Integration of electrical, structural, and anatomical imaging for the guidance of cardiac resynchronization therapy

Background: Placing the left ventricular (LV) lead at a site of late electrical activation remote from scar is desired for cardiac resynchronization therapy (CRT) response. Objective: The purpose of this study was to integrate electrocardiographic imaging (ECGi) with computed tomography (CT) derived coronary venous anatomy and delayed enhancement cardiac magnetic resonance imaging (DE-CMR) derived scar to reconstruct a pre-procedural roadmap for LV lead guidance in CRT. Methods: Three CRT candidates with focal scar defined by DE-CMR were prospectively included. Intrinsic body surface potentials measurements (BSPM) were carried out. Inverse reconstruction using the CT heart-torso geometry were used for ECGi. Meshes of the CT coronary veins, epicardium with ECGi activation times, and DE-CMR scar were integrated. Results: The ECGi-CT-CMR roadmap was used for CRT implantation in 2/3 patients. Placing the LV lead remote from scar was accomplished in 2/2 patients. Target veins from the ECGi-CT-CMR roadmap were located in a region of 80–105 ms electrical delay. Conclusion: ECGi-CT-CMR roadmaps can be used during CRT implantation to guide LV lead placement to a coronary vein remote from scar in a region of late electrical activation, possibly improving CRT.