What is the clinical evidence from this study?

Study design: Review. Population: Heart Failure. Intervention: Cardiac resynchronization therapy (CRT) left ventricular lead placement.

September 8, 2021Open Access

Optimal CRT Implantation—Where and How To Place the Left-Ventricular Lead?

CBChristian ButterInterventional Cardiology CGChristian GeorgiMedizinische Hochschule Brandenburg Theodor Fontane MSMartin StockburgerDRK Kliniken Berlin

Key Result

Optimal left ventricular lead placement during cardiac resynchronization therapy relies on empirical positioning and intraoperative testing in routine cases, with pre-implant imaging reserved for complex anatomies.

Structured PICO

Do optimal left ventricular lead placement strategies improve hemodynamic and clinical response in heart failure patients receiving cardiac resynchronization therapy?

Population

Heart failure patients eligible for cardiac resynchronization therapy (CRT)

Intervention

Optimal left ventricular lead placement strategies including multimodal imaging guidance, intraprocedural hemodynamic optimization, and alternative pacing strategies (e.g., multipoint pacing, conduction system pacing)

Comparator

Empirical lead positioning or standard biventricular pacing

Outcome

Hemodynamic improvement, reverse remodeling, and clinical response to CRT

While empirical lead positioning remains standard for most CRT implantations, pre-implant imaging and intraoperative hemodynamic testing can optimize LV lead placement and improve response in complex cases.

Abstract

PURPOSE OF REVIEW: Cardiac resynchronization therapy (CRT) represents a well-established and effective non-pharmaceutical heart failure (HF) treatment in selected patients. Still, a significant number of patients remain CRT non-responders. An optimal placement of the left ventricular (LV) lead appears crucial for the intended hemodynamic and hence clinical improvement. A well-localized target area and tools that help to achieve successful lead implantation seem to be of utmost importance to reach an optimal CRT effect. RECENT FINDINGS: Recent studies suggest previous multimodal imaging (CT/cMRI/ECG torso) to guide intraprocedural LV lead placement. Relevant benefit compared to empirical lead optimization is still a matter of debate. Technical improvements in leads and algorithms (e.g., multipoint pacing (MPP), adaptive algorithms) promise higher procedural success. Recently emerging alternatives for ventricular synchronization such as conduction system pacing (CSP), LV endocardial pacing, or leadless pacing challenge classical biventricular pacing. This article reviews current strategies for a successful planning, implementation, and validation of the optimal CRT implantation. Pre-implant imaging modalities offer promising assistance for complex cases; empirical lead positioning and intraoperative testing remain the cornerstone in most cases and ensure a successful CRT effect.

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