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Neves Pereira MT, Tinoco M, Castro M, Pinheiro L, Cardoso F, Calvo L, Ribeiro S, Monteiro V, Sanfins V, Lourenço A. Assessing cardiac resynchronization therapy response in heart failure patients: a comparative analysis of efficacy and outcomes between transvenous and epicardial leads. Monaldi Arch Chest Dis 2024. [PMID: 38332712 DOI: 10.4081/monaldi.2024.2845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/23/2024] [Indexed: 02/10/2024] Open
Abstract
Cardiac resynchronization therapy (CRT) is an effective treatment for selected heart failure (HF) patients. Although transvenous implantation is the standard method, it is not feasible in some patients, so the epicardial lead emerges as an alternative. We aim to compare CRT response, procedure-related complications, and the occurrence of clinical outcomes between patients with transvenous and epicardial leads. In a single-center retrospective study, we enrolled consecutive HF patients submitted to CRT implantation with a defibrillator between 2013 and 2022. Clinical response was defined as an improvement of at least one of the New York Heart Association classes with no occurrence of cardiovascular death or HF hospitalization in the first year of follow-up. Echocardiographic response was attained with an increase in left ventricular ejection fraction 10% or a reduction of left ventricular end-diastolic volume >15% at 6-12 months after CRT implantation. Major adverse cardiovascular events (MACE) (cardiovascular mortality and HF hospitalization) and all-cause mortality were evaluated. From a total of 149 patients, 38% (n=57) received an epicardial lead. Clinical (63% versus 60%, p=0.679) and echocardiographic (63% versus 60%, p=0.679) responses were similar between the transvenous and epicardial groups. Patients in the transvenous group had a shorter hospital stay (2 versus 7 days, p<0.001). Procedure-related complications were comparable between groups (24% versus 28%, p=0.572), but left ventricular lead-related complications were more frequent in the transvenous group (14% versus 2%). During a median follow-up of 4.7 years, the rate of MACE was 30% (n=44), with no differences in both groups (p=0.591), neither regarding HF hospitalization (p=0.917) nor cardiovascular mortality (p=0.060). Nevertheless, the epicardial group had a higher rate of all-cause mortality (35% versus 20%, p=0.005), the majority occurring during long-term follow-up (>12 months), with no deaths in the postoperative period. Considering the comparable rates of CRT response, procedure-related complications, and MACE between groups, we conclude that epicardial lead is a feasible alternative for CRT when transvenous lead implantation is not possible. The occurrence of a higher number of all-cause deaths in epicardial patients in the long-term follow-up was mainly due to infectious complications (unrelated to the lead) and the progression of oncological/chronic diseases.
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Affiliation(s)
| | | | | | | | | | - Lucy Calvo
- Senhora da Oliveira Hospital, Guimarães.
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2
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Nguyên UC, Prinzen FW, Vernooy K. Left ventricular lead placement in cardiac resynchronization therapy: Current data and potential explanations for the lack of benefit. Heart Rhythm 2024; 21:197-205. [PMID: 37806647 DOI: 10.1016/j.hrthm.2023.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 10/02/2023] [Indexed: 10/10/2023]
Abstract
The present article reviews the literature on image-guided cardiac resynchronization therapy (CRT) studies. Improved outcome to CRT has been associated with the placement of a left ventricular (LV) lead in the latest activated segment free from scar. The majority of randomized controlled trials investigating guided LV lead implantation did not show superiority over conventional implantation approaches. Several factors may contribute to this paradoxical observation, including inclusion criteria favoring patients with left bundle branch block who already respond well to conventional anatomical LV lead implantation, differences in activation wavefronts during simultaneous right ventricular and LV pacing, incorrect definition of target regions, and limitations in coronary venous anatomy that prevent access to target regions that are detected by imaging. It is imperative that exclusion of patients lacking access to target regions from these studies would lead to larger benefit of image-guided CRT.
