Targeted left ventricular lead placement in biventricular pacing for heart failure: a national, multicentre, double-blind, randomised controlled trial in Denmark

Q: What did DANISH-CRT show at ESC Congress 2026?

Targeted left-ventricular lead placement at the latest electrical activation site did not reduce death or first unplanned heart-failure hospitalisation versus standard posterolateral non-apical placement (27.9% vs 25.5%; HR 1.10, 95% CI 0.86-1.39; p=0.45) after a median 45.8 months.

Q: What is the clinical evidence from this study?

Study design: RCT. Population: Heart failure and left bundle branch block (n=1000). Intervention: Targeted left-ventricular lead placement vs. Standard posterolateral non-apical placement. Primary outcome: Death or first unplanned hospitalisation for heart failure (HR 1.10, 95% CI 0.86 to 1.39, p=0.45).

Jens Cosedis Nielsen; Jesper Hastrup Svendsen; Jesper Hastrup Svendsen; Jens Brock Johansen; Jens Brock Johansen; Jacob Moesgaard Larsen; Jacob Moesgaard Larsen; Charlotte Larroudé; Charlotte Larroudé; Steen Hvitfeldt Poulsen; Steen Hvitfeldt Poulsen; Hans Eiskjær; Hans Eiskjær; Bjarne Linde Nørgaard; Bjarne Linde Nørgaard; Niels Risum; Niels Risum; Lars Køber; Lars Køber; Jens Kristensen; Jens Kristensen; Kristian Øvrehus; Kristian Øvrehus; A Sommer; A Sommer; Morten Schou; Morten Schou; Peter Søgaard; Peter Søgaard; Mikael Kjær Poulsen; Mikael Kjær Poulsen; Klaus F. Kofoed; Klaus F. Kofoed; Thomas Fritz Hansen; Thomas Fritz Hansen; Claus Graff; Claus Graff; Regitze Gyldenholm Skals; Regitze Gyldenholm Skals; Maria Hee Jung Park Frausing; Maria Hee Jung Park Frausing; Emil Anton Frandsen; Emil Anton Frandsen; Jesper Møller Jensen; Jesper Møller Jensen; Michael Vinther; Michael Vinther; Henrik Kjærulf Jensen; Henrik Kjærulf Jensen; Jens Haarbo; Jens Haarbo; Tomás Zaremba; Tomás Zaremba; Mindaugas Vieželis; Mindaugas Vieželis; Berit Philbert; Berit Philbert; Jakob Hjort; Jakob Hjort; Christian Gerdes; M. B. Kronborg; M. B. Kronborg; Jens Cosedis Nielsen; Jens Christian Gerdes; Jens Kristensen; Jens Kristensen; Hans Eiskjær; Hans Eiskjær; Steen Hvitfeldt Poulsen; Steen Hvitfeldt Poulsen; Bjarne Linde Nørgaard; Bjarne Linde Nørgaard; M. B. Kronborg; M. B. Kronborg; A Sommer; A Sommer; Maria Hee Jung Park Frausing; Maria Hee Jung Park Frausing; Jesper Møller Jensen; Jesper Møller Jensen; Henrik Kjærulf Jensen; Henrik Kjærulf Jensen; Jakob Hjort; Jakob Hjort; Jacob Moesgaard Larsen; Jacob Moesgaard Larsen; Peter Søgaard; Peter Søgaard; Tomás Zaremba; Tomás Zaremba; Jens Brock Johansen; Jens Brock Johansen; Mindaugas Vieželis; Mindaugas Vieželis; Kristian Øvrehus; Kristian Øvrehus; Mikael Kjær Poulsen; Mikael Kjær Poulsen; Jesper Hastrup Svendsen; Jesper Hastrup Svendsen

doi:10.1016/s0140-6736(26)01597-7

View all ESC 2026 trials

DANISH-CRTDevices & ArrhythmiasThe Lancet

Targeted left ventricular lead placement in biventricular pacing for heart failure: a national, multicentre, double-blind, randomised controlled trial in Denmark

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What happened

Targeted LV lead placement fails to reduce death or HF hospitalization versus standard placement.

139/499 (27.9%) vs 128/501 (25.5%) at Median 45.8 months (IQR 28.5-65.7)

Who says what

Jens Cosedis NielsenPresenting author

“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.”

News Coverage ↗

From published coverage, not an answer posted here.

Full evidence

Why the trial, key points, tables, limitations, PICO, abstract, media & sources

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?

