European Heart Journal Advance Access originally published online on February 9, 2008
European Heart Journal 2008 29(5):684; doi:10.1093/eurheartj/ehn003
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Impact of left ventricular lead position in cardiac resynchronization therapy on left ventricular remodelling: a circumferential strain analysis based on 2D echocardiography
Department of Ultrasound
The First Affiliated Hospital
College of Medicine
Zhejiang University
#79, Qingchun Road
Hangzhou
People's Republic of China
Fax: +86 571 8723 6628
Email: zezhou_song{at}126.com
I read with great interest the study by Becker et al., 1 which confirmed that detailed analysis of the myocardial contraction sequence using circumferential strain imaging allows determination of the left ventricular (LV) lead position in cardiac resynchronization therapy (CRT) and that optimal LV lead position in CRT defined by circumferential strain analysis results in greater improvement in LV function and more LV reverse remodelling than non-optimal LV lead position. The methods and interpretation of the results, however, raise several concerns.
Current lead implantation strategies in CRT are anatomically driven, with little attention being paid to the functional characteristics of the segment underlying the lead. It is possible that this unpredictable response is a consequence of the LV lead being positioned on a structurally and functionally inappropriate site (i.e. akinetic or infarcted segment), which has impaired contraction and delayed electrical coupling to surrounding, non-scarred myocardium.2 Although the study by Arzola-Castaner et al.2 confirmed that LV lead proximity to an akinetic segment does not impact acute haemodynamic or 12-month clinical response to CRT, did LV lead proximity to an akinetic and latest segment result in greater improvement in LV function and more LV reverse remodelling than only LV lead position proximity to a latest segment? Did LV lead proximity to an akinetic and second latest segment result in greater improvement in LV function and more LV reverse remodelling than only LV lead position proximity to a latest segment?
The study by Riedlbauchová et al.3 confirmed that Midseptal positioning of the RV lead in CRT results in a significant reduction in LV end-diastolic diameter over 12 months of follow-up, suggesting that additional clinical benefit of cardiac resynchronization therapy can be achieved through proper placement of the right ventricular (RV) lead. In this study by Becker et al.,1 however, the RV leads were positioned conventionally. Did most optimization of LV and RV lead position collectively result in greater improvement in LV function and more LV reverse remodelling than only optimization of LV lead position? Could maximum benefit be obtained in patients with heart failure by most optimization of LV and RV lead position collectively and how could maximum benefit be obtained by most optimization of LV and right ventricular lead position collectively?
References
- Becker M, Kramann R, Franke A, Breithardt OA, Heussen N, Knachstedt C, Stellbrink C, Schauerte P, Kelm M, Hoffmann R. Impact of LV lead position in cardiac resynchronization therapy on LV remodelling: A circumferential strain analysis based on 2D echocardiography. Eur Heart J (2007) 28:1211–1220.
[Abstract/Free Full Text] - Arzola-Castaner D, Taub C, Heist E.K, Fan D, Haelewyn K, Mela TH, Picard MN, Ruskin JP, Singh J. LV lead proximity to an akinetic segment and impact on outcome of cardiac resynchronization therapy. J Cardiovasc Electrophysiol (2006) 17:623–627.[CrossRef][Web of Science][Medline]
- Riedlbauchová L,
ihák R, Byte
ník J, Van
ura V, Frídl P, Hoková L, Kautzner J. Optimization of right ventricular lead position in cardiac resynchronisation therapy. Eur J of Heart Fail (2006) 8:609–614.[CrossRef]
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