Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery of Cardiac Resynchronization Therapy

Jonathan M. Behar; Peter Mountney; Daniel Toth; Sabrina Reiml; Maria Panayiotou; Alexander Brost; Bernhard Fahn; Rashed Karim; Simon Claridge; Tom Jackson; Ben Sieniewicz; Nik Patel; Mark O’Neill; Reza Razavi; Kawal Rhode; Christopher Aldo Rinaldi

doi:10.1016/j.jacep.2017.01.018

Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery of Cardiac Resynchronization Therapy

Jonathan M. Behar, Peter Mountney, Daniel Toth, Sabrina Reiml, Maria Panayiotou, Alexander Brost, Bernhard Fahn, Rashed Karim, Simon Claridge, Tom Jackson, Ben Sieniewicz, Nik Patel, Mark O’Neill, Reza Razavi, Kawal Rhode, Christopher Aldo Rinaldi

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Abstract

Objectives This study sought to test the feasibility of a purpose-built, integrated software platform to process, analyze, and overlay cardiac magnetic resonance (CMR) data in real time within a cardiac catheter laboratory and magnetic resonance imaging scanner in the same facility with the ability to transfer patients from one to the other (X-MRI) environment to guide left ventricular (LV) lead implantation. Background Suboptimal LV lead position is a major determinant of poor cardiac resynchronization therapy (CRT) response, and the optimal site is highly patient specific. Pacing myocardial scar is associated with poorer outcomes; conversely, targeting latest mechanical activation (LMA) may improve them. Methods Fourteen patients (age 74 ± 5.1 years; New York Heart Association functional class: 2.7 ± 0.4; 86% ischemic with ejection fraction 27 ± 7.6%; QRSd: 157 ± 19 ms) underwent CMR followed by immediate CRT implantation using derived scar and dyssynchrony data, overlaid onto fluoroscopy in an X-MRI suite. Rapid LV segmentation enabled detailed scar quantification, identification of LMA segments, and selection of myocardial targets. At coronary venography, the CMR-derived 3-dimensional shell was fused, enabling identification of viable venous targets subtended by target segments for LV lead placement. Results The platform was successful in all 14 patients, of whom 10 (71%) were paced in pre-procedurally defined target segments. Pacing in CMR-defined target segments (out of scar) showed a significant decrease in the LV capture threshold (mean difference: 2.4 [1.5 to 3.2]; p < 0.001) and shorter paced QRS duration (mean difference: 25 [15 to 34]; p < 0.001) compared with pacing in areas of CMR determined scar. In 5 (36%) patients with extensive scar in the posterolateral wall, CMR guidance enabled successful lead delivery in an alternative anatomically favorable site. Radiation dose and implant times were similar to historical controls (p = NS). Conclusions Real-time CMR-guided LV lead placement is feasible and achievable in a single clinical setting and may prove helpful to preferentially select sites for LV lead placement.

Original language	English
Journal	JACC: Clinical Electrophysiology
Early online date	26 Apr 2017
DOIs	https://doi.org/10.1016/j.jacep.2017.01.018
Publication status	E-pub ahead of print - 26 Apr 2017

Keywords

cardiac magnetic resonance (CMR)
cardiac resynchronization therapy (CRT) image guidance
image overlay
targeted LV lead placement

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10.1016/j.jacep.2017.01.018

Real-Time X-MRI-Guided_BEHAR_Publishedonline26April2017_GOLD CP (CC-BY-NC-ND)Accepted author manuscript, 2.74 MBLicence: CC BY-NC-ND

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Behar, J. M., Mountney, P., Toth, D., Reiml, S., Panayiotou, M., Brost, A., Fahn, B., Karim, R., Claridge, S., Jackson, T., Sieniewicz, B., Patel, N., O’Neill, M., Razavi, R., Rhode, K., & Rinaldi, C. A. (2017). Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery of Cardiac Resynchronization Therapy. JACC: Clinical Electrophysiology. Advance online publication. https://doi.org/10.1016/j.jacep.2017.01.018

