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.
1Therefore, 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,
- Singh J.P.
- Klein H.U.
- Huang D.T.
- et al.
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
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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
3the 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.
- Saba S.
- Marek J.
- Schwartzman D.
- et al.
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
4Consequently, based on the principle of electromechanical coupling,
- Borgquist R.
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- et al.
Cardiac resynchronization therapy guided by echocardiography, MRI, and CT imaging: a randomized controlled study.
JACC Clin Electrophysiol. 2020; 6: 1300-1309
5electrical indices of cardiac dyssynchrony have become more frequently used for guiding LV lead placement.
- Singh J.P.
- Fan D.
- Heist E.K.
- et al.
Left ventricular lead electrical delay predicts response to cardiac resynchronization therapy.
Heart Rhythm. 2006; 3: 1285-1292
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- 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
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- Comparison of measures of ventricular delay on cardiac resynchronization therapy response.Heart Rhythm. 2020; 17: 615-620
- Interventricular electrical delay is predictive of response to cardiac resynchronization therapy.JACC Clin Electrophysiol. 2016; 2: 438-447
- Association of interventricular activation delay with clinical outcomes in cardiac resynchronization therapy.Heart Rhythm. 2023; 20: 385-392
- 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
- Left bundle branch area pacing for cardiac resynchronization therapy: results from the International LBBAP Collaborative Study Group.JACC Clin Electrophysiol. 2021; 7: 135-147
Published online: December 07, 2022
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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