Prevention of pacemaker lead induced tricuspid regurgitAtion by transesophageal eCho guidEd implantation (PLACE Pilot)

Background Lead-induced tricuspid regurgitation (TR) is a frequent complication after pacemaker- and ICD-implantation that is associated with increased mortality and hospitalizations. Purpose The aim of this pilot study was to investigate if lead implantation guided by transesophageal echocardiography (TEE) is feasible and might be able to reduce lead-associated TR. Methods 21 patients with indication for new pacemaker/ICD including a trans-tricuspid lead implantation and TR < grade 2+ were prospectively enrolled and underwent TEE-guided lead implantation in addition to fluoroscopy. Leads were placed according to a dedicated echo protocol with focus on a transgastric en face view of the tricuspid valve targeting a lead position in a tricuspid valve commissure (preferentially postero-septal) and an apical ventricular lead position. (Figure 1) Transthoracic echocardiography (TTE) was performed before implantation and at discharge. 121 consecutive patients with standard lead implantation guided by fluoroscopy only served as a historical control group. TR was assessed by an experienced cardiologist and graded according to current guidelines. Results Key baseline characteristics of overall 124 patients with a mean age of 74 years didn't differ between groups. Of note, there was no significant difference regarding device type and baseline TR. TEE-guided lead implantation was possible in all 21 patients in the TEE-group in deep conscious sedation without occurrence of serious adverse events. Lead placement in a commissure, mostly postero-septal, was possible in 95.2% of patients without worsening of TR (20/21 pts). Based on TEE-guidance, lead position or length was altered in 52.4% of patients (11/21 pts, 6 pts with lead repositioning, 5 pts with modification of lead length). Compared to baseline, the 21 patients in the TEE-group did not show worsening of TR at discharge. In contrast, TR worsening by one grade occurred in 13.6% of patients (14/103 pts) with new onset of TR ≥2+ in 6.8% of patients (07/103 pts) in the control group (p=0.001). At discharge, lead position was evaluated using 2D and 3D TTE in a subset of patients. In all examined patients (14/14 pts) lead position was unchanged compared to intraprocedural position and stable during inspiration vs. expiration as well as in upright vs. horizontal position. Conclusion TEE-guidance during PM/ICD-implantation was safe and feasible and resulted in steps to optimize lead position in a relevant number of patients. At discharge lead position remained stable and TEE-guided lead implantation was associated with less worsening of TR than standard lead implantation guided by fluoroscopy. FUNDunding Acknowledgement Type of funding sources: None. TEE view with targeted lead position

Reduction in QRS area correlates with hemodynamic response during CRT-device implantation

Funding Acknowledgements Type of funding sources: None. Background Previous studies have shown that reduction in QRS area after cardiac resynchronization therapy (CRT) is associated with improved long-term clinical outcome. Purpose To investigate whether reduction in QRS area is associated with hemodynamic improvement and whether QRS area reduction could be used for CRT optimization, with respect to LV lead position and device programming in individual patients. Methods A total of 78 patients with indication for CRT were prospectively included in 4 hospitals. QRS area was calculated from vectorcardiograms that were synthesized from 12-lead ECG’s. Acute hemodynamic response was assessed invasively as the maximum rate of percentual left ventricular (LV) pressure (%LVdP/dtmax) rise. QRS area reduction was studied in relation to LV-lead position (n = 26), proximal versus distal LV lead position (n = 27), and VV-delay (n = 25). Results Combining all measurements in all patients showed a significant correlation between QRS area reduction and %LVdP/dTmax increase (R = 0.49, P < 0.0001). Also, when one fixed routine implantation setting was used for each patient (lateral lead position, distal, AV-delay 120-150ms, VV-delay 0ms) this correlation was present (R = 0.45, p < 0.0001, figure panel A). In 21 patients in which at least 3 lead positions were available there was also a significant correlation between QRS area reduction and %LVdP/dtmax increase (average R = 0.69, p < 0.0001, panel B). For VV-delay, 25 other patients as well showed a significant correlation (average R = 0.53, p < 0.0001). Conclusion Within patients, QRS area reduction is associated with %LVdP/dtmax increase with various LV lead positions and VV-intervals. Therefore, QRS area, which is an easily obtainable and objective parameter, might be a promising tool for optimization of LV lead position and device programming in CRT. Abstract Figure.

