Integration of cardiac magnetic resonance imaging, electrocardiographic imaging, and coronary venous computed tomography angiography for guidance of left ventricular lead positioning

Nguyên, Uyên Châu; Cluitmans, Matthijs; Strik, Marc; Luermans, Justin; Gommers, Suzanne; Wildberger, Joachim E.; Bekkers, Sebastiaan C.A.M.; Volders, Paul G.A.; Mihl, Casper; Prinzen, Frits W.; Vernooy, Kevin

doi:10.1093/europace/euy292

Cited by 21 publications

(25 citation statements)

References 30 publications

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“…Lead location concordant to regions of maximal wall thickness was associated with reduced MACE ( p < .01), however, CT dyssynchrony metrics and myocardial scar assessment did not predict 6‐month CRT response and prior knowledge of coronary venous anatomy by CT did not reduce implant or fluoroscopy time 6 . More recently, Nguyên et al successfully integrated CS roadmaps acquired from cardiac CTAs, with LGE imaging from Cardiac MRI and electrocardiographic imaging (ECGI) into 3D CRT roadmaps in 14 patients undergoing CRT implantation 16 . The LV lead was positioned outside scar in LMA regions determined from ECGI in 11 out of 14 patients; in the remaining three patients LV scar could not be avoided and in two patients cannulation of the target vein was not possible due to limited coronary venous anatomy 16 .…”

Section: Discussionmentioning

confidence: 99%

“…These results suggest promise in targeting optimal LV lead placement, however, this is potentially a time and resource heavy preprocedural planning exercise requiring two cross‐sectional imaging modalities with ECGI integration. Nguyên et al 16 did not report preprocedural imaging and data processing or planning time which is likely to be reasonably long and may limit its clinical utility in real‐world clinical practice. Furthermore, validation of the optimal pacing site was not performed using hemodynamic assessment 16 .…”

Section: Discussionmentioning

confidence: 99%

“…Nguyên et al 16 did not report preprocedural imaging and data processing or planning time which is likely to be reasonably long and may limit its clinical utility in real‐world clinical practice. Furthermore, validation of the optimal pacing site was not performed using hemodynamic assessment 16 . Whilst LV scar imaging acquired from CMR is currently more reliable and reproducible than CT, if this were to change then CT and ECGI integration would certainly be a viable and potentially robust option for guiding LV lead implantation into LMA segments outside scar.…”

Section: Discussionmentioning

confidence: 99%

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Feasibility of intraprocedural integration of cardiac CT to guide left ventricular lead implantation for CRT upgrades

Gould

Sidhu

Sieniewicz

et al. 2021

Cardiovasc electrophysiol

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Background Optimal positioning of the left ventricular (LV) lead is an important determinant of cardiac resynchronization therapy (CRT) response. Objective Evaluate the feasibility of intraprocedural integration of cardiac computed tomography (CT) to guide LV lead implantation for CRT upgrades. Methods Patients undergoing LV lead upgrade underwent ECG‐gated cardiac CT dyssynchrony and LV scar assessment. Target American Heart Association segment selection was determined using latest non‐scarred mechanically activating segments overlaid onto real‐time fluoroscopy with image co‐registration to guide optimal LV lead implantation. Hemodynamic validation was performed using a pressure wire in the LV cavity (dP/dtmax)). Results 18 patients (male 94%, 55.6% ischemic cardiomyopathy) with RV pacing burden 60.0 ± 43.7% and mean QRS duration 154 ± 30 ms underwent cardiac CT. 10/10 ischemic patients had CT evidence of scar and these segments were excluded as targets. Seventeen out of 18 (94%) patients underwent successful LV lead implantation with delivery to the CT target segment in 15 out of 18 (83%) of patients. Acute hemodynamic response (dP/dtmax ≥ 10%) was superior with LV stimulation in CT target versus nontarget segments (83.3% vs. 25.0%; p = .012). Reverse remodeling at 6 months (LV end‐systolic volume improvement ≥15%) occurred in 60% of subjects (4/8 [50.0%] ischemic cardiomyopathy vs. 5/7 [71.4%] nonischemic cardiomyopathy, p = .608). Conclusion Intraprocedural integration of cardiac CT to guide optimal LV lead placement is feasible with superior hemodynamics when pacing in CT target segments and favorable volumetric response rates, despite a high proportion of patients with ischemic cardiomyopathy. Multicentre, randomized controlled studies are needed to evaluate whether intraprocedural integration of cardiac CT is superior to standard care.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Feasibility of intraprocedural integration of cardiac CT to guide left ventricular lead implantation for CRT upgrades

