January 1, 2015Journal of Cardiovascular Magnetic Resonance22 citationsOpen Access

Prediction of response to cardiac resynchronization therapy using left ventricular pacing lead position and cardiovascular magnetic resonance derived wall motion patterns: a prospective cohort study

GHGregory Hartlage JSJonathan D Suever SCStéphanie Clément-Guinaudeau

Structured PICO

Does the combination of a type II wall motion pattern on CMR and a concordant LV lead improve echocardiographic response to cardiac resynchronization therapy in patients with systolic heart failure?

Population

33 patients with systolic heart failure (LVEF ≤35% by transthoracic echocardiography), QRS duration > 120 ms, and NYHA functional class II or III symptoms despite optimal medical therapy, referred for cardiac resynchronization therapy (CRT). Mean age 61, 55% male.

Intervention

Cardiac resynchronization therapy (CRT) with the left ventricular (LV) lead positioned concordant to the latest contracting LV site in patients with a type II (U-shaped) wall motion pattern identified by cardiovascular magnetic resonance (CMR) (T2CL).

Comparator

CRT in patients without T2CL (i.e., type I wall motion pattern and/or remote LV lead placement).

Outcome

Positive echocardiographic response to CRT, defined as reverse LV remodeling with a reduction in end-systolic volume (ESV) by ≥15% at 6 months.surrogate

The combination of a type II left ventricular wall motion pattern on CMR and a concordant LV pacing lead strongly predicts echocardiographic response to cardiac resynchronization therapy.

Limitations

Low prevalence of significant LGE precluded statistical analysis of the effect of T2CL in patients with scar
Method utilizes radial displacement of LV myocardium which does not directly measure mechanical contraction onset or peaks
Passive motion cannot be totally excluded despite correction for translational movement

Abstract

BACKGROUND: Despite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately. Recently, a "U-shaped" (type II) wall motion pattern identified by cardiovascular magnetic resonance (CMR) has been associated with improved CRT response compared to a homogenous (type I) wall motion pattern. There is also evidence that a left ventricular (LV) lead localized to the latest contracting LV site predicts superior response, compared to an LV lead localized remotely from the latest contracting LV site. METHODS: We prospectively evaluated patients undergoing CRT with pre-procedural CMR to determine the presence of type I and type II wall motion patterns and pre-procedural echocardiography to determine end systolic volume (ESV). We assessed the final LV lead position on post-procedural fluoroscopic images to determine whether the lead was positioned concordant to or remote from the latest contracting LV site. CRT response was defined as a ≥ 15% reduction in ESV on a 6 month follow-up echocardiogram. RESULTS: The study included 33 patients meeting conventional indications for CRT with a mean New York Heart Association class of 2.8 ± 0.4 and mean LV ejection fraction of 28 ± 9%. Overall, 55% of patients were echocardiographic responders by ESV criteria. Patients with both a type II pattern and an LV lead concordant to the latest contracting site (T2CL) had a response rate of 92%, compared to a response rate of 33% for those without T2CL (p = 0.003). T2CL was the only independent predictor of response on multivariate analysis (odds ratio 18, 95% confidence interval 1.6-206; p = 0.018). T2CL resulted in significant incremental improvement in prediction of echocardiographic response (increase in the area under the receiver operator curve from 0.69 to 0.84; p = 0.038). CONCLUSIONS: The presence of a type II wall motion pattern on CMR and a concordant LV lead predicts superior CRT response. Improving patient selection by evaluating wall motion pattern and targeting LV lead placement may ultimately improve the response rate to CRT.

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