title: Multimodality imaging-guided left ventricular lead placement in cardiac resynchronization therapy: a randomized controlled trial.
abstract: Left ventricular (LV) lead position at the latest mechanically activated non-scarred myocardial LV region confers improved response to cardiac resynchronization therapy (CRT). We conducted a double-blind, randomized controlled trial to evaluate the clinical benefit of multimodality imaging-guided LV lead placement in CRT.
  
  
  
  Patients were allocated (1:1) to imaging-guided LV lead placement using cardiac computed tomography (CT) venography,99mTechnetium myocardial perfusion imaging, and speckle-tracking echocardiography radial strain to target the optimal coronary sinus (CS) branch closest to the non-scarred myocardial segment with latest mechanical activation (imaging group, n = 89) or to routine LV lead implantation in a posterolateral region with late electrical activation (control group, n = 93). The primary endpoint was clinical non-response to CRT [≥1 of the following after 6 months: (1) death, (2) heart failure hospitalization, or (3) no improvement in New York Heart Association class and <10% increase in 6-min walk distance]. Secondary outcomes included LV remodelling and the combination of all-cause mortality and hospitalization owing to heart failure during 1.8 ± 0.9 years. Analysis was intention-to-treat. In the imaging group, fewer patients reached the primary endpoint (26% vs. 42%, P = 0.02). More patients in the imaging group had the LV lead placed in the optimal CS branch (83% vs. 65%, P = 0.01). There were no between-group differences in reverse LV remodelling or the combined endpoint of death or hospitalizations for heart failure.
  
  
  
  Multimodality imaging-guided LV lead placement towards the CS branch closest to latest mechanically activated non-scarred myocardial LV segment reduces the proportion of clinical non-responders to CRT. Larger long-term multicentre studies are needed.
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark. a.sommer@dadlnet.dk.
authors.forename: Anders
authors.initials: A
authors.lastname: Sommer
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
authors.forename: Mads Brix
authors.initials: MB
authors.lastname: Kronborg
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
authors.forename: Bjarne Linde
authors.initials: BL
authors.lastname: Nørgaard
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
authors.forename: Steen Hvitfeldt
authors.initials: SH
authors.lastname: Poulsen
authors.affiliation: Department of Nuclear Medicine, Aarhus University Hospital, Skejby, Aarhus N, Denmark.
authors.forename: Kirsten
authors.initials: K
authors.lastname: Bouchelouche
authors.affiliation: Department of Cardiology, Herning Hospital, Herning, Denmark.
authors.forename: Morten
authors.initials: M
authors.lastname: Böttcher
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
authors.forename: Henrik Kjaerulf
authors.initials: HK
authors.lastname: Jensen
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
authors.forename: Jesper Møller
authors.initials: JM
authors.lastname: Jensen
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
authors.forename: Jens
authors.initials: J
authors.lastname: Kristensen
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
authors.forename: Christian
authors.initials: C
authors.lastname: Gerdes
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
authors.forename: Peter Thomas
authors.initials: PT
authors.lastname: Mortensen
authors.affiliation: Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, DK-8200, Aarhus N, Denmark.
authors.forename: Jens Cosedis
authors.initials: JC
authors.lastname: Nielsen
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D058406:Cardiac Resynchronization Therapy; D058409:Cardiac Resynchronization Therapy Devices; D002423:Cause of Death; D000072226:Computed Tomography Angiography; D017023:Coronary Angiography; D004311:Double-Blind Method; D004452:Echocardiography; D005260:Female; D006321:Heart / Q000000981:diagnostic imaging*; D006333:Heart Failure / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D006352:Heart Ventricles; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D064847:Multimodal Imaging; D055414:Myocardial Perfusion Imaging; D010690:Phlebography; D019919:Prosthesis Implantation / Q000379:methods*; D025321:Surgery, Computer-Assisted / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D020257:Ventricular Remodeling; D000070857:Walk Test
keywords: Cardiac computed tomography; Cardiac resynchronization therapy; Left ventricular lead placement; Myocardial perfusion imaging; Speckle-tracking echocardiography