title: Left ventricular lead placement in the latest activated region guided by coronary venous electroanatomic mapping.
abstract: OBJECTIVE
  Left ventricular (LV) lead placement in the latest activated region is an important determinant of response to cardiac resynchronization therapy (CRT). We investigated the feasibility of coronary venous electroanatomic mapping (EAM) to guide LV lead placement to the latest activated region.
  
  
  RESULTS
  Twenty-five consecutive CRT candidates with left bundle-branch block underwent intra-procedural coronary venous EAM using EnSite NavX. A guidewire was used to map the coronary veins during intrinsic activation, and to test for phrenic nerve stimulation (PNS). The latest activated region, defined as the region with an electrical delay >75% of total QRS duration, was located anterolaterally in 18 (basal, n = 10; mid, n = 8) and inferolaterally in 6 (basal, n = 3; mid, n = 3). In one patient, identification of the latest activated region was impeded by limited coronary venous anatomy. In patients with >1 target vein (n = 12), the anatomically targeted inferolateral vein was rarely the vein with maximal electrical delay (n = 3). A concordant LV lead position was achieved in 18 of 25 patients. In six patients, this was hampered by PNS (n = 4), lead instability (n = 1), and coronary vein stenosis (n = 1).
  
  
  CONCLUSIONS
  Coronary venous EAM can be used intraprocedurally to guide LV lead placement to the latest activated region free of PNS. This approach especially contributes to optimization of LV lead electrical delay in patients with multiple target veins. Conventional anatomical LV lead placement strategy does not target the vein with maximal electrical delay in many of these patients.
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, P. Debeyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands masih.mafirad@mumc.nl.
authors.forename: Masih Mafi
authors.initials: MM
authors.lastname: Rad
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, P. Debeyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Yuri
authors.initials: Y
authors.lastname: Blaauw
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, P. Debeyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Trang
authors.initials: T
authors.lastname: Dinh
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, P. Debeyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Laurent
authors.initials: L
authors.lastname: Pison
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, P. Debeyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Harry J
authors.initials: HJ
authors.lastname: Crijns
authors.affiliation: Department of Physiology, Cardiovascular Research Institute Maastricht, PO Box 616, Maastricht 6200 MD, The Netherlands.
authors.forename: Frits W
authors.initials: FW
authors.lastname: Prinzen
authors.affiliation: Department of Cardiology, Maastricht University Medical Center, P. Debeyelaan 25, PO Box 5800, 6202 AZ Maastricht, The Netherlands.
authors.forename: Kevin
authors.initials: K
authors.lastname: Vernooy
mesh_terms: D000368:Aged; D018780:Body Surface Potential Mapping / Q000379:methods*; D002037:Bundle-Branch Block / Q000175:diagnosis / Q000517:prevention & control*; D006328:Cardiac Catheterization / Q000379:methods*; D058406:Cardiac Resynchronization Therapy / Q000379:methods*; D058409:Cardiac Resynchronization Therapy Devices; D003331:Coronary Vessels; D004567:Electrodes, Implanted; D005260:Female; D006352:Heart Ventricles / Q000601:surgery*; D006801:Humans; D008297:Male; D019919:Prosthesis Implantation / Q000379:methods*; D016896:Treatment Outcome
keywords: Cardiac resynchronization therapy; Electroanatomic mapping; Feasibility; Left ventricular electrical activation; Left ventricular lead placement