Relation of Optimal Lead Positioning as Defined by Three-Dimensional Echocardiography to Long-Term Benefit of Cardiac Resynchronization

Becker, Michael; Hoffmann, Rainer; Schmitz, Fabian; Hundemer, Anne; Kühl, Harald P.; Schauerte, Patrick; Kelm, Malte; Franke, Andreas

doi:10.1016/j.amjcard.2007.07.019

Cited by 93 publications

(45 citation statements)

References 25 publications

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“…In a retrospective analysis where TDI assessment of mechanical activation was performed prior to CRT implantation, patients in whom the LV lead was situated at the site exhibiting the latest activation showed increased functional and echocardiographic improvements [15]. Superior response to CRT was also observed when the site of LMA was targeted using tissue synchronization imaging (TSI) [90], 3D echocardiography [91], and speckle tracking [92]. The TARGET [13] and STARTER [16] trials prospectively assessed the utility of echocardiographic speckle-tracking two-dimensional radial strain imaging to inform LV lead deployment.…”

Section: Dyssynchrony Assessment and Identification Of The Site Of Lamentioning

confidence: 99%

Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy

Sieniewicz

Gould

Porter

et al. 2018

Expert Review of Medical Devices

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Introduction: Cardiac resynchronization therapy (CRT) has emerged as one of the few effective treatments for heart failure. However, up to 50% of patients derive no benefit. Suboptimal left ventricle (LV) lead position is a potential cause of poor outcomes while targeted lead deployment has been associated with enhanced response rates. Image-fusion guidance systems represent a novel approach to CRT delivery, allowing physicians to both accurately track and target a specific location during LV lead deployment.Areas covered: This review will provide a comprehensive evaluation of how to define the optimal pacing site. We will evaluate the evidence for delivering targeted LV stimulation at sites displaying favorable viability or advantageous mechanical or electrical properties. Finally, we will evaluate several emerging image-fusion guidance systems which aim to facilitate optimal site selection during CRT.Expert commentary: Targeted LV lead deployment is associated with reductions in morbidity and mortality. Assessment of tissue characterization and electrical latency are critical and can be achieved in a number of ways. Ultimately, the constraints of coronary sinus anatomy have forced the exploration of novel means of delivering CRT including endocardial pacing which hold promise for the future of CRT delivery.

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Section: Dyssynchrony Assessment and Identification Of The Site Of Lamentioning

confidence: 99%

Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy

Sieniewicz

Gould

Porter

et al. 2018

Expert Review of Medical Devices

View full text Add to dashboard Cite

show abstract

“…With the use of pulse wave Doppler imaging, 46 tissue synchronization imaging, 47 realtime 3-dimensional echocardiography, 48 or 2-dimensional strain with speckle tracking, 49 the wall demonstrating maximal mechanical delay was identified and targeted for the LV lead position, leading to improved CRT response over nonoptimized lead localization. The degree of scar burden, as assessed by varied modalities, has also been associated with echocardiographic response to resynchronization therapy.…”

Section: Other Mechanisms Of Crt Responsementioning

confidence: 99%

“…In addition to the role of baseline mechanical dyssynchrony, other determinants of CRT response include LV lead position, [43][44][45][46][47][48][49] scar burden, 50 -53 electric dyssynchrony as measured by intracardiac electrogram (Q-LV interval), 54 and device optimization. 55 With so many variables at play, it is not surprising that dyssynchrony alone is inadequate to predict response to CRT.…”

Section: Other Mechanisms Of Crt Responsementioning

confidence: 99%

Assessment of Systolic Dyssynchrony for Cardiac Resynchronization Therapy Is Not Clinically Useful

Sung

Foster

2011

Circulation

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C ardiac resynchronization therapy (CRT) is an effective treatment in patients with medically refractory heart failure. Several clinical trials have shown improvement in both left ventricular (LV) function and symptoms with CRT compared with controls, 1-4 with the 2 largest trials showing a reduction in rates of hospitalization and death. 5,6 On the basis of data from these studies, most international guidelines agree on the standard indications for CRT: impaired functional status with New York Heart Association functional class III or IV, LV ejection fraction (LVEF) Յ35%, and prolonged QRS duration Ն120 ms in the setting of optimal medical therapy. 7-9 However, not all patients experienced improvement in symptoms or LV function, and numerous studies have focused on improving the selection criteria for CRT in the hopes of excluding these "nonresponders." [1][2][3][4] One of the most frequently studied modalities for patient selection is echocardiographic measurement of LV systolic dyssynchrony based on the supposition that there is a threshold for mechanical dyssynchrony below which there is no therapeutic benefit. Despite these studies, we argue that current echocardiographic methods of measuring dyssynchrony should not be used to exclude patients who are otherwise candidates for CRT. Conversely, in patients with narrow QRS, echocardiographic evidence of dyssynchrony is insufficient to warrant CRT on the basis of current data. Response by Delgado and Bax on p 663There are important unresolved issues regarding the use of mechanical dyssynchrony measurements for determining CRT eligibility in an individual patient. Let us examine the case of a 60-year-old man with ischemic cardiomyopathy, recurrent hospitalizations, and New York Heart Association functional class III despite an excellent heart failure drug regimen. He inquires about additional therapy to help improve his symptoms and keep him out of the hospital. His LVEF is 30% by echocardiogram, and the ECG shows a QRS duration of 150 ms in a left bundle-branch block configuration. Current guidelines clearly state that this patient qualifies for CRT. However, proponents of mechanical dyssynchrony would require additional evaluation before referring him for CRT. If evaluation for mechanical dyssynchrony is undertaken, many issues are unresolved, including the value of measuring intraventricular and/or interventricular dyssynchrony, the best modality to use for intraventricular dyssynchrony, and the threshold values that define the presence of mechanical dyssynchrony. Most importantly, if mechanical dyssynchrony is not demonstrated, is the weight of this evidence sufficient to advise against CRT implantation in the patient, contrary to guidelines?After reviewing the available data, we will present the case that current measures of mechanical dyssynchrony do not add clinical utility in selecting patients for CRT beyond current guidelines. Key issues to be addressed include the following: (1) defining "response" to CRT; (2) the clinical relevance of employing echo...

