Combined computed tomographic perfusion and mechanics with predicted activation pattern can successfully guide implantation of a wireless endocardial pacing system

The WiSE-CRT system (EBR Systems, CA, USA) delivers wireless endocardial left ventricular (LV) pacing and has a number of advantages, including early access to fast endocardial conduction and a pacing location unconstrained by coronary anatomy. Currently, the optimal location for the electrode is unknown. Pacing in an area of latest mechanical activation and avoiding myocardial scar is advisable. We hypothesized that cardiac computed tomography with dynamic perfusion would have the ability to identify areas of heterogenous perfusion and when combined with areas of latest mechanical and electrical activation, would be able to identify the optimal location for the endocardial electrode. A 70-year-old patient with ischaemic cardiomyopathy was listed for a WiSE-CRT system after their epicardial left ventricular lead resulted in phrenic nerve stimulation in all configurations. Cardiac computed tomography with dynamic perfusion identified areas of perfusion heterogeneity, latest mechanical and electrical activation, which were combined to predict the optimal pacing location between the basal inferior (coloured orange in Figure 1) and inferolateral (coloured red in Figure 1) segments. During the procedure, these segments were overlaid onto live fluoroscopy as shown in Figure 1 and the greatest improvement in haemodynamic measurements corresponded to this target segment which was where the electrode was deployed. The full-length version of this report can be viewed at: https://www.escardio.org/Education/E-Learning/Clinical-cases/Electrophysiology.