (3%). On average, 86% of patients demonstrated a volumetric response (mean LV end-systolic volume reduction 36 ± 29%), and 66% of all patients were super-responders. Conclusion: On-screen image guidance for LV lead placement in CRT was feasible in a multicenter setting. Efficacy will be further investigated in the randomized controlled ADVISE (Advanced Image Supported Lead Placement in Cardiac Resynchronization Therapy) trial (NCT05053568).
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Wouters et al. (2022) conducted a cohort in Heart failure with class I or IIa guideline indication for de novo cardiac resynchronization therapy (CRT) (n=30). On-screen cardiac magnetic resonance (CMR)-guided left ventricular lead placement with periprocedural fluoroscopy fusion was evaluated on Reduction of left ventricular end-systolic volume (ΔLVESV) at 6 months after CRT implantation (volumetric response defined as ≥15% reduction) (p=<0.001). On-screen CMR-guided LV lead placement for CRT achieved a mean 36±29% reduction in LV end-systolic volume (p<0.001) and an 86% volumetric response rate at 6 months.
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