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

Justin Gould; Baldeep S Sidhu; Benjamin J Sieniewicz; Bradley Porter; Angela W C Lee; Orod Razeghi; Jonathan M Behar; Vishal Mehta; Mark K Elliott; Daniel Toth; Ulrike Haberland; Reza Razavi; Ronak Rajani; Steven Niederer; Christopher A Rinaldi

doi:10.1111/jce.14896

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

J Cardiovasc Electrophysiol. 2021 Mar;32(3):802-812. doi: 10.1111/jce.14896. Epub 2021 Feb 10.

Authors

Justin Gould^{1

2}, Baldeep S Sidhu^{1

2}, Benjamin J Sieniewicz^{1

2}, Bradley Porter^{1

2}, Angela W C Lee², Orod Razeghi², Jonathan M Behar^{1

2}, Vishal Mehta^{1

2}, Mark K Elliott^{1

2}, Daniel Toth², Ulrike Haberland³, Reza Razavi^{1

2}, Ronak Rajani^{1

2}, Steven Niederer², Christopher A Rinaldi^{1

2}

Affiliations

¹ Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, UK.
² School of Biomedical Engineering and Imaging Sciences, King's College, London, UK.
³ Medical Imaging Technologies, Siemens Healthineers, Malvern, Pennsylvania, USA.

Abstract

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/dt_max) ).

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/dt_max ≥ 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.

Keywords: CRT; cardiac CT; image guidance; improving CRT response.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Cardiac Resynchronization Therapy*
Feasibility Studies
Heart Failure* / diagnostic imaging
Heart Failure* / therapy
Heart Ventricles / diagnostic imaging
Heart Ventricles / surgery
Humans
Male
Tomography
Tomography, X-Ray Computed
Treatment Outcome

Abstract

Publication types

MeSH terms

Grants and funding