Localization of right ventricular non-apical lead position: comparison of three-dimensional echocardiography, computed tomography, and fluoroscopic imaging

Objective Right ventricular (RV) septal pacing is considered a better pacing procedure compared with traditional apical pacing. This study aimed to investigate agreement among computed tomography (CT), three-dimensional echocardiography (3D-echo), and fluoroscopy for evaluating the tip of the RV pacing lead in the non-apical position in patients with permanent pacemaker implantation. Methods Fifty-four patients were prospectively enrolled. Data on patients’ characteristics and imaging findings were analyzed. The agreement rate in distinguishing the RV septal lead position among the three imaging modalities was determined. Results Thirty-three (61%) patients were men and the median age was 76 years. Overall, the agreement rate among the three imaging modalities was 87% (47/54; Kappa ratio: 0.734). The agreement of 3D-echo compared with thoracic CT (Kappa ratio: 0.893) was better than that for thoracic CT and fluoroscopy (Kappa ratio: 0.658). Agreement between fluoroscopy and 3D-echo was lowest (Kappa ratio: 0.632). Conclusions Agreement in evaluating the position of the septal lead between thoracic CT and 3D-echo is better than that between other imaging modalities. Our findings indicate that 3D-echo imaging might be the best imaging tool for defining the tip of the RV non-apical lead position and be useful for guiding positioning of the RV lead.

Acute response to cardiac re-synchronization therapy: ventricular properties adaptation?

Background Cardiac re-synchronization therapy (CRT) reduces mortality and hospitalization in patients with heart failure, reduced left ventricular ejection fraction (LVEF) and left bundle branch block (LBBB). However, there is no conclusive evidence on baseline parameters able to discriminate responder vs non-responder patients. Purpose In this study, we tested whether echocardiographic parameters describing LV dyssynchrony and efficiency may predict an acute LV recovery after CRT and whether lead position can modify such relationship. Methods We enrolled 65 consecutive patients (75% males, aged 71.2±10.5 years) referred for CRT according to current guidelines; 45% had an underlying ischaemic cardiopathy and 1/3 of them presented diabetes mellitus. We performed a CRT-off and CRT–on 2D and 3D echocardiography during devices optimization (time between programming change 10/12 min). We evaluated ventricular dyssynchrony by speckle-tracking analysis based on temporary uniformity of strain (TUS) 3D longitudinal and circumferential. We also derived non-invasive myocardial efficiency (Effic) by interaction between pressure work index (PWI), representing an estimation of myocardial oxygen consumption, and mechanical external work. We indicated as concordant those patients presenting a LV lead position (defined from a chest X-ray using 2 orthogonal views) in the same segment as the latest systolic 3D circumferential strain curves. Results In the CRT-on phase, a non-statistically significant raise in LVEF was observed [from 0.37 (0.28–0.46) to 0.41 (0.34–0.47), p=0.27]. No improvement in both longitudinal and circumferential 3D TUS was demonstrated during CRT-on (p=0.44 and 0.47, respectively). Conversely, the gain in Effic from CRT-off to CRT-on phase was overall significant (from 0.43±0.14 to 0.50±0.16; p<0.001). After switching to CRT-on, the increase in longitudinal 3D TUS was higher in concordant compared to discordant patients (from 0.83±0.08 to 0.87±0.07 vs 0.88±0.11 to 0.87±0.12, respectively), but without significant interaction (interaction p 0.24). No interaction was also found between variations of PWI after switching to CRT-on and LV lead position (concordant: from 12.99±4.18 to 12.84±2.99 ml/min/100g; discordant: from 13.58±3.89 to 13.95±3.97 ml/min/100g; interaction p 0.75). Conclusions Effic was overall acutely augmented during CRT-on phase in patients with LV dysfunction undergoing cardiac re-synchronization. In the acute phase, no significant relationship between LV changes in speckle-tracking analyses after CRT and LV lead position was found. 2-way ANOVA for myocardial efficiency Funding Acknowledgement Type of funding source: None

