Utilization of Computed Tomography for Left Ventricular Lead Placement to Optimize Cardiac Resynchronization Therapy

Objective: This study evaluates the possible utility of computed tomography angiography (CTA) to optimize planning and lead placement during cardiac resynchronization therapy (CRT). We sought to evaluate how often leads were suboptimally placed and determine if CTA could identify a more optimal lead placement. Background: CRT has been shown to improve morbidity and mortality associated with systolic heart failure. Nevertheless, a significant proportion of patients remain CRT non-responders, which may be due to location of LV lead placement. Evaluation of patients with CTA before device implantation may aid clinicians by providing a roadmap for LV lead placement. Hence, CTA may aide to decrease the number of CRT non-responders. Methods: CTAs of 39 post-CRT patients were reviewed to assess LV lead placement. LV lead vein position was identified as the anterior interventricular vein (AIV), coronary sinus (CS), or posterolateral vein (PLV). If placed in the AIV, PLV identification was attempted. Also, each CTA was assessed for the presence of myocardial scar in the distribution of the LV lead. Suboptimal placement was considered when the lead was in the AIV (in the presence of a large, >3 mm, PLV) or when scar tissue was present in the distribution of the lead. Results: The LV lead was positioned in the AIV in 19 (48.7%) patients, PLV in 19 (48.7%) patients; CS in 1 (2.6%) patient. 16 (41%) patients with AIV lead placements had a more optimal PLV present. Myocardial scar tissue was in the immediate vicinity of the LV lead in 7 (17.9%) patients. Thus, a total of 14 of 39 (35.9%) patients had suboptimal lead placement. Conclusion: CTA can be used to delineate the coronary venous anatomy to aid in LV lead placement for optimization of CRT.