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Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands.
| | - Frits W Prinzen
- Department of Physiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
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3
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Eerenberg F, Luermans J, Lumens J, Nguyên UC, Vernooy K, van Stipdonk A. Exploring QRS Area beyond Patient Selection in CRT-Can It Guide Left Ventricular Lead Placement? J Cardiovasc Dev Dis 2024; 11:18. [PMID: 38248888 PMCID: PMC10816025 DOI: 10.3390/jcdd11010018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/04/2024] [Accepted: 01/04/2024] [Indexed: 01/23/2024] Open
Abstract
Vectorcardiographic QRS area is a promising tool for patient selection and implantation guidance in cardiac resynchronization therapy (CRT). Research has mainly focused on the role of QRS area in patient selection for CRT. Recently, QRS area has been proposed as a tool to guide left ventricular lead placement in CRT. Theoretically, vector-based electrical information of ventricular fusion pacing, calculated from the basic 12-lead ECG, can give real-time insight into the extent of resynchronization at any LV lead position, as well as any selected electrode on the LV lead. The objective of this review is to provide an overview of the background of vectorcardiographic QRS area and its potential in optimizing LV lead location in order to optimize the benefits of CRT.
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Affiliation(s)
- Frederieke Eerenberg
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, 6229 ER Maastricht, The Netherlands; (J.L.); (U.C.N.); (K.V.); (A.v.S.)
| | - Justin Luermans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, 6229 ER Maastricht, The Netherlands; (J.L.); (U.C.N.); (K.V.); (A.v.S.)
| | - Joost Lumens
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht (UM), 6229 ER Maastricht, The Netherlands;
| | - Uyên Châu Nguyên
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, 6229 ER Maastricht, The Netherlands; (J.L.); (U.C.N.); (K.V.); (A.v.S.)
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, 6229 ER Maastricht, The Netherlands; (J.L.); (U.C.N.); (K.V.); (A.v.S.)
| | - Antonius van Stipdonk
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, 6229 ER Maastricht, The Netherlands; (J.L.); (U.C.N.); (K.V.); (A.v.S.)
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4
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Jurak P, Bear LR, Nguyên UC, Viscor I, Andrla P, Plesinger F, Halamek J, Vondra V, Abell E, Cluitmans MJM, Dubois R, Curila K, Leinveber P, Prinzen FW. 3-Dimensional ventricular electrical activation pattern assessed from a novel high-frequency electrocardiographic imaging technique: principles and clinical importance. Sci Rep 2021; 11:11469. [PMID: 34075135 PMCID: PMC8169848 DOI: 10.1038/s41598-021-90963-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/19/2021] [Indexed: 11/29/2022] Open
Abstract
The study introduces and validates a novel high-frequency (100–400 Hz bandwidth, 2 kHz sampling frequency) electrocardiographic imaging (HFECGI) technique that measures intramural ventricular electrical activation. Ex-vivo experiments and clinical measurements were employed. Ex-vivo, two pig hearts were suspended in a human-torso shaped tank using surface tank electrodes, epicardial electrode sock, and plunge electrodes. We compared conventional epicardial electrocardiographic imaging (ECGI) with intramural activation by HFECGI and verified with sock and plunge electrodes. Clinical importance of HFECGI measurements was performed on 14 patients with variable conduction abnormalities. From 3 × 4 needle and 108 sock electrodes, 256 torso or 184 body surface electrodes records, transmural activation times, sock epicardial activation times, ECGI-derived activation times, and high-frequency activation times were computed. The ex-vivo transmural measurements showed that HFECGI measures intramural electrical activation, and ECGI-HFECGI activation times differences indicate endo-to-epi or epi-to-endo conduction direction. HFECGI-derived volumetric dyssynchrony was significantly lower than epicardial ECGI dyssynchrony. HFECGI dyssynchrony was able to distinguish between intraventricular conduction disturbance and bundle branch block patients.
