Individually tailored left ventricular lead placement: lessons from multimodality integration between three-dimensional echocardiography and coronary sinus angiogram

Non-responder rates for cardiac resynchronization therapy (CRT) vary from 11 to 46. Retrospective data imply a better outcome with stimulation of the latest contracting left ventricular (LV) region. Our study analysed the feasibility, safety and clinical outcome of prospectively planned LV lead placement at the site of latest mechanical activation. Thirty-eight heart failure patients with CRT indication were assessed by three-dimensional (3D) transoesophageal echocardiography and rotation angiography of the coronary sinus (CS). Both images were merged into a single 3D-model to identify CS target veins close to the site of latest mechanical activation. Subsequently, LV lead deployment was attempted at the desired target position. Patients were clinically and echocardiographically evaluated at baseline, after 3 and 6 months. The area of latest mechanical activation covered 6 2 segments (38 13 of LV surface) and was found lateral in 24 of 37 (65), anterior in 11 of 37 (30), inferior in 2 of 37 (5), and septal in 1 of 37 (3) patients. In 36 of 37 (97) patients an appropriate target vein was identified and successful implantation could be performed in 34 of 37 (92) patients. Among those patients clinical and echocardiographic response was observed in 91 and 81, respectively. Individualized lead placement at the latest contracting LV site can be performed safely and successfully in the majority of patients. Initial clinical outcome data are encouraging. Identification of target sites requires multimodality integration between LV wall motion data and CS anatomy. Future developments need to improve those technologies and require randomized data on clinical outcome parameters.