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“…[8][9] Several myocardial imaging techniques have been developed to identify this position, such as echocardiography, [10][11] cardiac magnetic resonance imaging (CMR) 12 and nuclear imaging.…”

Section: -7mentioning

confidence: 99%

“…[4][5][6][7] The optimal LV lead position is in the viable myocardial region with the latest contraction onset. [8][9] Several myocardial imaging techniques have been developed to identify this position, such as echocardiography, [10][11] cardiac magnetic resonance imaging (CMR) 12 and nuclear imaging. [13][14][15] Placing the LV lead in the recommended position through coronary veins is a challenge.…”

mentioning

confidence: 99%

A Review of Image-guided Approaches for Cardiac Resynchronisation Therapy

Tang

Zhou

2017

Arrhythmia &Amp; Electrophysiology Review

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Device TherapyAccess at: www.AERjournal.com Cardiac resynchronisation therapy (CRT) is a widely-performedstandard treatment for improving cardiac function and quality of life in patients with heart failure.1 After CRT, however, 30-40 % of patients do not experience improvements in left ventricular (LV) function and clinical symptoms. [2][3] The key factors for increasing the response rate to CRT are identification of the optimal LV lead position and accurate lead placement at the optimal site. 4-7The optimal LV lead position is in the viable myocardial region with the latest contraction onset. [8][9] Several myocardial imaging techniques have been developed to identify this position, such as echocardiography, [10][11] cardiac magnetic resonance imaging (CMR) 12 and nuclear imaging. 13-15Placing the LV lead in the recommended position through coronary veins is a challenge. 16,17 This procedure requires high accuracy, since a difference of 20 mm in LV lead location on the myocardial wall can influence CRT response, and an incorrect LV lead pacing site may lead to greater myocardial dyssynchrony. 18This paper reviews the technical advances and clinical studies being used in image-guided LV lead placement in CRT, including the identification of optimal LV lead position and placement of the LV lead at the recommended site. Image-guided LV Lead Placement in CRT Optimal LV Lead PositionMyocardial viability at the LV lead position is a key factor in enhancing CRT response rate. that the U-shaped activation pattern induced by true LBBB and a QRS duration of ≥120 ms could be used as criteria to predict CRT response.Pacing the latest mechanical activated site may significantly reduce the total LV electromechanical activation time compared with pacing other sites on the myocardial wall. 17 An animal study demonstrated that the regions with maximal resynchronisation after CRT had maximum improvements in systolic LV function. These regions are the 'sweet spots' and regarded as optimal regions for LV lead placement. 33,34A recent study shows that the latest activated regions may vary AbstractCardiac resynchronisation therapy (CRT) is a standard treatment for patients with heart failure; however, the low response rate significantly reduces its cost-effectiveness. A favourable CRT response primarily depends on whether implanters can identify the optimal left ventricular (LV) lead position and accurately place the lead at the recommended site. Myocardial imaging techniques, including echocardiography, cardiac magnetic resonance imaging and nuclear imaging, have been used to assess LV myocardial viability and mechanical dyssynchrony, and deduce the optimal LV lead position. The optimal position, presented as a segment of the myocardial wall, is then overlaid with images of the coronary veins from fluoroscopy to aid navigation of the LV lead to the target venous site. Once validated by large clinical trials, these image-guided techniques for CRT lead placement may have an impact on current clinical practice.

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Relation of Optimal Lead Positioning as Defined by Three-Dimensional Echocardiography to Long-Term Benefit of Cardiac Resynchronization

Cited by 93 publications

References 25 publications

Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy

Optimal site selection and image fusion guidance technology to facilitate cardiac resynchronization therapy

Assessment of Systolic Dyssynchrony for Cardiac Resynchronization Therapy Is Not Clinically Useful

A Review of Image-guided Approaches for Cardiac Resynchronisation Therapy

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