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Affiliation(s)
- Pavel Jurak
- Institute of Scientific Instruments, The Czech Academy of Sciences, Kralovopolska 147, Brno, 635 00, Czech Republic.
| | - Laura R Bear
- IHU Liryc, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, CRCTB, U1045, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
| | - Uyên Châu Nguyên
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ivo Viscor
- Institute of Scientific Instruments, The Czech Academy of Sciences, Kralovopolska 147, Brno, 635 00, Czech Republic
| | - Petr Andrla
- Institute of Scientific Instruments, The Czech Academy of Sciences, Kralovopolska 147, Brno, 635 00, Czech Republic
| | - Filip Plesinger
- Institute of Scientific Instruments, The Czech Academy of Sciences, Kralovopolska 147, Brno, 635 00, Czech Republic
| | - Josef Halamek
- Institute of Scientific Instruments, The Czech Academy of Sciences, Kralovopolska 147, Brno, 635 00, Czech Republic
| | - Vlastimil Vondra
- Institute of Scientific Instruments, The Czech Academy of Sciences, Kralovopolska 147, Brno, 635 00, Czech Republic
| | - Emma Abell
- IHU Liryc, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, CRCTB, U1045, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
| | - Matthijs J M Cluitmans
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Rémi Dubois
- IHU Liryc, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, CRCTB, U1045, Bordeaux, France.,INSERM, CRCTB, U1045, Bordeaux, France
| | - Karol Curila
- Cardiocenter, Department of Cardiology, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Pavel Leinveber
- International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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5
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Yagishita D, Yagishita Y, Kataoka S, Yazaki K, Kanai M, Ejima K, Shoda M, Hagiwara N. Left Ventricular Stimulation With Electrical Latency Predicts Mortality in Patients Undergoing Cardiac Resynchronization Therapy. JACC Clin Electrophysiol 2021; 7:796-805. [PMID: 34167755 DOI: 10.1016/j.jacep.2020.10.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/08/2020] [Accepted: 10/27/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVES This study sought to evaluate the prognostic value of the time interval from left ventricular (LV) pacing to the earliest onset of QRS complex (S-QRS) for long-term clinical outcomes in patients who underwent cardiac resynchronization therapy (CRT). BACKGROUND The electrical latency during LV pacing evaluated by S-QRS is associated with local tissue property, and the S-QRS ≥37 ms has been previously proposed as an independent predictor of mechanical response to CRT. METHODS This study included 82 consecutive patients with heart failure with reduced LV ejection fraction (≤35%) and a wide QRS complex (≥120 ms) who underwent CRT. Patients were divided into a short S-QRS group (SS-QRS; <37 ms) and a long S-QRS group (LS-QRS; ≥37 ms). The primary endpoint was total mortality, including LV assist device implantation or heart transplantation, whereas the secondary endpoint was total mortality or HF hospitalization. RESULTS S-QRS was 25.9 ± 5.3 ms in SS-QRS and 51.5 ± 13.7 ms in LS-QRS (p < 0.01), and baseline QRS duration and electrical activation at the LV pacing site (i.e., Q-LV) were similar. During mean follow-up of 44.5 ± 21.1 months, 24 patients (29%) reached the primary endpoint, whereas the secondary endpoints were observed in 47 patients (57%). LS-QRS had significantly worse event-free survival for both endpoints. LS-QRS was an independent predictor of total mortality (hazard ratio: 2.6; 95% confidence interval: 1.11 to 6.12; p = 0.03) and the secondary composite events (hazard ratio: 2.4; 95% confidence interval: 1.31 to 4.33; p < 0.01). CONCLUSIONS The S-QRS ≥37 ms at the LV pacing site was a significant predictor of total mortality and HF hospitalization. S-QRS-guided optimal LV lead placement is critical in patients who receive CRT.
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Affiliation(s)
- Daigo Yagishita
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Yoshimi Yagishita
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Shohei Kataoka
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kyoichiro Yazaki
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Miwa Kanai
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Koichiro Ejima
- Clinical Research Division for Heart Rhythm Management, Tokyo Women's Medical University, Tokyo, Japan
| | - Morio Shoda
- Clinical Research Division for Heart Rhythm Management, Tokyo Women's Medical University, Tokyo, Japan.
