A novel approach for left ventricular lead placement in cardiac resynchronization therapy: Intraprocedural integration of coronary venous electroanatomic mapping with delayed enhancement cardiac magnetic resonance imaging.
Placing the left ventricular (LV) lead at a site of late electrical activation remote from scar is desired to improve cardiac resynchronization therapy (CRT) response.



The purpose of this study was to integrate coronary venous electroanatomic mapping (EAM) with delayed enhancement cardiac magnetic resonance (DE-CMR) enabling LV lead guidance to the latest activated vein remote from scar.



Eighteen CRT candidates with focal scar on DE-CMR were prospectively included. DE-CMR images were semi-automatically analyzed. Coronary venous EAM was performed intraprocedurally and integrated with DE-CMR to guide LV lead placement in real time. Image integration accuracy and electrogram parameters were evaluated offline.



Integration of EAM and DE-CMR was achieved using 8.9 ± 2.8 anatomic landmarks and with accuracy of 4.7 ± 1.1 mm (mean ± SD). Maximal electrical delay ranged between 72 and 197ms (57%-113% of QRS duration) and was heterogeneously located among individuals. In 12 patients, the latest activated vein was located outside scar, and placing the LV lead in the latest activated vein remote from scar was accomplished in 10 patients and prohibited in 2 patients. In the other 6 patients, the latest activated vein was located in scar, and targeting alternative veins was considered. Unipolar voltages were on average lower in scar compared to nonscar (6.71 ± 3.45 mV vs 8.18 ± 4.02 mV [median ± interquartile range), P <.001) but correlated weakly with DE-CMR scar extent (R -0.161, P <.001) and varied widely among individual patients.



Integration of coronary venous EAM with DE-CMR can be used during CRT implantation to guide LV lead placement to the latest activated vein remote from scar, possibly improving CRT.
Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands. Electronic address: chau27@gmail.com.
Uyên Châu
UC
Nguyên
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Masih
M
Mafi-Rad
Pie Medical Imaging, Maastricht, the Netherlands.
Jean-Paul
JP
Aben
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Martijn W
MW
Smulders
Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
Elien B
EB
Engels
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Antonius M W
AM
van Stipdonk
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Justin G L M
JG
Luermans
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Sebastiaan C A M
SC
Bekkers
Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.
Frits W
FW
Prinzen
Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands.
Kevin
K
Vernooy
D000368:Aged; D018780:Body Surface Potential Mapping / Q000379:methods*; D058406:Cardiac Resynchronization Therapy / Q000379:methods*; D015331:Cohort Studies; D003331:Coronary Vessels / Q000000981:diagnostic imaging*; D004567:Electrodes, Implanted; D005260:Female; D006333:Heart Failure / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D006801:Humans; D019028:Magnetic Resonance Imaging, Cine / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D016896:Treatment Outcome
Cardiac resynchronization therapy; Delayed enhancement cardiac magnetic resonance; Electroanatomic mapping; Left ventricular lead placement