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

Population

1,000 patients with heart failure and left bundle branch block on guideline-directed medication, followed for a median of 45.8 months.

Intervention

Left ventricular lead placement at the latest electrically activated site within the coronary sinus branches.

Comparator

Left ventricular lead placement in a posterolateral non-apical branch (conventional placement).

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.

Discussion

No takes yet. Share an insight, caveat, or question.

Expert reaction

What experts said about DANISH-CRT

Lancet · ESC Congress 2026

Heart failure evidence still forming

1 expert has reacted so far. We show the split once 3 have.

“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,…”
Dr. Jens Cosedis Nielsen, Principal Investigator of the DANISH-CRT trial ·

Expert labels are toward DANISH-CRT's result, from named public quotes (n=1). As of Sep 1, 2026.

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.

1 take classified by contention axis so far — the map appears as more land.

Jens Cosedis NielsenProfessor of cardiology, Aarhus University Hospital

“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.”

News Coverage

Implication

Standard LV lead placement suffices for CRT; challenges observational data favoring electrically guided targeting.

Abstract

BACKGROUND: Left ventricular lead position is a key determinant of optimal biventricular pacing for heart failure. Observational data indicate better outcomes in patients with late myocardial activation at the left ventricular lead site. We aimed to test whether targeting the left ventricular lead at site of latest electrical activation improves outcomes. METHODS: In this national, randomised, controlled, double-blinded, superiority trial we included patients from all five Danish university centres performing device implantation who had heart failure and wide QRS on guideline-directed medication, eligible for biventricular pacing. We randomly assigned (1:1) patients to either the intervention group, with left ventricular lead placement at the latest electrically activated site within the coronary sinus branches, or to control group, with left ventricular lead placement in a posterolateral non-apical branch. Primary outcome was a composite of time to death or first unplanned heart failure hospitalisation. We used block randomisation and masked patients and all study personnel (except operating room personnel) to treatment allocation. The primary outcome was a composite of time to death or first unplanned hospitalisation for heart failure. Analysis followed a modified intention-to-treat approach. Safety was assessed in all correctly assigned patients. The trial is registered at ClinicalTrials.gov (NCT03280862) and is complete. FINDINGS: From March 20, 2018, to June 3, 2024, we included 1001 patients (255 females and 746 males); 499 were randomly assigned to the intervention group and 502 to the control group. One incorrectly enrolled patient was excluded, leaving 1000 patients for the modified intention-to-treat analysis. Electrical activation at left ventricular lead was a mean of 9 milliseconds (95% CI 5-13) later in the intervention group. Follow-up was completed on Feb 27, 2026, after a median 45·8 months (IQR 28·5-65·7). The primary endpoint occurred in 139 (28%) of 499 patients in the intervention group and 128 (26%) of 501 in control group (hazard ratio 1·10 [95% CI 0·86-1·39]; p=0·45). Overall complication risk was similar between groups (71 [14%] patients in the intervention group vs 64 [13%] in the control group), but lead-related complications were more frequent in the intervention group. One procedure-related death occurred in the intervention group. INTERPRETATION: In patients with heart failure and prolonged QRS, targeted left ventricular lead placement at the site of latest electrical activation did not reduce the composite endpoint of death or unplanned hospitalisation for heart failure compared with conventional lead placement in a posterolateral, non-apical position.

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).

synapsesocial.com/papers/6a8fbb6617152b56e6b6483b https://doi.org/10.1016/s0140-6736(26)01597-7

Implication

Standard LV lead placement suffices for CRT; challenges observational data favoring electrically guided targeting.

Targeted left ventricular lead placement in biventricular pacing for heart failure: a national, multicentre, double-blind, randomised controlled trial in Denmark

Who says what

Full evidence

Key Points

Evidence details

What drove the result?

Limitations & tradeoffs

Structured PICO

Main Result

Discussion

What experts said about DANISH-CRT

Key expert perspectives

Implication

Abstract

Coverage & sources

Cite This Study

Targeted left ventricular lead placement in biventricular pacing for heart failure: a national, multicentre, double-blind, randomised controlled trial in Denmark

Who says what

Full evidence

Key Points

Evidence details

What drove the result?

Limitations & tradeoffs

Structured PICO

Main Result

Discussion

What experts said about DANISH-CRT

Key expert perspectives

Implication

Abstract

Coverage & sources

Cite This Study

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