| | - Nobuhisa Hagiwara
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
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Patel PA, Nadarajah R, Ali N, Tan F, Hammond C, Burnet N, Cole CA, Paton MF, Cubbon RM, Kearney MT, Gierula J, Witte KK. Long‐term performance of left ventricular leads in cardiac resynchronisation therapy. Pacing Clin Electrophysiol 2020; 43:1501-1507. [DOI: 10.1111/pace.14034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/03/2020] [Accepted: 08/09/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Peysh A. Patel
- Department of Cardiology Leeds General Infirmary Leeds UK
| | | | - Noman Ali
- Department of Cardiology Leeds General Infirmary Leeds UK
| | - Felicia Tan
- Department of Cardiology Leeds General Infirmary Leeds UK
| | | | - Naomi Burnet
- Department of Cardiology Leeds General Infirmary Leeds UK
| | | | - Maria F. Paton
- Department of Cardiology Leeds General Infirmary Leeds UK
| | | | | | - John Gierula
- Department of Cardiology Leeds General Infirmary Leeds UK
| | - Klaus K. Witte
- Department of Cardiology Leeds General Infirmary Leeds UK
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7
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Fudim M, Borges-Neto S. Moving towards a synchronized left ventricle. J Nucl Cardiol 2020; 27:431-433. [PMID: 31087264 DOI: 10.1007/s12350-019-01749-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/15/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Marat Fudim
- Department of Medicine, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710, USA.
- Duke Clinical Research Institute, Durham, NC, USA.
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8
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Auricchio A, Faletra FF. Use of Contemporary Imaging Techniques for Electrophysiological and Device Implantation Procedures. JACC Cardiovasc Imaging 2019; 13:851-865. [PMID: 31326496 DOI: 10.1016/j.jcmg.2019.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Revised: 01/14/2019] [Accepted: 01/16/2019] [Indexed: 10/26/2022]
Abstract
Recent technological advances in cardiac imaging allow the visualization of anatomic details up to millimeter size in 3-dimensional format. Thus, it is not surprising that electrophysiologists increasingly rely upon cardiac imaging for the diagnosis, treatment, and subsequent management of patients affected by various arrhythmic disorders. Cardiac imaging methods reviewed in the present work involve: 1) the prediction of arrhythmic risk for sudden cardiac death in patients with heart disease; 2) catheter ablation of atrial fibrillation or ventricular tachycardia; and 3) cardiac resynchronization therapy. Future integration of diagnostic and interventional cardiac imaging will further increase the effectiveness of cardiac electrophysiological procedures and will help in delivering patient-specific therapies with ablation and cardiac implantable electronic devices.
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Affiliation(s)
- Angelo Auricchio
- Division of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland.
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9
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Lee AWC, Nguyen UC, Razeghi O, Gould J, Sidhu BS, Sieniewicz B, Behar J, Mafi-Rad M, Plank G, Prinzen FW, Rinaldi CA, Vernooy K, Niederer S. A rule-based method for predicting the electrical activation of the heart with cardiac resynchronization therapy from non-invasive clinical data. Med Image Anal 2019; 57:197-213. [PMID: 31326854 PMCID: PMC6746621 DOI: 10.1016/j.media.2019.06.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 06/20/2019] [Accepted: 06/27/2019] [Indexed: 12/13/2022]
Abstract
Background Cardiac Resynchronization Therapy (CRT) is one of the few effective treatments for heart failure patients with ventricular dyssynchrony. The pacing location of the left ventricle is indicated as a determinant of CRT outcome. Objective Patient specific computational models allow the activation pattern following CRT implant to be predicted and this may be used to optimize CRT lead placement. Methods In this study, the effects of heterogeneous cardiac substrate (scar, fast endocardial conduction, slow septal conduction, functional block) on accurately predicting the electrical activation of the LV epicardium were tested to determine the minimal detail required to create a rule based model of cardiac electrophysiology. Non-invasive clinical data (CT or CMR images and 12 lead ECG) from eighteen patients from two centers were used to investigate the models. Results Validation with invasive electro-anatomical mapping data identified that computer models with fast endocardial conduction were able to predict the electrical activation with a mean distance errors of 9.2 ± 0.5 mm (CMR data) or (CT data) 7.5 ± 0.7 mm. Conclusion This study identified a simple rule-based fast endocardial conduction model, built using non-invasive clinical data that can be used to rapidly and robustly predict the electrical activation of the heart. Pre-procedural prediction of the latest electrically activating region to identify the optimal LV pacing site could potentially be a useful clinical planning tool for CRT procedures.
