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CLINICAL RESEARCH: CARDIAC RESYNCHRONIZATION THERAPY

Optimal Left Ventricular Lead Position Predicts Reverse Remodeling and Survival After Cardiac Resynchronization Therapy

Claudia Ypenburg, MD^_*, Rutger J. van Bommel, MD^_*, Victoria Delgado, MD^_*, Sjoerd A. Mollema, MD^_*, Gabe B. Bleeker, MD, PhD^_*, Eric Boersma, PhD, Martin J. Schalij, MD, PhD^_* and Jeroen J. Bax, MD, PhD^_*,_*

^_* Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
Department of Epidemiology and Statistics, Erasmus University, Rotterdam, the Netherlands

Manuscript received March 26, 2008; revised manuscript received June 2, 2008, accepted June 17, 2008.

^_* Reprint requests and correspondence: Dr. Jeroen J. Bax, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands (Email: j.j.bax{at}lumc.nl).

Objectives: The aim of the current study was to evaluate echocardiographic parameters after 6 months of cardiac resynchronization therapy (CRT) as well as long-term outcome in patients with the left ventricular (LV) lead positioned at the site of latest activation (concordant LV lead position) as compared with that seen in patients with a discordant LV lead position.

Background: A nonoptimal LV pacing lead position may be a potential cause for nonresponse to CRT.

Methods: The site of latest mechanical activation was determined by speckle tracking radial strain analysis and related to the LV lead position on chest X-ray in 244 CRT candidates. Echocardiographic evaluation was performed after 6 months. Long-term follow-up included all-cause mortality and hospitalizations for heart failure.

Results: Significant LV reverse remodeling (reduction in LV end-systolic volume from 189 ± 83 ml to 134 ± 71 ml, p < 0.001) was noted in the group of patients with a concordant LV lead position (n = 153, 63%), whereas patients with a discordant lead position showed no significant improvements. In addition, during long-term follow-up (32 ± 16 months), less events (combined for heart failure hospitalizations and death) were reported in patients with a concordant LV lead position. Moreover, a concordant LV lead position appeared to be an independent predictor of hospitalization-free survival after long-term CRT (hazard ratio: 0.22, p = 0.004).

Conclusions: Pacing at the site of latest mechanical activation, as determined by speckle tracking radial strain analysis, resulted in superior echocardiographic response after 6 months of CRT and better prognosis during long-term follow-up.

Key Words: resynchronization therapy • lead position • echocardiography • heart failure

Abbreviations and Acronyms   CI = confidence interval   CRT = cardiac resynchronization therapy   HR = hazard ratio   LV = left ventricle/ventricular   LVEDV = left ventricular end-diastolic volume   LVEF = left ventricular ejection fraction   LVESV = left ventricular end-systolic volume   NYHA = New York Heart Association   PH = proportional hazards   2D = two-dimensional

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