On-screen image-guided lead placement in cardiac resynchronization therapy: Feasibility and outcome in a multicenter setting

BACKGROUND Image guidance to assist left ventricular (LV) lead placement may improve outcome after cardiac resynchronization therapy (CRT), but previous approaches and results varied greatly, and multicenter feasibility is lacking altogether.OBJECTIVE We sought to investigate the multicenter feasibility of image guidance for periprocedural assistance of LV lead placement for CRT.METHODS In 30 patients from 3 hospitals, cardiac magnetic reso-nance imaging was performed within 3 months prior to CRT to iden-tify myocardial scar and late mechanical activation (LMA). LMA was determined using radial strain, plotted over time. Segments without scar but clear LMA were classified as optimal for LV lead placement, according to an accurate 36-segment model of the whole heart. LV leads were navigated using image overlay with periprocedural fluo-roscopy. After 6 months, volumetric response and super-response were defined as >15% or >30% reduction in LV end-systolic vol -ume, respectively.RESULTS Periprocedural image guidance was successfully per-formed in all CRT patients (age 66 +/- 10 years; 59% men, 62% with nonischemic cardiomyopathy, 69% with left bundle branch block). LV leads were placed as follows: within (14%), adjacent (62%), or remote (24%) from the predefined target. According to the conventional 18-segment model, a remote position occurred only once (3%). On average, 86% of patients demonstrated a volu-metric response (mean LV end-systolic volume reduction 36 +/- 29%), and 66% of all patients were super-responders.CONCLUSION On-screen image guidance for LV lead placement in CRT was feasible in a multicenter setting. Efficacy will be further investigated in the randomized controlled ADVISE (Advanced Image Supported Lead Placement in Cardiac Resynchronization Therapy) trial (NCT05053568).