Integration of cardiac magnetic resonance imaging, electrocardiographic imaging, and coronary venous computed tomography angiography for guidance of left ventricular lead positioning.

Abstract

AIMS\nAn appropriate left ventricular (LV) lead position is a pre-requisite for response to cardiac resynchronization therapy (CRT) and is highly patient-specific. The purpose of this study was to develop a non-invasive pre-procedural CRT-roadmap to guide LV lead placement to a coronary vein in late-activated myocardium remote from scar.\n\n\nMETHODS AND RESULTS\nSixteen CRT candidates were prospectively included. Electrocardiographic imaging (ECGI), computed tomography angiography (CTA), and delayed enhancement cardiac magnetic resonance imaging (DE-CMR) were integrated into a 3D cardiac model (CRT-roadmap) using anatomic landmarks from CTA and DE-CMR. Electrocardiographic imaging was performed using 184 electrodes and a CT-based heart-torso geometry. Coronary venous anatomy was visualized using a designated CTA protocol. Focal scar was assessed from DE-CMR. Cardiac resynchronization therapy-roadmaps were constructed for all 16 patients [left bundle branch block: n\u2009=\u20096; intraventricular conduction disturbance: n\u2009=\u20098; narrow-QRS (ablate and pace strategy); n\u2009=\u20091; right bundle branch block: n\u2009=\u20091]. The number of coronary veins ranged between 3 and 4 per patient. The CRT-roadmaps showed no (n\u2009=\u20095), 1 (n\u2009=\u20096), or 2 (n\u2009=\u20095) veins per patient located outside scar in late-activated myocardium [≥50% QRS duration (QRSd)]. Final LV lead position was outside scar in late-activated myocardium in 11 out of 14 implanted patients, while a LV lead in scar was unavoidable in the remaining three patients.\n\n\nCONCLUSION\nA non-invasive pre-implantation CRT-roadmap was feasible to develop in a case series by integration of coronary venous anatomy, myocardial-scar localization, and epicardial electrical activation patterns, anticipating on clinically relevant features.