The role of guidance in delivering cardiac resynchronization therapy: A systematic review and network meta-analysis

3D computed tomography integration guiding permanent Aveir AR leadless pacemaker implantation: a case report

Background

The use of single-chamber, right ventricular (RV) leadless pacemakers (LPs) has been well established, the introduction of a right atrial LPs has opened the door for dual-chamber leadless pacing. Cardiac computed tomography (CT) segmentation integration might provide proper visual guide during the procedure.

Case summary

A 58-year-old male patient was brought to the emergency department with dizziness and complete heart block. The patient underwent single-chamber permanent LP implantation. During the upgrade to a dual-chamber LP, 3D CT image fusion with fluoroscopy was utilized to accurately identify the ideal and safe implantation site for the device.

Discussion

Integrating CT image guidance with fluoroscopy could enhance procedure safety, success rates, and reduces fluoroscopy time.

Role of speckle tracking echocardiography beyond current guidelines in cardiac resynchronization therapy

Cardiac resynchronization therapy (CRT) is a device-based treatment applied to patients with a specific profile of heart failure. According to current guidelines, indication for CRT is given on the basis of QRS morphology and duration, and traditional transthoracic echocardiography is mainly used to estimate left ventricular (LV) ejection fraction. However, the identification of patients who may benefit from CRT remains challenging, since the application of the above-mentioned guidelines is still associated with a high rate of non-responders. The assessment of various aspects of LV mechanics (including contractile synchrony, coordination and propagation, and myocardial work) performed by conventional and novel ultrasound technologies, first of all speckle tracking echocardiography (STE), may provide additional, useful information for CRT patients' selection, in particular among non-LBBB patients, who generally respond less to CRT. A multiparametric approach, based on the combination of ECG criteria and echocardiographic indices of LV dyssynchrony/discoordination would be desirable to improve the prediction of CRT response.

Clinical practice guidelines for diagnostic and treatment of the chronic heart failure

Chronic heart failure continues to be one of the main causes of impairment in the functioning and quality of life of people who suffer from it, as well as one of the main causes of mortality in our country and around the world. Mexico has a high prevalence of risk factors for developing heart failure, such as high blood pressure, diabetes, and obesity, which makes it essential to have an evidence-based document that provides recommendations to health professionals involved in the diagnosis and treatment of these patients. This document establishes the clinical practice guide (CPG) prepared at the initiative of the Mexican Society of Cardiology (SMC) in collaboration with the Iberic American Agency for the Development and Evaluation of Health Technologies, with the purpose of establishing recommendations based on the best available evidence and agreed upon by an interdisciplinary group of experts. This document complies with international quality standards, such as those described by the US Institute of Medicine (IOM), the National Institute of Clinical Excellence (NICE), the Intercollegiate Network for Scottish Guideline Development (SIGN) and the Guidelines International Network (G-I-N). The Guideline Development Group was integrated in a multi-collaborative and interdisciplinary manner with the support of methodologists with experience in systematic literature reviews and the development of CPG. A modified Delphi panel methodology was developed and conducted to achieve an adequate level of consensus in each of the recommendations contained in this CPG. We hope that this document contributes to better clinical decision making and becomes a reference point for clinicians who manage patients with chronic heart failure in all their clinical stages and in this way, we improve the quality of clinical care, improve their quality of life and reducing its complications.

The role of CT in arrhythmia management-treatment planning and post-procedural imaging surveillance

Several interventional treatment options exist in patients with atrial and ventricular arrhythmia. Cardiac CT is routinely performed prior to occlusion of the left atrial appendage, pulmonary vein isolation, and cardiac device implantation. Besides the evaluation of coronary artery disease, cardiac CT provides isotropic, high-resolution CT images of the cardiac anatomy with the possibility of multiplanar reformations and three-dimensional reconstructions which are helpful to guide interventional treatment. In addition, cardiac CT is increasingly used to rapidly evaluate periprocedural complications and for the routine post-procedural imaging surveillance in patients after interventions. This review article will discuss current applications of pre- and post-interventional CT imaging in patients with arrhythmia.

Targeted left ventricular lead positioning to the site of latest activation in cardiac resynchronization therapy: a systematic review and meta-analysis

AIMS

Several studies have evaluated the use of electrically- or imaging-guided left ventricular (LV) lead placement in cardiac resynchronization therapy (CRT) recipients. We aimed to assess evidence for a guided strategy that targets LV lead position to the site of latest LV activation.

METHODS AND RESULTS

A systematic review and meta-analysis was performed for randomized controlled trials (RCTs) until March 2023 that evaluated electrically- or imaging-guided LV lead positioning on clinical and echocardiographic outcomes. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization, and secondary endpoints were quality of life, 6-min walk test (6MWT), QRS duration, LV end-systolic volume, and LV ejection fraction. We included eight RCTs that comprised 1323 patients. Six RCTs compared guided strategy (n = 638) to routine (n = 468), and two RCTs compared different guiding strategies head-to-head: electrically- (n = 111) vs. imaging-guided (n = 106). Compared to routine, a guided strategy did not significantly reduce the risk of the primary endpoint after 12-24 (RR 0.83, 95% CI 0.52-1.33) months. A guided strategy was associated with slight improvement in 6MWT distance after 6 months of follow-up of absolute 18 (95% CI 6-30) m between groups, but not in remaining secondary endpoints. None of the secondary endpoints differed between the guided strategies.

CONCLUSION

In this study, a CRT implantation strategy that targets the latest LV activation did not improve survival or reduce heart failure hospitalizations.