Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery ofCardiac Resynchronization Therapy.
Real-Time X-MRI-Guided Left Ventricular Lead Implantation for Targeted Delivery ofCardiac Resynchronization Therapy.
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DOI：
10.1016/j.jacep.2017.01.018
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发表时间：
2017-08-01
期刊：
影响因子：
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通讯作者：
Rinaldi, Christopher Aldo
中科院分区：
文献类型：
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作者：
Behar, Jonathan M;Mountney, Peter;Rinaldi, Christopher Aldo
目的：本研究旨在测试专用集成软件平台的可行性，该平台可在联合心脏导管实验室和磁共振成像扫描仪套件（X-MRI）内真实的处理、分析和叠加心脏磁共振（CMR）数据，以指导左心室（LV）电极导线植入。背景：次优LV电极导线位置是心脏起搏治疗（CRT）反应不良的主要决定因素，最佳部位具有高度的患者特异性。起搏心肌瘢痕与较差的结局相关;相反，靶向最新机械激活（LMA）可能会改善结局。（年龄74 ± 5.1岁;纽约心脏协会功能分级：2.7 ± 0.4; 86%缺血性，射血分数27 ± 7.6%; QRS d：157 ± 19 ms）进行CMR，随后使用导出的瘢痕和不同步数据立即植入CRT，并在X-MRI套件中叠加到荧光透视上。快速LV分割能够实现详细的瘢痕量化、LMA节段的识别和心肌靶点的选择。在冠状静脉造影，CMR衍生的三维壳融合，使识别可行的静脉目标对着目标段LV lead placement.Results：该平台是成功的，在所有14例患者中，其中10（71%）起搏在pre-procedurally定义的目标段。与CMR确定的瘢痕区域起搏相比，CMR确定的目标节段（瘢痕外）起搏显示LV夺获阈值显著降低（平均差异：2.4 [1.5至3.2]; p< 0.001），起搏QRS持续时间缩短（平均差异：25 [15至34]; p< 0.001）。在5例（36%）后外侧壁有广泛瘢痕的患者中，CMR引导使电极导线成功输送到替代解剖学有利部位。辐射剂量和植入时间与历史对照组相似（p= NS）。结论：实时CMR引导的LV电极导线放置在单一临床环境中是可行和可实现的，并可能有助于优先选择LV电极导线放置部位。
OBJECTIVES: This study sought to test the feasibility of a purpose-built, integrated software platform to process, analyze, and overlay cardiac magnetic resonance (CMR) data in real time within a combined cardiac catheter laboratory and magnetic resonance imaging scanner suite (X-MRI) to guide left ventricular (LV) lead implantation.BACKGROUND: Suboptimal LV lead position is a major determinant of poor cardiac resynchronization therapy (CRT) response, and the optimal site is highly patient specific. Pacing myocardial scar is associated with poorer outcomes; conversely, targeting latest mechanical activation (LMA) may improve them.METHODS: Fourteen patients (age 74 ± 5.1 years; New York Heart Association functional class: 2.7 ± 0.4; 86% ischemic with ejection fraction 27 ± 7.6%; QRSd: 157 ± 19 ms) underwent CMR followed by immediate CRT implantation using derived scar and dyssynchrony data, overlaid onto fluoroscopy in an X-MRI suite. Rapid LV segmentation enabled detailed scar quantification, identification of LMA segments, and selection of myocardial targets. At coronary venography, the CMR-derived 3-dimensional shell was fused, enabling identification of viable venous targets subtended by target segments for LV lead placement.RESULTS: The platform was successful in all 14 patients, of whom 10 (71%) were paced in pre-procedurally defined target segments. Pacing in CMR-defined target segments (out of scar) showed a significant decrease in the LV capture threshold (mean difference: 2.4 [1.5 to 3.2]; p< 0.001) and shorter paced QRS duration (mean difference: 25 [15 to 34]; p< 0.001) compared with pacing in areas of CMR determined scar. In 5 (36%) patients with extensive scar in the posterolateral wall, CMR guidance enabled successful lead delivery in an alternative anatomically favorable site. Radiation dose and implant times were similar to historical controls (p= NS).CONCLUSIONS: Real-time CMR-guided LV lead placement is feasible and achievable in a single clinical setting andmayprove helpful to preferentially select sites for LV lead placement.