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

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Abstract

Aims An appropriate left ventricular (LV) lead position is a pre-requisite for response to cardiac resynchronization therapy (CRT) and is highly patient-specific. The purpose of this study was to develop a non-invasive pre-procedural CRT-roadmap to guide LV lead placement to a coronary vein in late-activated myocardium remote from scar.

Methods and results Sixteen CRT candidates were prospectively included. Electrocardiographic imaging (ECGI), computed tomography angiography (CTA), and delayed enhancement cardiac magnetic resonance imaging (DE-CMR) were integrated into a 3D cardiac model (CRT-roadmap) using anatomic landmarks from CTA and DE-CMR. Electrocardiographic imaging was performed using 184 electrodes and a CT-based heart-torso geometry. Coronary venous anatomy was visualized using a designated CTA protocol. Focal scar was assessed from DE-CMR. Cardiac resynchronization therapy-roadmaps were constructed for all 16 patients [left bundle branch block: n=6; intraventricular conduction disturbance: n=8; narrow-QRS (ablate and pace strategy); n=1; right bundle branch block: n=1]. The number of coronary veins ranged between 3 and 4 per patient. The CRT-roadmaps showed no (n=5), 1 (n=6), or 2 (n=5) veins per patient located outside scar in late-activated myocardium [50% QRS duration (QRSd)]. Final LV lead position was outside scar in late-activated myocardium in 11 out of 14 implanted patients, while a LV lead in scar was unavoidable in the remaining three patients.

Conclusion A non-invasive pre-implantation CRT-roadmap was feasible to develop in a case series by integration of coronary venous anatomy, myocardial-scar localization, and epicardial electrical activation patterns, anticipating on clinically relevant features.

Original languageEnglish
Pages (from-to)626-635
Number of pages10
JournalEP Europace
Volume21
Issue number4
DOIs
Publication statusPublished - Apr 2019

Keywords

  • Cardiac resynchronization therapy
  • Left ventricular lead
  • Image integration
  • Coronary venous anatomy
  • Computed tomography angiography
  • Electrocardiographic imaging
  • Cardiac magnetic resonance imaging
  • Myocardial scar
  • Heart failure
  • RESYNCHRONIZATION THERAPY
  • PLACEMENT
  • CT
  • ECHOCARDIOGRAPHY
  • RADIATION
  • MODEL

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