Abstract 17238: Suboptimal or `Remote' Left Ventricular Lead Position in Cardiac Resynchronisation Therapy May be No Better Than Medical Therapy Alone
Background Left ventricular (LV) lead position concordant or adjacent with the site of latest mechanical activation, in viable myocardium, appears to offer superior reverse remodelling response and improved prognosis. We present intermediate follow-up of a cohort of patients following CRT. A qualitative comparison with all cause mortality of the CARE-HF population was made.
Methods We obtained follow up mortality data for 250 patients, comprising the TARGET Cohort, undergoing CRT between 2008- 2010. Optimum LV lead position was defined prior to CRT implantation using speckle tracking radial strain echocardiography with 10% radial strain cut off value to define a viable segment. Final lead position was determined by fluoroscopy at implant defined as: concordant (optimal segment on echo), adjacent (within one segment of optimal site on echo) or remote (greater that one segment away from optimal site).
Results Lead position was concordant or adjacent in 80% and remote in 20% (median age 72 yrs, IQR 59-85; 88% NYHA class 3; QRS 157ms IQR 133-181; EF 23.3% IQR 13-33; 53% ischemic etiology). Patients with either concordant or adjacent LV lead position had a more favorable survival, up to maximum of 3.8 years follow-up, than those with remote LV leads (p=0.001, figure A). Of 202 patients with concordant or adjacent leads there were 33 deaths, and 17 deaths from 48 patients with a remote lead. In a qualitative comparison with KM curves from CARE-HF, for death from any cause, patients with a remote LV lead position appear to mirror survival at 3.8 years for the optimum medical therapy arm (figure B).
Conclusion The beneficial effects of an optimally placed LV lead (concordant or adjacent) on survival are sustained over longer-term follow up. A remotely positioned LV lead may confer no additional benefit beyond medical therapy alone. If an optimal lead position cannot be achieved via a standard percutaneous transvenous approach an alternative strategy should be sought.
- © 2012 by American Heart Association, Inc.