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. 2011 Jun 13;13(1):29.
doi: 10.1186/1532-429X-13-29.

Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance

Francisco Leyva  1 , Paul W X Foley, Shajil Chalil, Karim Ratib, Russell E A Smith, Frits Prinzen, Angelo Auricchio
Affiliations

Cardiac resynchronization therapy guided by late gadolinium-enhancement cardiovascular magnetic resonance

Francisco Leyva et al. J Cardiovasc Magn Reson. .

Abstract

Background: Myocardial scarring at the LV pacing site leads to incomplete resynchronization and a suboptimal symptomatic response to CRT. We sought to determine whether the use of late gadolinium cardiovascular magnetic resonance (LGE-CMR) to guide left ventricular (LV) lead deployment influences the long-term outcome of cardiac resynchronization therapy (CRT).

Methods: 559 patients with heart failure (age 70.4 ± 10.7 yrs [mean ± SD]) due to ischemic or non-ischemic cardiomyopathy underwent CRT. Implantations were either guided (+CMR) or not guided (-CMR) by LGE-CMR prior to implantation. Fluoroscopy and LGE-CMR were used to localize the LV lead tip and and myocardial scarring retrospectively. Clinical events were assessed in three groups: +CMR and pacing scar (+CMR+S); CMR and not pacing scar (+CMR-S), and; LV pacing not guided by CMR (-CMR).

Results: Over a maximum follow-up of 9.1 yrs, +CMR+S had the highest risk of cardiovascular death (HR: 6.34), cardiovascular death or hospitalizations for heart failure (HR: 5.57) and death from any cause or hospitalizations for major adverse cardiovascular events (HR: 4.74) (all P < 0.0001), compared with +CMR-S. An intermediate risk of meeting these endpoints was observed for -CMR, with HRs of 1.51 (P = 0.0726), 1.61 (P = 0.0169) and 1.87 (p = 0.0005), respectively. The +CMR+S group had the highest risk of death from pump failure (HR: 5.40, p < 0.0001) and sudden cardiac death (HR: 4.40, p = 0.0218), in relation to the +CMR-S group.

Conclusions: Compared with a conventional implantation approach, the use of LGE-CMR to guide LV lead deployment away from scarred myocardium results in a better clinical outcome after CRT. Pacing scarred myocardium was associated with the worst outcome, in terms of both pump failure and sudden cardiac death.

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Figures

Figure 1
Figure 1
Mapping LV lead positions. Example of the main screen of the software programme used for mapping LV lead positions. The longitudinal distance from the atrioventricular plane to the lead tip, in a base-to-apex direction, is quantified in mm using the 30° right anterior oblique fluoroscopic view (upper left hand panel). This longitudinal distance is transposed to the four-chamber CMR view (upper right hand panel), so as to determine the LGE-CMR short axis slice (yellow line, left lower panel) that corresponds to the LV lead tip position. The 30° left anterior oblique fluoroscopic view (right lower panel) is then used to determine the circumferential position (yellow arrow). The longitudinal and circumferential coordinates permit localization of the LV lead tip in relation to myocardial segments [35] and myocardial scars, which appear as white enhancement on LGE-CMR (white arrow).
Figure 2
Figure 2
Clinical outcome of CRT according to implantation strategy. +CMR-S = group with CMR showing no scar at the LV pacing position; +CMR+S = group with CMR showing scar at the LV pacing position; -CMR = non-CMR guided group.
Figure 3
Figure 3
Symptomatic and echocardiographic response according to implantation strategy. Numbers refer to the proportion of patients meeting the respective endpoints by the end of the study.
See this image and copyright information in PMC

References

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