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

TY - JOUR

T1 - Feasibility of intraprocedural integration of cardiac CT to guide left ventricular lead implantation for CRT upgrades

AU - Gould, Justin

AU - Sidhu, Baldeep S.

AU - Sieniewicz, Benjamin J.

AU - Porter, Bradley

AU - Lee, Angela W.C.

AU - Razeghi, Orod

AU - Behar, Jonathan M.

AU - Mehta, Vishal

AU - Elliott, Mark K.

AU - Toth, Daniel

AU - Haberland, Ulrike

AU - Razavi, Reza

AU - Rajani, Ronak

AU - Niederer, Steven

AU - Rinaldi, Christopher A.

N1 - Funding Information: : Outside the submitted work Justin Gould/Bradley Porter/Mark K. Elliott/Vishal Mehta have received fellowship funding from Abbott. Baldeep S. Sidhu is funded by an NIHR project grant. Ulrike Haberland is an employee of Siemens who manufactured the imaging equipment or software used in this study. Steven Niederer is supported by EPSRC(EP/P01268X/1; NS/A000049/1; EP/M012492/1), BHF(PG/15/91/31812; FS/18/27/33543), NIHR (II‐LB‐1116‐20001) and Wellcome Trust (WT 203148/Z/16/Z). Christopher A. Rinaldi receives research funding and/or consultation fees from Abbott, Medtronic, Boston Scientific, Spectranetics, and MicroPort outside the submitted work. Disclosures Funding Information: The authors would like to thank Dr A. Shetty, Dr S. Adhya, Dr C. Chan, Dr P. Mehta, Professor N. Patel, and Professor J. Gill for helping with the CT guided implants and Mrs H. Chadwick and Professor G. Carr‐White for helping with recruitment. The authors are also grateful to Dr P. Mountney, Mr A‐A. Amadou, Dr T. Kurzendorfer, and Dr M. Ostermeier of Siemens Healthineers for their technical support and expertize in co‐developing and using the Guide CRT platform. This study was supported by the Rosetrees Trust and Wellcome/Engineering and Physical Sciences Research Council Center for Medical Engineering (WT203148/Z/16/Z). Publisher Copyright: © 2021 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

PY - 2021/3

Y1 - 2021/3

N2 - 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.

AB - 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.

KW - cardiac CT

KW - CRT

KW - image guidance

KW - improving CRT response

UR - https://www.scopus.com/pages/publications/85100919726

U2 - 10.1111/jce.14896

DO - 10.1111/jce.14896

M3 - Article

C2 - 33484216

AN - SCOPUS:85100919726

SN - 1045-3873

VL - 32

SP - 802

EP - 812

JO - Journal of Cardiovascular Electrophysiology

JF - Journal of Cardiovascular Electrophysiology

IS - 3

ER -