Multimodality imaging for real-time image-guided left ventricular lead placement during cardiac resynchronization therapy implantations

Figures

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  Fig. 1. Schematic overview of study. Each step resembles a phase during the study. In step 1 a CMR scan was made to assess the location of myocardial scar tissue (patients 1–3). In step 2 scar identification and contraction timing analysis was performed on CMR images (patients 4–6). In step 3 a CT scan was added to identify the left phrenic nerve and coronary sinus ostium (patients 7–9). In step 1–3 the feasibility of CARTBox was tested for identification and live visualization of the structures. In step 4, steps 1–3 were combined and used for real-time image-guidance of left ventricular lead placement (patients 10–15). CMR cardiac magnetic resonance, CRT cardiac resynchronization therapy, CT computed tomography

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  Fig. 2. CARTBox workflow and time requirement. The pre-procedural workflow a consists of the acquisition of cardiac MRI and CT (60 min in total), and image processing in CARTBox. The image processing, required to identify the optimal site for LV stimulation, and necessary to produce a detailed 3D-model of the heart, takes approximately 25 min per scan. The implantation procedure b starts with acquiring a 3D-rotational X-ray scan (minutes). The 3D-treatment files are then semi-automatically fused with the 3D-rotational scan based on anatomy landmarks. This takes approximately 20 min and can be performed during RV lead implantation and coronary sinus cannulation. Using this approach, LV target areas can be visualised on live fluoroscopic images during LV lead implantation. CMR cardiac magnetic resonance, CT computed tomography

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  Fig. 3. CARTBox workflow in images. a Segmentation of left ventricle. b Myocardial scar detected on CMR LGE scans. c Contraction timing analysis displaying delayed contraction of anterior and lateral segments. d Transmurality of scar showing inferolateral infarct of the left ventricle. e, f 3D-model of contraction timing (e) and scar transmurality (f) with manual selected target segment (green). ANT anterior, ANTSEPT anteroseptal, INF inferior, INFSEPT inferoseptal, LAT lateral, LV left ventricle, SEPT septal

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  Fig. 4. Real-time visualization of CMR and CT targets. a, b 3D-treatment file of CMR data (a) and CT data (b). c–f After 3D image fusion of the 3D-treatment dataset with fluoroscopy, the LV lead targets and scar segments (c, e) together with left phrenic nerve and coronary ostium (d, f) are visualized on live fluoroscopy during the LV lead implantation. CMR cardiac magnetic resonance, CT computed tomography