Multimodality imaging-guided left ventricular lead placement in cardiac resynchronization therapy: a randomized controlled trial

Abstract Aim Left ventricular ( LV ) lead position at the latest mechanically activated non‐scarred myocardial LV region confers improved response to cardiac resynchronization therapy ( CRT ). We conducted a double‐blind, randomized controlled trial to evaluate the clinical benefit of multimodality imaging‐guided LV lead placement in CRT . Methods and results Patients were allocated (1:1) to imaging‐guided LV lead placement using cardiac computed tomography ( CT ) venography, 99m Technetium myocardial perfusion imaging, and speckle‐tracking echocardiography radial strain to target the optimal coronary sinus ( CS ) branch closest to the non‐scarred myocardial segment with latest mechanical activation (imaging group, n = 89) or to routine LV lead implantation in a posterolateral region with late electrical activation (control group, n = 93). The primary endpoint was clinical non‐response to CRT [≥1 of the following after 6 months: (1) death, (2) heart failure hospitalization, or (3) no improvement in New York Heart Association class and <10% increase in 6‐min walk distance]. Secondary outcomes included LV remodelling and the combination of all‐cause mortality and hospitalization owing to heart failure during 1.8 ± 0.9 years. Analysis was intention‐to‐treat. In the imaging group, fewer patients reached the primary endpoint (26% vs. 42%, P = 0.02). More patients in the imaging group had the LV lead placed in the optimal CS branch (83% vs. 65%, P = 0.01). There were no between‐group differences in reverse LV remodelling or the combined endpoint of death or hospitalizations for heart failure. Conclusions Multimodality imaging‐guided LV lead placement towards the CS branch closest to latest mechanically activated non‐scarred myocardial LV segment reduces the proportion of clinical non‐responders to CRT . Larger long‐term multicentre studies are needed.