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

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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

Original languageEnglish
JournalJACC: Clinical Electrophysiology
Early online date26 Apr 2017
Accepted/In press27 Jan 2017
E-pub ahead of print26 Apr 2017


King's Authors


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.

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