Assessment of the post-implant final left ventricular lead position: a comparative study between radiographic and angiographic modalities.

PURPOSE: Post-implant lateral and postero-anterior chest X-rays (CXR) are often utilized to determine the final LV lead tip position after cardiac resynchronization therapy (CRT). This study sought to compare post-implant standard CXRs with intra-procedural rotational coronary venous angiography (RCVA) to localize the final LV lead position. METHODS: Sixty-four patients undergoing CRT (69.2 ± 11.4 years; males 68.7%; ischemic cardiomyopathy 59.4%; NYHA class 2.9 ± 0.5 and LV ejection fraction 24% ± 9%) were included in the study. RCVA was done by recording a rapid 4-second isocentric cine-loop from RAO 55° to LAO 55° (120 frames). Conventional CXR method (CC) and a composite CXR strategy (CM) based on two-view CXR were separately compared with RCVA. RESULTS: The most common pacing site was lateral (64.1%), followed by postero-lateral (23.4%) and antero-lateral (10.9%). In 73.4% (47) cases, the LV lead position was misclassified by CC as compared to RCVA. Among the 47 (73.4%) cases misclassified by CC approach, 35 had lateral LV lead position misclassified by CC as postero-lateral (77%), posterior (20%) and antero-lateral (3%). On the other hand, CM strategy classified the LV lead position correctly in 46 (71.9%) of the patients (p < 0.0001). CONCLUSIONS: The composite CXR strategy is a useful method for post-procedure LV lead localization. Due to its simplicity, it can be widely applied in post-implant evaluation of LV lead position in CRT patients.

The impact of age and gender on cardiac resynchronization therapy outcome.

BACKGROUND: Cardiac resynchronization therapy (CRT) outcome varies significantly among patients. We aimed to determine the impact of age, gender, and heart failure etiology on the long-term outcome of patients receiving CRT. METHODS: A total of 117 patients with drug-refractory heart failure, New York Heart Association (NYHA) Class III or IV, and a wide QRS complex, who received CRT, were followed for one year. Long-term outcome was measured as a combined end point of hospitalization for heart failure and/or all cause mortality. Efficacy of CRT was compared between men and women, between older and younger patients, and between patients with ischemic and nonischemic heart disease. Time to the primary end point was estimated by the Kaplan-Meier method and comparisons were made using the Breslow-Wilcoxon test. RESULTS: Baseline clinical characteristics were comparable between gender, age, and heart failure etiology subgroups. There was no significant difference in the combined end point between older versus younger (age >70, (n = 71), versus age < 70, (n = 46), P = 0.52); both genders (men, n = 91 vs women, n = 26, P = 0.46) and etiology of the cardiomyopathy (ischemic (n = 79) vs nonischemic (n = 38), P = 0.12). Substratification of the genders by the etiology of the cardiomyopathy, showed that women with ischemic cardiomyopathy (IW, n = 10) had a trend to a worse outcome compared to the other groups i.e., nonischemic women (NIW, n = 16), ischemic men (IM, n = 69), and nonischemic men (NIM, n = 22), P = 0.04. After adjusting for potential covariates, a Cox regression analysis showed no significant difference between the groups (P = 0.61). CONCLUSIONS: CRT outcome appears independent of age, gender, and heart failure etiology in this single institution study.

Usefulness of high-speed rotational coronary venous angiography during cardiac resynchronization therapy.

Standard coronary venous angiography (SCVA) provides a static, fixed projection of the coronary venous (CV) tree. High-speed rotational coronary venous angiography (RCVA) is a novel method of mapping CV anatomy using dynamic, multiangle visualization. The purpose of this study was to assess the value of RCVA during cardiac resynchronization therapy. Digitally acquired rotational CV angiograms from 49 patients (mean age 69 +/- 11 years) who underwent left ventricular lead implantation were analyzed. RCVA, which uses rapid isocentric rotation over a 110 degrees arc, acquiring 120 frames/angiogram, was compared with SCVA, defined as 2 static orthogonal views: right anterior oblique 45 degrees and left anterior oblique 45 degrees . RCVA demonstrated that the posterior vein-to-coronary sinus (CS) angle and the left marginal vein-to-CS angle were misclassified in 5 and 11 patients, respectively, using SCVA. RCVA identified a greater number of second-order tributaries with diameters >1.5 mm than SCVA. The CV branch selected for lead placement was initially identified in 100% of patients using RCVA but in only 74% of patients using SCVA. RCVA showed that the best angiographic view for visualizing the CS and its tributaries differed significantly among different areas of the CV tree and among patients. The area of the CV tree that showed less variability was the CS ostium, which had a fairly constant relation with the spine in shallow right anterior oblique and left anterior oblique projections. In conclusion, RCVA provided a more precise map of CV anatomy and the spatial relation of venous branches. It allowed the identification of fluoroscopic views that could facilitate cannulation of the CS. The final x-ray view displaying the appropriate CV branch for left ventricular lead implantation was often different from the conventional left anterior oblique and right anterior oblique views. RCVA identified the target branch for lead implantation more often than SCVA.

Variability of coronary venous anatomy in patients undergoing cardiac resynchronization therapy: a high-speed rotational venography study.

BACKGROUND: Imaging the coronary venous (CV) tree to delineate the coronary sinus and its tributaries can facilitate electrophysiological procedures, such as cardiac resynchronization therapy (CRT) and catheter ablation. Venography also allows visualization of the left atrial (LA) veins, which may be a potential conduit for ablative or pacing strategies given their proximity to foci that can trigger atrial fibrillation. OBJECTIVE: The aim of this study was to provide a detailed description of CV anatomy using rotational venography in patients undergoing CRT. METHODS: Coronary sinus (CS) size and the presence, size, and angulation of its tributaries were determined from the analysis of rotational CV angiograms from 51 patients (age 68 +/- 11 years; n = 12 women) undergoing CRT. RESULTS: The CS, posterior veins, and lateral veins were identified in 100%, 76%, and 91% of patients. Lateral veins were less prevalent in patients with a history of lateral myocardial infarction than in patients without such a history (33% vs. 96%; P = .014). The diameters of the CS and its tributaries were fairly variable (7.3-18.9 mm for CS, 1.3-10.5 mm for CS tributaries). The CS was larger in men than in women and in cases of ischemic than in cases of nonischemic cardiomyopathy (all P <.05). The vein of Marshall, the most constant LA vein, was identified in 37 patients; its diameter is 1.7 +/- 0.5 mm, and its takeoff angle is 154 degrees +/- 15 degrees , making the vein potentially accessible for cannulation. CONCLUSIONS: Differences in CV anatomy that are related to either gender or coronary artery disease could have important practical implications during the left ventricular lead implantation. The anatomical features of the vein of Marshall make it a feasible potential conduit for epicardial LA pacing.

Integrating functional and anatomical information to facilitate cardiac resynchronization therapy.

Multiple imaging modalities are required in patients receiving cardiac resynchronization therapy. We have developed a strategy to integrate echocardiographic and angiographic information to facilitate left ventricle (LV) lead position. Full three-dimensional LV-volumes (3DLVV) and dyssynchrony maps were acquired before and after resynchronization. At the time of device implantation, 3D-rotational coronary venous angiography was performed. 3D-models of the veins were then integrated with the pre- and post-3DLVV. In the case displayed, prior to implantation, the lateral wall was delayed compared to the septum. The LV lead was positioned into the vein over the most delayed region, resulting in improved LV synchrony.