title: Prediction of response to cardiac resynchronization therapy using left ventricular pacing lead position and cardiovascular magnetic resonance derived wall motion patterns: a prospective cohort study.
abstract: BACKGROUND
  Despite marked benefits in many heart failure patients, a considerable proportion of patients treated with cardiac resynchronization therapy (CRT) fail to respond appropriately. Recently, a "U-shaped" (type II) wall motion pattern identified by cardiovascular magnetic resonance (CMR) has been associated with improved CRT response compared to a homogenous (type I) wall motion pattern. There is also evidence that a left ventricular (LV) lead localized to the latest contracting LV site predicts superior response, compared to an LV lead localized remotely from the latest contracting LV site.
  
  
  METHODS
  We prospectively evaluated patients undergoing CRT with pre-procedural CMR to determine the presence of type I and type II wall motion patterns and pre-procedural echocardiography to determine end systolic volume (ESV). We assessed the final LV lead position on post-procedural fluoroscopic images to determine whether the lead was positioned concordant to or remote from the latest contracting LV site. CRT response was defined as a ≥ 15% reduction in ESV on a 6 month follow-up echocardiogram.
  
  
  RESULTS
  The study included 33 patients meeting conventional indications for CRT with a mean New York Heart Association class of 2.8 ± 0.4 and mean LV ejection fraction of 28 ± 9%. Overall, 55% of patients were echocardiographic responders by ESV criteria. Patients with both a type II pattern and an LV lead concordant to the latest contracting site (T2CL) had a response rate of 92%, compared to a response rate of 33% for those without T2CL (p = 0.003). T2CL was the only independent predictor of response on multivariate analysis (odds ratio 18, 95% confidence interval 1.6-206; p = 0.018). T2CL resulted in significant incremental improvement in prediction of echocardiographic response (increase in the area under the receiver operator curve from 0.69 to 0.84; p = 0.038).
  
  
  CONCLUSIONS
  The presence of a type II wall motion pattern on CMR and a concordant LV lead predicts superior CRT response. Improving patient selection by evaluating wall motion pattern and targeting LV lead placement may ultimately improve the response rate to CRT.
authors.affiliation: Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA. ghartlagemd@gmail.com.|Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA. ghartlagemd@gmail.com.
authors.forename: Gregory R
authors.initials: GR
authors.lastname: Hartlage
authors.affiliation: Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA, USA. suever@gmail.com.
authors.forename: Jonathan D
authors.initials: JD
authors.lastname: Suever
authors.affiliation: Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA. stephanie.clement@gmail.com.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Clement-Guinaudeau
authors.affiliation: Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA. patrick.strickland@emory.edu.
authors.forename: Patrick T
authors.initials: PT
authors.lastname: Strickland
authors.affiliation: Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA. nghasem@emory.edu.
authors.forename: Nima
authors.initials: N
authors.lastname: Ghasemzadeh
authors.affiliation: Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA, USA. rmagrath3@gmail.com.
authors.forename: R Patrick
authors.initials: RP
authors.lastname: Magrath
authors.affiliation: Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA. ankit.parikh@emory.edu.
authors.forename: Ankit
authors.initials: A
authors.lastname: Parikh
authors.affiliation: Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA. sleraki@emory.edu.|Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA. sleraki@emory.edu.
authors.forename: Stamatios
authors.initials: S
authors.lastname: Lerakis
authors.affiliation: Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA. mhoski2@emory.edu.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Hoskins
authors.affiliation: Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA. aleon@emory.edu.
authors.forename: Angel R
authors.initials: AR
authors.lastname: Leon
authors.affiliation: Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA, USA. mlloyd2@emory.edu.
authors.forename: Michael S
authors.initials: MS
authors.lastname: Lloyd
authors.affiliation: Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA. jnoshin@emory.edu.|Department of Biomedical Engineering, Georgia Institute of Technology/Emory University, Atlanta, GA, USA. jnoshin@emory.edu.
authors.forename: John N
authors.initials: JN
authors.lastname: Oshinski
mesh_terms: D000368:Aged; D019540:Area Under Curve; D001696:Biomechanical Phenomena; D058406:Cardiac Resynchronization Therapy; D058409:Cardiac Resynchronization Therapy Devices; D004452:Echocardiography; D004562:Electrocardiography; D005260:Female; D006333:Heart Failure / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D007090:Image Interpretation, Computer-Assisted; D016015:Logistic Models; D019028:Magnetic Resonance Imaging, Cine; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009200:Myocardial Contraction; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012372:ROC Curve; D015203:Reproducibility of Results; D013318:Stroke Volume; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left