Gould

Sidhu

Sieniewicz

et al. 2021

Cardiovasc electrophysiol

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“…In an attempt to improve response in CRT recipients with ischemic heart disease, scar imaging may be used to guide LV lead placement away from scar tissue. In a recent feasibility study, Nguyen and colleagues combined scar imaging with CT angiography in order to construct roadmaps which allowed the implanting cardiologist to place the LV lead away from scar tissue in 11 of 14 patients [19]. Randomized controlled trials are needed to decide whether scar imaging should be performed in CRT candidates with known ischemic heart disease.…”

Section: Traditional Determinants Of Crt Responsementioning

confidence: 99%

Non-invasive cardiac mapping for non-response in cardiac resynchronization therapy

et al. 2019

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Cardiac resynchronization therapy (CRT) is an effective intervention in selected patients with moderate-to-severe heart failure with reduced ejection fraction and abnormal left ventricular activation time. The non-response rate of approximately 30% has remained nearly unchanged since this therapy was introduced 25 years ago. While intracardiac mapping is widely used for diagnosis and guidance of therapy in patients with tachyarrhythmia, its application in characterization of the electrical substrate to elucidate the mechanisms involved in CRT response remain anecdotal. In the present review, we describe the traditional determinants of CRT response before presenting novel non-invasive techniques used for CRT optimization. We discuss efforts to identify the target electrical substrate to guide the deployment of pacing electrodes during the operative procedure. Non-invasive body surface mapping technologies such as ECG imaging or ECG belt enables prediction of acute and chronic CRT response. While electrical dyssynchrony parameters provide high predictive accuracy for CRT response when obtained during intrinsic conduction, their predictive value is less when acquired during CRT or LV-pacing. KEY MESSAGES Classic predictors of CRT response are female gender, NYHA class III, left ventricular ejection fraction !25%, QRS duration !150 ms and estimated glomerular filtration rate !60 mL/min. ECG-imaging is a comprehensive non-invasive mapping system which allows to express the amount of electrical asynchrony of a CRT candidate. Non-invasive body surface mapping technologies enables excellent prediction of acute and chronic CRT response before implantation. When performed during CRT or LV-pacing, the added value of these mapping systems remains unclear.

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“…As compared to standard dual‐source CT, we employed a different approach using LIE‐CT with image subtraction to obtain optimal image sets. Iodine has pharmacokinetic properties similar to those of gadolinium 22 and there is a good correlation between LIE‐CT and LGE‐CMR in identifying MS 25 . Subtraction CT is obtained by subtracting non‐contrast images of high‐density structures (coronary calcium, stents, or, here, the LV lead) from delayed contrast images to focus on the density of iodine 11 .…”

Section: Discussionmentioning

confidence: 99%

Characterization of non‐response to cardiac resynchronization therapy by post‐procedural computed tomography

Pezel

Mika

Logeart

et al. 2020

Pacing Clinical Electrophis

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Introduction Causes of non‐response to cardiac resynchronization therapy (CRT) include mechanical dyssynchrony, myocardial scar, and suboptimal left ventricular (LV) lead location. We aimed to assess the utility of Late Iodine Enhancement Computed Tomography (LIE‐CT) with image subtraction in characterizing CRT non‐response. Methods CRT response was defined as a decrease in LV end‐systolic volume > 15% at 6 months. LIE‐CT was performed after 6 months, and analyzed global and segmental dyssynchrony, myocardial scar, coronary venous anatomy, and position of LV lead relative to scar and segment of latest mechanical contraction. Results We evaluated 29 patients (age 71 ± 12 years; 72% men) including 18 (62%) responders. All metrics evaluating residual dyssynchrony such as wall motion index and wall thickness index were worse in non‐responders. There was no difference in presence and extent of scar between responders and non‐responders. However, in non‐responders, the LV lead was more often over an akinetic/dyskinetic area (72% vs. 22%, p = .007), a fibrotic area (64% vs. 8%, p = .0007), an area with myocardial thickness < 6 mm (82% vs. 22%, p = .002), and less often concordant with the region of maximal wall thickness (9% vs. 72%, p = .001). Among the 11 non‐responders, eight had at least another coronary venous branch visualized by CT, including three (27%) coursing over a potentially interesting myocardial area (free of scar, with normal wall motion, and with a myocardial thickness ≥6 mm). Conclusion LIE‐CT with image subtraction allows a comprehensive characterization of patients after CRT and may provide clues for management of non‐responders.

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Integration of cardiac magnetic resonance imaging, electrocardiographic imaging, and coronary venous computed tomography angiography for guidance of left ventricular lead positioning

Cited by 21 publications

References 30 publications

Feasibility of intraprocedural integration of cardiac CT to guide left ventricular lead implantation for CRT upgrades

Feasibility of intraprocedural integration of cardiac CT to guide left ventricular lead implantation for CRT upgrades

Non-invasive cardiac mapping for non-response in cardiac resynchronization therapy

Characterization of non‐response to cardiac resynchronization therapy by post‐procedural computed tomography

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