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Affiliation(s)
- A W C Lee
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom.
| | - U C Nguyen
- Department of Physiology, Maastricht University Medical Center (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of Cardiology, Maastricht University Medical Center (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - O Razeghi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - J Gould
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - B S Sidhu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - B Sieniewicz
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - J Behar
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom; Bart's Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - M Mafi-Rad
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - G Plank
- Department of Biophysics, Medical University of Graz, Graz, Austria
| | - F W Prinzen
- Department of Physiology, Maastricht University Medical Center (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - C A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - K Vernooy
- Department of Cardiology, Maastricht University Medical Center (MUMC+), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - S Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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10
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Surface electrogram-guided left ventricular lead placement improves response to cardiac resynchronization therapy. Anatol J Cardiol 2019. [PMID: 29521312 PMCID: PMC5864768 DOI: 10.14744/anatoljcardiol.2018.09216] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Failure to select the optimal left ventricular (LV) segment for lead implantation is one of the most important causes of unresponsiveness to the cardiac resynchronization therapy (CRT). In our study, we aimed to investigate the echocardiographic and clinical benefits of LV lead implantation guided by an intraoperative 12-lead surface electrocardiogram (ECG) in patients with multiple target veins. METHODS We included 80 [42 (62.5%) male] heart failure patients who successfully underwent CRT defibrillator (CRT-D) implantation. Patients were divided into two groups. In group 1, LV lead was positioned at the site with the shortest biventricular-paced (BiV-paced) QRS duration (QRSd), as intraprocedurally measured using surface ECG. In group 2 (control), we included patients who underwent the standard unguided CRT. ECG, echocardiogram, and functional status were evaluated before and 6 months after CRT implantation in all patients. RESULTS In group 1, BiV-paced QRSd measurements were successfully performed in 112 of 120 coronary sinus branches during CRT and an LV lead was successfully placed at the optimal site in all patients. Compared with group 2, group 1 had a significantly higher rate (85% vs. 50%, p=0.02) of response (>15% reduction in LV end-systolic volume) to CRT as well as a shorter QRSd (p<0.001) and a greater QRS shortening (ΔQRS) associated with CRT compared with baseline (p<0.001). The mean New York Heart Association functional class was significantly improved in both groups, and no significant differences were found in clinical response to CRT (85% vs. 70%, p=0.181). CONCLUSION Surface ECG can be used to guide LV lead placement in patients with multiple target veins for improving response to CRT. Thus, it is a safe, feasible, and economic approach for CRT-D implantation.
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11
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Zabihollahy F, White JA, Ukwatta E. Convolutional neural network-based approach for segmentation of left ventricle myocardial scar from 3D late gadolinium enhancement MR images. Med Phys 2019; 46:1740-1751. [PMID: 30734937 DOI: 10.1002/mp.13436] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 01/10/2019] [Accepted: 01/31/2019] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Accurate three-dimensional (3D) segmentation of myocardial replacement fibrosis (i.e., scar) is emerging as a potentially valuable tool for risk stratification and procedural planning in patients with ischemic cardiomyopathy. The main purpose of this study was to develop a semiautomated method using a 3D convolutional neural network (CNN)-based for the segmentation of left ventricle (LV) myocardial scar from 3D late gadolinium enhancement magnetic resonance (LGE-MR) images. METHODS Our proposed CNN is built upon several convolutional and pooling layers aimed at choosing appropriate features from LGE-MR images to distinguish between myocardial scar and healthy tissues of the left ventricle. In contrast to previous methods that consider image intensity as the sole feature, CNN-based algorithms have the potential to improve the accuracy of scar segmentation through the creation of unconventional features that separate scar from normal myocardium in the feature space. The first step of our pipeline was to manually delineate the left ventricular myocardium, which was used as the region of interest for scar segmentation. Our developed algorithm was trained using 265,220 volume patches extracted from ten 3D LGE-MR images, then was validated on 450,454 patches from a testing dataset of 24 3D LGE-MR images, all obtained from patients with chronic myocardial infarction. We evaluated our method in the context of several alternative methods by comparing algorithm-generated segmentations to manual delineations performed by experts. RESULTS Our CNN-based method reported an average Dice similarity coefficient (DSC) and Jaccard Index (JI) of 93.63% ± 2.6% and 88.13% ± 4.70%. In comparison to several previous methods, including K-nearest neighbor (KNN), hierarchical max flow (HMF), full width at half maximum (FWHM), and signal threshold to reference mean (STRM), the developed algorithm reported significantly higher accuracy for DSC with a P-value less than 0.0001. CONCLUSIONS Our experimental results demonstrated that our CNN-based proposed method yielded the highest accuracy of all contemporary LV myocardial scar segmentation methodologies, inclusive of the most widely used signal intensity-based methods, such as FWHM and STRM. To our knowledge, this is the first description of LV myocardial scar tissue segmentation from 3D LGE-MR images using a CNN-based method.