@article{5860e96f0c464e2eb5c7821f116873cd,

title = "Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery of Cardiac Resynchronization Therapy",

abstract = "Objectives This study sought to test the feasibility of a purpose-built, integrated software platform to process, analyze, and overlay cardiac magnetic resonance (CMR) data in real time within a cardiac catheter laboratory and magnetic resonance imaging scanner in the same facility with the ability to transfer patients from one to the other (X-MRI) environment to guide left ventricular (LV) lead implantation. Background Suboptimal LV lead position is a major determinant of poor cardiac resynchronization therapy (CRT) response, and the optimal site is highly patient specific. Pacing myocardial scar is associated with poorer outcomes; conversely, targeting latest mechanical activation (LMA) may improve them. Methods Fourteen patients (age 74 ± 5.1 years; New York Heart Association functional class: 2.7 ± 0.4; 86% ischemic with ejection fraction 27 ± 7.6%; QRSd: 157 ± 19 ms) underwent CMR followed by immediate CRT implantation using derived scar and dyssynchrony data, overlaid onto fluoroscopy in an X-MRI suite. Rapid LV segmentation enabled detailed scar quantification, identification of LMA segments, and selection of myocardial targets. At coronary venography, the CMR-derived 3-dimensional shell was fused, enabling identification of viable venous targets subtended by target segments for LV lead placement. Results The platform was successful in all 14 patients, of whom 10 (71%) were paced in pre-procedurally defined target segments. Pacing in CMR-defined target segments (out of scar) showed a significant decrease in the LV capture threshold (mean difference: 2.4 [1.5 to 3.2]; p < 0.001) and shorter paced QRS duration (mean difference: 25 [15 to 34]; p < 0.001) compared with pacing in areas of CMR determined scar. In 5 (36%) patients with extensive scar in the posterolateral wall, CMR guidance enabled successful lead delivery in an alternative anatomically favorable site. Radiation dose and implant times were similar to historical controls (p = NS). Conclusions Real-time CMR-guided LV lead placement is feasible and achievable in a single clinical setting and may prove helpful to preferentially select sites for LV lead placement.",

keywords = "cardiac magnetic resonance (CMR), cardiac resynchronization therapy (CRT) image guidance, image overlay, targeted LV lead placement",

author = "Behar, {Jonathan M.} and Peter Mountney and Daniel Toth and Sabrina Reiml and Maria Panayiotou and Alexander Brost and Bernhard Fahn and Rashed Karim and Simon Claridge and Tom Jackson and Ben Sieniewicz and Nik Patel and Mark O{\textquoteright}Neill and Reza Razavi and Kawal Rhode and Rinaldi, {Christopher Aldo}",

year = "2017",

month = apr,

day = "26",

doi = "10.1016/j.jacep.2017.01.018",

language = "English",

journal = "JACC: Clinical Electrophysiology",

issn = "2405-500X",

publisher = "Elsevier USA",

}

Behar, JM, Mountney, P, Toth, D, Reiml, S, Panayiotou, M, Brost, A, Fahn, B, Karim, R , Claridge, S , Jackson, T , Sieniewicz, B, Patel, N, O’Neill, M, Razavi, R , Rhode, K & Rinaldi, CA 2017, 'Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery of Cardiac Resynchronization Therapy', JACC: Clinical Electrophysiology. https://doi.org/10.1016/j.jacep.2017.01.018

TY - JOUR

T1 - Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery of Cardiac Resynchronization Therapy

AU - Behar, Jonathan M.

