Approximately one-third of patients with cardiac resynchronization therapy (CRT) do
not experience clinical benefit despite fulfilling the criteria for guideline-recommended
device implant. To reduce the nonresponder rate and enhance the benefit of CRT in
responders, robust research studies on CRT have concentrated on the optimal selection
of CRT candidates and ideal sites of ventricular leads. Based on acute hemodynamic
data from early CRT studies, the left ventricular (LV) lead position was guided by
anatomical criteria with the lateral wall being the preferable location. However,
there was little linkage between CRT outcomes and anatomically guided LV lead placement,
aside from the observation that apical sites were associated with worse outcomes.
1
Therefore, later studies shifted their focus to a more physiologic approach by targeting
the area with delayed mechanical or electrical activation. Several advanced imaging
modalities have been used to identify the delayed mechanical activation area. Although
identifying the sites of late LV activation using speckle tracking echocardiography
was linked to better CRT outcomes,
2
,3
the difficulties in reliably performing speckle tracking and translating the area
in the echocardiogram to its location in fluoroscopic views perioperatively is a barrier
to adoption. Additionally, a randomized controlled trial using integrated cardiac
imaging with radial strain echocardiography, cardiac computed tomography, and cardiac
magnetic resonance imaging with gadolinium contrast to guide LV lead placement failed
to significantly lower death or heart failure (HF) hospitalization.
4
Consequently, based on the principle of electromechanical coupling,
5
electrical indices of cardiac dyssynchrony have become more frequently used for guiding
LV lead placement.To read this article in full you will need to make a payment
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References
- Left ventricular lead position and clinical outcome in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) trial.Circulation. 2011; 123: 1159-1166
- Targeted left ventricular lead placement to guide cardiac resynchronization therapy: the TARGET study: a randomized, controlled trial.J Am Coll Cardiol. 2012; 59: 1509-1518
- Echocardiography-guided left ventricular lead placement for cardiac resynchronization therapy: results of the Speckle Tracking Assisted Resynchronization Therapy for Electrode Region trial.Circ Heart Fail. 2013; 6: 427-434
- Cardiac resynchronization therapy guided by echocardiography, MRI, and CT imaging: a randomized controlled study.JACC Clin Electrophysiol. 2020; 6: 1300-1309
- Left ventricular lead electrical delay predicts response to cardiac resynchronization therapy.Heart Rhythm. 2006; 3: 1285-1292
- The relationship between ventricular electrical delay and left ventricular remodelling with cardiac resynchronization therapy.Eur Heart J. 2011; 32: 2516-2524
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- Interventricular electrical delay is predictive of response to cardiac resynchronization therapy.JACC Clin Electrophysiol. 2016; 2: 438-447
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- His corrective pacing or biventricular pacing for cardiac resynchronization in heart failure.J Am Coll Cardiol. 2019; 74: 157-159
- Rescue left bundle branch area pacing in coronary venous lead failure or nonresponse to biventricular pacing: results from International LBBAP Collaborative Study Group.Heart Rhythm. 2022; 19: 1272-1280
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Article info
Publication history
Published online: December 07, 2022
Footnotes
Funding Sources: The authors have no funding sources to disclose.
Disclosures: Dr Miller has received fellowship support and lecture fees from Medtronic, Boston Scientific, Biosense Webster, Abbott Electrophysiology, and Biotronik. Dr Tanawuttiwat has no disclosure to report.
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