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Affiliation(s)
- Fatemeh Zabihollahy
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
| | - James A White
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, USA
| | - Eranga Ukwatta
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
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12
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Sassone B, Nucifora G, Mele D, Valzania C, Bisignani G, Boriani G. Role of cardiovascular imaging in cardiac resynchronization therapy: a literature review. J Cardiovasc Med (Hagerstown) 2018; 19:211-222. [PMID: 29470248 DOI: 10.2459/jcm.0000000000000635] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
: Cardiac resynchronization therapy (CRT) is an established treatment in patients with symptomatic drug-refractory heart failure and broad QRS complex on the surface ECG. Despite the presence of either mechanical dyssynchrony or viable myocardium at the site where delivering left ventricular pacing being necessary conditions for a successful CRT, their direct assessment by techniques of cardiovascular imaging, though feasible, is not recommended in clinical practice by the current guidelines. Indeed, even though there is growing body of data providing evidence of the additional value of an image-based approach as compared with routine approach in improving response to CRT, these results should be confirmed in prospective and large multicentre trials before their impact on CRT guidelines is considered.
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Affiliation(s)
- Biagio Sassone
- Department of Cardiology, SS.ma Annunziata Hospital.,Department of Cardiology, Delta Hospital, Azienda Unità Sanitaria Locale Ferrara, Ferrara, Italy
| | - Gaetano Nucifora
- Cardiology Department, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Flinders University, Adelaide, Australia
| | - Donato Mele
- Noninvasive Cardiology Unit, University Hospital of Ferrara, Ferrara
| | - Cinzia Valzania
- Institute of Cardiology, University of Bologna, Policlinico S. Orsola-Malpighi, Bologna
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico of Modena, Modena, Italy
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Nguyên UC, Cluitmans MJM, Strik M, Luermans JG, Gommers S, Wildberger JE, Bekkers SCAM, Volders PGA, Mihl C, Prinzen FW, Vernooy K. Integration of cardiac magnetic resonance imaging, electrocardiographic imaging, and coronary venous computed tomography angiography for guidance of left ventricular lead positioning. Europace 2018; 21:626-635. [DOI: 10.1093/europace/euy292] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 11/12/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Matthijs J M Cluitmans
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marc Strik
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Justin G Luermans
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Suzanne Gommers
- Department of Radiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Joachim E Wildberger
- Department of Radiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Sebastiaan C A M Bekkers
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Radiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Paul G A Volders
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Casper Mihl
- Department of Radiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands
| | - Kevin Vernooy
- Department of Cardiology, CARIM, Maastricht University Medical Center, Maastricht, the Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
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14
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Nguyên UC, Potse M, Vernooy K, Mafi-Rad M, Heijman J, Caputo ML, Conte G, Regoli F, Krause R, Moccetti T, Auricchio A, Prinzen FW, Maffessanti F. A left bundle branch block activation sequence and ventricular pacing influence voltage amplitudes: anin vivoandin silicostudy. Europace 2018; 20:iii77-iii86. [DOI: 10.1093/europace/euy233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 10/31/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), PO Box 616, Maastricht MD, the Netherlands
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Mark Potse
- CARMEN Research Team, Inria Bordeaux Sud-Ouest, Talence F-33400, France
- Université de Bordeaux, IMB, UMR 5251, Talence F-33400, France
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Foundation Bordeaux Université, Pessac, Bordeaux F-33600, France
| | - Kevin Vernooy
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Masih Mafi-Rad
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Jordi Heijman
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Maria Luce Caputo
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Giulio Conte
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - François Regoli
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Rolf Krause
- Center for Computational Medicine in Cardiology (CCMC), Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Tiziano Moccetti
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Angelo Auricchio
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
- Center for Computational Medicine in Cardiology (CCMC), Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), PO Box 616, Maastricht MD, the Netherlands
| | - Francesco Maffessanti
- Center for Computational Medicine in Cardiology (CCMC), Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
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15
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Heist EK. Left Ventricular Endocardial Cardiac Resynchronization Therapy Is Here, But Where Should We Place the Lead? JACC Clin Electrophysiol 2018; 4:869-871. [PMID: 30025685 DOI: 10.1016/j.jacep.2018.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/26/2018] [Indexed: 11/28/2022]
Affiliation(s)
- E Kevin Heist
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston, Massachusetts.