Lateral left ventricular lead position is superior to posterior position in long-term outcome of patients underwent cardiac resynchronization therapy

Background Preferring side branch of coronary sinus during cardiac resynchronization therapy (CRT) implantation is empirical due to the limited data on the association of left ventricular (LV) lead position and long-term clinical outcome. Purpose We evaluated the long-term all-cause mortality by LV lead non-apical positions and further characterized them by interlead electrical delay (IED). Methods In our retrospective database 2087 patients were registered between 2000 and 2018. Those with non-apical LV lead locations were classified into anterior (n=108), posterior (n=643), and lateral (n=1336) groups. All-cause mortality was assessed by Kaplan-Meier and Cox analyses. Echocardiographic response was measured 6 months after CRT implantation. Results During the median follow-up time of 3.7 years, 1150 (55.1%) patients died, 710 (53.1%) with lateral, 78 (72.2%) with anterior and 362 (56.3%) with posterior positions. Patients with lateral position had significantly better outcome in all-cause mortality compared to others (HR 0.80; 95% CI: 0.71–0.90; p<0.0001), which was also confirmed by multivariate analysis after adjusting for relevant clinical covariates (HR 0.81; 95% CI: 0.72–0.91; p<0.0001). When echocardiographic response was evaluated in the lateral group, patients with an IED longer than 110 ms (ROC AUC 0.63; 95% CI: 0.53–0.73; p=0.012) showed 2.1 times higher odds of improvement in echocardiographic response 6 months after the implantation. Conclusions In this study we proved that after CRT implantation only the lateral LV lead location was associated with long-term mortality benefit. Moreover, patients with this position showed the greatest echocardiographic response over 110 ms IED. Survival of total patient cohort Funding Acknowledgement Type of funding source: None

Precise targeting of the globus pallidus internus with quantitative susceptibility mapping for deep brain stimulation surgery

OBJECTIVEThe goal of this study was to demonstrate the use of quantitative susceptibility mapping (QSM)–based images to precisely localize the globus pallidus internus (GPi) for deep brain stimulation (DBS) planning and to enhance postsurgical visualization of the DBS lead positions.METHODSPresurgical T1-weighted (T1w), T2-weighted (T2w), and QSM images as well as postsurgical CT images were obtained in 29 patients with Parkinson’s disease. To enhance the contrast within the GP, a hybrid contrast was created by linearly combining T1w and QSM images. Contrast-to-noise ratios (CNRs) of the GPi on T1w, T2w, QSM, and hybrid images were compared. The CNR differences were tested using the 1-way ANOVA method. The visualization of the DBS lead position was demonstrated by merging the postsurgical CT with presurgical MR images.RESULTSThe hybrid images yield the best CNRs for GPi depiction and the visualization of the postsurgical DBS lead position was significantly improved.CONCLUSIONSQSM-based images allow for confident localization of borders of the GPi that is superior to T1w and T2w images. High-contrast hybrid images can be used for precisely directed DBS targeting, e.g., GPi DBS for the treatment of advanced Parkinson’s disease.

Orientation of Directional Deep Brain Stimulation Leads on CT: Resolving the Ambiguity

While directional deep brain stimulation (DBS) shows promising clinical effects by providing a new degree of freedom in programming, precise knowledge of the lead position and orientation is necessary to mitigate the resulting increased complexity. Two methods for orientation assessment based on postoperative CT imaging have become available, but neither of them is currently able to resolve the respective 180° artifact symmetry. Both rely on information about the intended orientation and assume that a deviation of more than ± 90° is very unlikely. Our aim was to develop an enhanced algorithm capable of detecting asymmetries in the CT data and to thus eliminate the need for user interaction. Two different approaches are presented: one based on the lead marker’s center of mass (COM) and one based on asymmetric sampling of the marker’s intensity profile (ASM). Both were tested on a total of 98 scans of 2 lead phantoms, resulting in 165 measurements with a large variety of lead implantation and orientation angles. The 180° ambiguity was correctly resolved in 99.4% of cases by COM and in 96.4% of cases by ASM. These results demonstrate the substantial and currently unused asymmetry in CT and the potential for a truly automated workflow.