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Comprehensive use of cardiac computed tomography to guide left ventricular lead placement in cardiac resynchronization therapy.

ABSTRACT: BACKGROUND:Optimal lead positioning is an important determinant of cardiac resynchronization therapy (CRT) response. OBJECTIVE:The purpose of this study was to evaluate cardiac computed tomography (CT) selection of the optimal epicardial vein for left ventricular (LV) lead placement by targeting regions of late mechanical activation and avoiding myocardial scar. METHODS:Eighteen patients undergoing CRT upgrade with existing pacing systems underwent preimplant electrocardiogram-gated cardiac CT to assess wall thickness, hypoperfusion, late mechanical activation, and regions of myocardial scar by the derivation of the stretch quantifier for endocardial engraved zones (SQUEEZ) algorithm. Cardiac venous anatomy was mapped to individualized American Heart Association (AHA) bull's-eye plots to identify the optimal venous target and compared with acute hemodynamic response (AHR) in each coronary venous target using an LV pressure wire. RESULTS:Fifteen data sets were evaluable. CT-SQUEEZ-derived targets produced a similar mean AHR compared with the best achievable AHR (20.4% ± 13.7% vs 24.9% ± 11.1%; P = .36). SQUEEZ-derived guidance produced a positive AHR in 92% of target segments, and pacing in a CT-SQUEEZ target vein produced a greater clinical response rate vs nontarget segments (90% vs 60%). CONCLUSION:Preprocedural CT-SQUEEZ-derived target selection may be a valuable tool to predict the optimal venous site for LV lead placement in patients undergoing CRT upgrade.

SUBMITTER: Behar JM

PROVIDER: S-EPMC5575356 | biostudies-literature | 2017 Sep

REPOSITORIES: biostudies-literature

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Comprehensive use of cardiac computed tomography to guide left ventricular lead placement in cardiac resynchronization therapy.

Behar Jonathan M JM Rajani Ronak R Pourmorteza Amir A Preston Rebecca R Razeghi Orod O Niederer Steve S Adhya Shaumik S Claridge Simon S Jackson Tom T Sieniewicz Ben B Gould Justin J Carr-White Gerry G Razavi Reza R McVeigh Elliot E Rinaldi Christopher Aldo CA

Heart rhythm 20170504 9

<h4>Background</h4>Optimal lead positioning is an important determinant of cardiac resynchronization therapy (CRT) response.<h4>Objective</h4>The purpose of this study was to evaluate cardiac computed tomography (CT) selection of the optimal epicardial vein for left ventricular (LV) lead placement by targeting regions of late mechanical activation and avoiding myocardial scar.<h4>Methods</h4>Eighteen patients undergoing CRT upgrade with existing pacing systems underwent preimplant electrocardiog ...[more]

PMID: 28479514

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Project description:BackgroundCardiac resynchronization therapy (CRT) is an effective treatment for patients with heart failure; however, 30% of patients do not respond to the treatment. We sought to derive patient-specific left ventricle maps of lead placement scores (LPS) that highlight target pacing lead sites for achieving a higher probability of CRT response.MethodsEighty-two subjects recruited for the ImagingCRT trial (Empiric Versus Imaging Guided Left Ventricular Lead Placement in Cardiac Resynchronization Therapy) were retrospectively analyzed. All 82 subjects had 2 contrast-enhanced full cardiac cycle 4-dimensional computed tomography scans: a baseline and a 6-month follow-up scan. CRT response was defined as a reduction in computed tomography-derived end-systolic volume ≥15%. Eight left ventricle features derived from the baseline scans were used to train a support vector machine via a bagging approach. An LPS map over the left ventricle was created for each subject as a linear combination of the support vector machine feature weights and the subject's own feature vector. Performance for distinguishing responders was performed on the original 82 subjects.ResultsFifty-two (63%) subjects were responders. Subjects with an LPS≤Q1 (lower-quartile) had a posttest probability of responding of 14% (3/21), while subjects with an LPS≥ Q3 (upper-quartile) had a posttest probability of responding of 90% (19/21). Subjects with Q1<LPS<Q3 had a posttest probability of responding that was essentially unchanged from the pretest probability (75% versus 63%, P=0.2). An LPS threshold that maximized the geometric mean of true-negative and true-positive rates identified 26/30 of the nonresponders. The area under the curve of the receiver operating characteristic curve for identifying responders with an LPS threshold was 87%.ConclusionsAn LPS map was defined using 4-dimensional computed tomography-derived features of left ventricular mechanics. The LPS correlated with CRT response, reclassifying 25% of the subjects into low probability of response, 25% into high probability of response, and 50% unchanged. These encouraging results highlight the potential utility of 4-dimensional computed tomography in guiding patient selection for CRT. The present findings need verification in larger independent data sets and prospective trials.

Dataset Information

Comprehensive use of cardiac computed tomography to guide left ventricular lead placement in cardiac resynchronization therapy.

Publications

Comprehensive use of cardiac computed tomography to guide left ventricular lead placement in cardiac resynchronization therapy.

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