AU - Mountney, Peter

AU - Toth, Daniel

AU - Reiml, Sabrina

AU - Panayiotou, Maria

AU - Brost, Alexander

AU - Fahn, Bernhard

AU - Karim, Rashed

AU - Claridge, Simon

AU - Jackson, Tom

AU - Sieniewicz, Ben

AU - Patel, Nik

AU - O’Neill, Mark

AU - Razavi, Reza

AU - Rhode, Kawal

AU - Rinaldi, Christopher Aldo

PY - 2017/4/26

Y1 - 2017/4/26

N2 - Objectives This study sought to test the feasibility of a purpose-built, integrated software platform to process, analyze, and overlay cardiac magnetic resonance (CMR) data in real time within a cardiac catheter laboratory and magnetic resonance imaging scanner in the same facility with the ability to transfer patients from one to the other (X-MRI) environment to guide left ventricular (LV) lead implantation. Background Suboptimal LV lead position is a major determinant of poor cardiac resynchronization therapy (CRT) response, and the optimal site is highly patient specific. Pacing myocardial scar is associated with poorer outcomes; conversely, targeting latest mechanical activation (LMA) may improve them. Methods Fourteen patients (age 74 ± 5.1 years; New York Heart Association functional class: 2.7 ± 0.4; 86% ischemic with ejection fraction 27 ± 7.6%; QRSd: 157 ± 19 ms) underwent CMR followed by immediate CRT implantation using derived scar and dyssynchrony data, overlaid onto fluoroscopy in an X-MRI suite. Rapid LV segmentation enabled detailed scar quantification, identification of LMA segments, and selection of myocardial targets. At coronary venography, the CMR-derived 3-dimensional shell was fused, enabling identification of viable venous targets subtended by target segments for LV lead placement. Results The platform was successful in all 14 patients, of whom 10 (71%) were paced in pre-procedurally defined target segments. Pacing in CMR-defined target segments (out of scar) showed a significant decrease in the LV capture threshold (mean difference: 2.4 [1.5 to 3.2]; p < 0.001) and shorter paced QRS duration (mean difference: 25 [15 to 34]; p < 0.001) compared with pacing in areas of CMR determined scar. In 5 (36%) patients with extensive scar in the posterolateral wall, CMR guidance enabled successful lead delivery in an alternative anatomically favorable site. Radiation dose and implant times were similar to historical controls (p = NS). Conclusions Real-time CMR-guided LV lead placement is feasible and achievable in a single clinical setting and may prove helpful to preferentially select sites for LV lead placement.

AB - Objectives This study sought to test the feasibility of a purpose-built, integrated software platform to process, analyze, and overlay cardiac magnetic resonance (CMR) data in real time within a cardiac catheter laboratory and magnetic resonance imaging scanner in the same facility with the ability to transfer patients from one to the other (X-MRI) environment to guide left ventricular (LV) lead implantation. Background Suboptimal LV lead position is a major determinant of poor cardiac resynchronization therapy (CRT) response, and the optimal site is highly patient specific. Pacing myocardial scar is associated with poorer outcomes; conversely, targeting latest mechanical activation (LMA) may improve them. Methods Fourteen patients (age 74 ± 5.1 years; New York Heart Association functional class: 2.7 ± 0.4; 86% ischemic with ejection fraction 27 ± 7.6%; QRSd: 157 ± 19 ms) underwent CMR followed by immediate CRT implantation using derived scar and dyssynchrony data, overlaid onto fluoroscopy in an X-MRI suite. Rapid LV segmentation enabled detailed scar quantification, identification of LMA segments, and selection of myocardial targets. At coronary venography, the CMR-derived 3-dimensional shell was fused, enabling identification of viable venous targets subtended by target segments for LV lead placement. Results The platform was successful in all 14 patients, of whom 10 (71%) were paced in pre-procedurally defined target segments. Pacing in CMR-defined target segments (out of scar) showed a significant decrease in the LV capture threshold (mean difference: 2.4 [1.5 to 3.2]; p < 0.001) and shorter paced QRS duration (mean difference: 25 [15 to 34]; p < 0.001) compared with pacing in areas of CMR determined scar. In 5 (36%) patients with extensive scar in the posterolateral wall, CMR guidance enabled successful lead delivery in an alternative anatomically favorable site. Radiation dose and implant times were similar to historical controls (p = NS). Conclusions Real-time CMR-guided LV lead placement is feasible and achievable in a single clinical setting and may prove helpful to preferentially select sites for LV lead placement.

KW - cardiac magnetic resonance (CMR)

KW - cardiac resynchronization therapy (CRT) image guidance

KW - image overlay

KW - targeted LV lead placement

U2 - 10.1016/j.jacep.2017.01.018

DO - 10.1016/j.jacep.2017.01.018

M3 - Article

SN - 2405-500X

JO - JACC: Clinical Electrophysiology

JF - JACC: Clinical Electrophysiology

ER -

Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery of Cardiac Resynchronization Therapy

Abstract

Keywords

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