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16
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Utility of dual-source computed tomography in cardiac resynchronization therapy-DIRECT study. Heart Rhythm 2018; 15:1206-1213. [PMID: 29572087 DOI: 10.1016/j.hrthm.2018.03.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Dual-source computed tomography (CT) can evaluate left ventricular (LV) dyssynchrony, myocardial scar, and coronary venous anatomy in patients undergoing cardiac resynchronization therapy (CRT). OBJECTIVE We aimed to determine whether dual-source CT predicts clinical CRT outcomes and reduces intraprocedural time. METHODS In this prospective study, 54 patients scheduled for CRT (mean age 63 ± 11 years; 74% men) underwent preprocedural CT to assess their venous anatomy as well as CT-derived dyssynchrony metrics and myocardial scar. Based on 1:1 randomization, the implanting physician had preimplant knowledge of the venous anatomy in half the patients. In blinded analyses, we measured time to maximal wall thickness and inward wall motion to determine (1) CT global and segmental dyssynchrony and (2) concordance of lead location to regional LV mechanical contraction. End points were 6-month CRT response measured using heart failure clinical composite score and 2-year major adverse cardiac events (MACE). RESULTS There were 72% CRT responders and 17% with MACE. Two wall motion dyssynchrony indices-global wall motion and opposing anteroseptal-inferolateral wall motion-predicted MACE (P < .01). Lead location concordant to regions of maximal wall thickness was associated with less MACE (P < .01). No CT dyssynchrony metrics predicted 6-month CRT response (P = NS for all). Myocardial scar (43%), posterolateral wall scar (28%), and total scar burden did not predict outcomes (P = NS for all). Preknowledge of coronary venous anatomy by CT did not reduce implant or fluoroscopy time (P = NS for both). CONCLUSION Two CT dyssynchrony metrics predicted 2-year MACE, and LV lead location concordant to regions of maximal wall thickness was associated with less MACE. Other CT factors had little utility in CRT.
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De Maria E, Aldrovandi A, Borghi A, Modonesi L, Cappelli S. Cardiac magnetic resonance imaging: Which information is useful for the arrhythmologist? World J Cardiol 2017; 9:773-786. [PMID: 29104737 PMCID: PMC5661133 DOI: 10.4330/wjc.v9.i10.773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 05/23/2017] [Accepted: 06/13/2017] [Indexed: 02/06/2023] Open
Abstract
Cardiac magnetic resonance (CMR) is a non-invasive, non-ionizing, diagnostic technique that uses magnetic fields, radio waves and field gradients to generate images with high spatial and temporal resolution. After administration of contrast media (e.g., gadolinium chelate), it is also possible to acquire late images, which make possible the identification and quantification of myocardial areas with scar/fibrosis (late gadolinium enhancement, LGE). CMR is currently a useful instrument in clinical cardiovascular practice for the assessment of several pathological conditions, including ischemic and non-ischemic cardiomyopathies and congenital heart disease. In recent years, its field of application has also extended to arrhythmology, both in diagnostic and prognostic evaluation of arrhythmic risk and in therapeutic decision-making. In this review, we discuss the possible useful applications of CMR for the arrhythmologist. It is possible to identify three main fields of application of CMR in this context: (1) arrhythmic and sudden cardiac death risk stratification in different heart diseases; (2) decision-making in cardiac resynchronization therapy device implantation, presence and extent of myocardial fibrosis for left ventricular lead placement and cardiac venous anatomy; and (3) substrate identification for guiding ablation of complex arrhythmias (atrial fibrillation and ventricular tachycardias).
