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Left ventricular lead implantation in cardiac resynchronisation therapy: Is an electrically guided strategy better than an imaging-guided approach?

EHRA congress news

Arrhythmias and Device Therapy

Dr. Charlotte StephensenDr. Charlotte Stephansen

Cardiac resynchronisation therapy (CRT) improves survival, symptoms and left ventricular (LV) function in patients with medical-refractory heart failure and prolonged QRS duration; however, around one- third of patients experience no clinical benefit.1

Positioning of the LV lead according to the latest activated myocardial segment has been shown to be an important determinant of response to CRT.1 Further, electrical resynchronisation with narrowing of the QRS width during CRT has been associated with better outcomes.1

Doctor Charlotte Stephansen and colleagues at Aarhus University Hospital (Aarhus, Denmark) conducted the ElectroCRT study to investigate the effect of an individualised electrical CRT implantation strategy on the LV ejection fraction. The LV lead was targeted towards the latest electrically activated myocardial segment as identified by procedural systematic electrical activation mapping of the coronary sinus tributaries.

Post-implant, the interventricular pacing delay was programmed to achieve the shortest QRS duration. In the imaging-guided control group, implantation was guided by pre-implant cardiac computed tomography to visualise cardiac venous anatomy, speckle-tracking echocardiography to identify the LV myocardial segment with the latest mechanical activation, and myocardial perfusion imaging (82Rubidium positron emission tomography) to avoid LV myocardial scar.

The main findings from ElectroCRT were presented at a late-breaking trial session yesterday. Dr. Stephansen said, “In the 122 patients studied, we found that electrically guided CRT implantation increased the pre-defined primary endpoint of change in LV ejection fraction at 6 months to 11% vs 7% with the imaging-guided strategy and this was a significant difference (p=0.03).

However, left ventricular remodelling, increase in six-minute walk-distance, improvement of NYHA functional class or quality-of-life were not significantly better with the electrically guided CRT implantation strategy. There was no difference in device-related complications between the two groups.”

Regarding next steps, Dr. Stephansen stated, “The findings in ElectroCRT are reassuring and may indicate that mapping for late activation for LV lead placement may have a future. However, the number of patients included was moderate, and the follow-up was not long. A larger national Danish randomised trial (DANISH-CRT) is currently being conducted to investigate the impact of electrically guided LV lead implantation towards latest electrically activated myocardial segment on the composite endpoint of time to death or first non-planned hospitalisation for heart failure.”

  1. Stephansen C, et al. Trials. 2018;19:600