Targeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization Therapy

• Published in: Journal of the American College of Cardiology 2012-04, Vol.59 (17), p.1509-1518
• Main Authors: Khan, Fakhar Z., MA, Virdee, Mumohan S., MD, Palmer, Christopher R., PhD, Pugh, Peter J., MD, O'Halloran, Denis, BCh, Elsik, Maros, PhD, Read, Philip A., MD, Begley, David, MD, Fynn, Simon P., MD, Dutka, David P., DM
• Format: Article
• Language: English
• Subjects: cardiac resynchronization therapy; Cardiology; Cardiovascular; Confidence intervals; Drug therapy; Heart attacks; Heart failure; Internal Medicine; left ventricular lead; Mortality; Regression analysis; speckle-tracking echocardiography; Transplants & implants
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2011.12.030

Objectives This study sought to assess the impact of targeted left ventricular (LV) lead placement on outcomes of cardiac resynchronization therapy (CRT). Background Placement of the LV lead to the latest sites of contraction and away from the scar confers the best response to CRT. We conducted a randomized, controlled trial to compare a targeted approach to LV lead placement with usual care. Methods A total of 220 patients scheduled for CRT underwent baseline echocardiographic speckle-tracking 2-dimensional radial strain imaging and were then randomized 1:1 into 2 groups. In group 1 (TARGET [Targeted Left Ventricular Lead Placement toGuide Cardiac Resynchronization Therapy]), the LV lead was positioned at the latest site of peak contraction with an amplitude of >10% to signify freedom from scar. In group 2 (control) patients underwent standard unguided CRT. Patients were classified by the relationship of the LV lead to the optimal site as concordant (at optimal site), adjacent (within 1 segment), or remote (≥2 segments away). The primary endpoint was a ≥15% reduction in LV end-systolic volume at 6 months. Secondary endpoints were clinical response (≥1 improvement in New York Heart Association functional class), all-cause mortality, and combined all-cause mortality and heart failure–related hospitalization. Results The groups were balanced at randomization. In the TARGET group, there was a greater proportion of responders at 6 months (70% vs. 55%, p = 0.031), giving an absolute difference in the primary endpoint of 15% (95% confidence interval: 2% to 28%). Compared with controls, TARGET patients had a higher clinical response (83% vs. 65%, p = 0.003) and lower rates of the combined endpoint (log-rank test, p = 0.031). Conclusions Compared with standard CRT treatment, the use of speckle-tracking echocardiography to the target LV lead placement yields significantly improved response and clinical status and lower rates of combined death and heart failure–related hospitalization. (Targeted Left Ventricular Lead Placement to Guide Cardiac Resynchronization Therapy [TARGET] study); ISRCTN19717943 )