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Affiliation(s)
- Elia De Maria
- Cardiology Unit, Ramazzini Hospital, 41012 Carpi (Modena), Italy
| | | | - Ambra Borghi
- Cardiology Unit, Ramazzini Hospital, 41012 Carpi (Modena), Italy
| | - Letizia Modonesi
- Cardiology Unit, Ramazzini Hospital, 41012 Carpi (Modena), Italy
| | - Stefano Cappelli
- Cardiology Unit, Ramazzini Hospital, 41012 Carpi (Modena), Italy
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18
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Nguyên UC, Prinzen FW, Vernooy K. Left ventricular lead positioning in cardiac resynchronization therapy: Mission accomplished? Heart Rhythm 2017; 14:1373-1374. [DOI: 10.1016/j.hrthm.2017.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 10/19/2022]
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19
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Nguyên UC, Maffessanti F, Mafi-Rad M, Conte G, Zeemering S, Regoli F, Caputo ML, van Stipdonk AMW, Bekkers SCAM, Suerder D, Moccetti T, Krause R, Prinzen FW, Vernooy K, Auricchio A. Evaluation of the use of unipolar voltage amplitudes for detection of myocardial scar assessed by cardiac magnetic resonance imaging in heart failure patients. PLoS One 2017; 12:e0180637. [PMID: 28678875 PMCID: PMC5498065 DOI: 10.1371/journal.pone.0180637] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 06/19/2017] [Indexed: 11/23/2022] Open
Abstract
Background Validation of voltage-based scar delineation has been limited to small populations using mainly endocardial measurements. The aim of this study is to compare unipolar voltage amplitudes (UnipV) with scar on delayed enhancement cardiac magnetic resonance imaging (DE-CMR). Methods Heart failure patients who underwent DE-CMR and electro-anatomic mapping were included. Thirty-three endocardial mapped patients and 27 epicardial mapped patients were investigated. UnipV were computed peak-to-peak. Electrograms were matched with scar extent of the corresponding DE-CMR segment using a 16-segment/slice model. Non-scar was defined as 0% scar, while scar was defined as 1–100% scar extent. Results UnipVs were moderately lower in scar than in non-scar (endocardial 7.1 [4.6–10.6] vs. 10.3 [7.4–14.2] mV; epicardial 6.7 [3.6–10.5] vs. 7.8 [4.2–12.3] mV; both p<0.001). The correlation between UnipV and scar extent was moderate for endocardial (R = -0.33, p<0.001), and poor for epicardial measurements (R = -0.07, p<0.001). Endocardial UnipV predicted segments with >25%, >50% and >75% scar extent with AUCs of 0.72, 0.73 and 0.76, respectively, while epicardial UnipV were poor scar predictors, independent of scar burden (AUC = 0.47–0.56). UnipV in non-scar varied widely between patients (p<0.001) and were lower in scar compared to non-scar in only 9/22 (41%) endocardial mapped patients and 4/19 (21%) epicardial mapped patients with scar. Conclusion UnipV are slightly lower in scar compared to non-scar. However, significant UnipV differences between and within patients and large overlap between non-scar and scar limits the reliability of accurate scar assessment, especially in epicardial measurements and in segments with less than 75% scar extent.
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Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
- * E-mail:
| | - Francesco Maffessanti
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Masih Mafi-Rad
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Giulio Conte
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Stef Zeemering
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
| | - François Regoli
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Maria Luce Caputo
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | | | | | - Daniel Suerder
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Tiziano Moccetti
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Rolf Krause
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Frits W. Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Kevin Vernooy
- Department of Physiology, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, the Netherlands
- Department of Cardiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Angelo Auricchio
- Center for Computational Medicine in Cardiology, Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
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