Outcomes of Cardiac Resynchronization Therapy with Image-Guided Left Ventricular Lead Placement at the Site of Latest Mechanical Activation: A Systematic Review and Meta-Analysis.



To assess evidence for an image-guided approach for cardiac resynchronization therapy (CRT) that targets left ventricular (LV) lead placement at the segment of latest mechanical activation.


A systematic review of EMBASE and PubMed was performed for randomized controlled trials (RCTs) and prospective observational studies from October 2008 through October 2020 that compared an image-guided CRT approach with a non-image-guided approach for LV lead placement. Meta-analyses were performed to assess the association between the image-guided approach and NYHA class improvement or changes in end-systolic volume (LVESV), end-diastolic volume (LVEDV), and ejection fraction (LVEF).


From 5897 citations, 5 RCTs including 818 patients (426 image-guided and 392 non-image-guided) were identified. The mean age ranged from 66 to 71 years, 76% were male, and 53% had ischemic cardiomyopathy. Speckle tracking echocardiography was the primary image-guided method in all studies. LV lead placement within the segment of the latest mechanical activation (concordant) was achieved in the image-guided arm in 45% of the evaluable patients. There was a statistically significant improvement in the NYHA class at 6 months (odds ratio 1.66; 95% confidence interval (CI) [1.02, 2.69]) with the image-guided approach, but no statistically significant change in LVESV (MD -7.1%; 95% CI [-16.0, 1.8]), LVEDV (MD -5.2%; 95% CI [-15.8, 5.4]), or LVEF (MD 0.68; 95% CI [-4.36, 5.73]) versus the non-image-guided approach.


The image-guided CRT approach was associated with improvement in the NYHA class but not echocardiographic measures, possibly due to the small sample size and a low rate of concordant LV lead placement despite using the image-guided approach. Therefore, our meta-analysis was not able to identify consistent improvement in CRT outcomes with an image-guided approach.





Published Version (Please cite this version)


Publication Info

Allen LaPointe, Nancy M, Fatima Ali-Ahmed, Frederik Dalgaard, Andrzej S Kosinski, Gillian Sanders Schmidler and Sana M Al-Khatib (2022). Outcomes of Cardiac Resynchronization Therapy with Image-Guided Left Ventricular Lead Placement at the Site of Latest Mechanical Activation: A Systematic Review and Meta-Analysis. Journal of interventional cardiology, 2022. p. 6285894. 10.1155/2022/6285894 Retrieved from https://hdl.handle.net/10161/25396.

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Allen LaPointe

Nancy Marie Allen LaPointe

Adjunct Associate Professor in the Department of Medicine

Dr. Allen LaPointe is an Adjunct Associate Professor in Medicine and Faculty Fellow at the Duke-Margolis Center for Health Policy at Duke University.  She is a researcher and cardiovascular clinical pharmacist with extensive experience in health outcomes and health services research, evidence synthesis, and the protection of human research subjects.  Her clinical and research work have been focused on patient safety, predominately in patients with cardiovascular disease.  This includes work in reducing medication errors, improving medication adherence, safely and effectively translating evidence into clinical practice, comparing safety and effectiveness of therapeutics, evaluating risk communication and mitigation strategies, and exploring the interface between health policy and patient safety.  


Andrzej Stanislaw Kosinski

Professor of Biostatistics & Bioinformatics

Statistical methodology for evaluation of diagnostic tests
Adjustment for misclassification
Missing data
Clinical trials
Analysis of cardiovascular and stroke data


Sana Mustapha Al-Khatib

Professor of Medicine

Dr. Sana M. Al-Khatib is a tenured Professor of Medicine at Duke University Medical Center, a board-certified clinical electrophysiologist and an experienced clinical researcher in cardiac arrhythmias.  She is currently the Director of the Fellowship Program at the Duke Clinical Research Institute.  As a graduate of the NIH-funded Clinical Research Training Program, she is one of a few electrophysiologists nationwide with expertise in quantitative research methods. Her clinical expertise is in sudden cardiac death prevention, atrial fibrillation and ventricular arrhythmias, and implantable cardiac devices. Her research expertise lies in the design and conduct of clinical trials, outcomes research, and cost-effectiveness analyses. She is a recipient of a National Heart, Lung and Blood Institute’s R-01 grant titled “Implantable Cardioverter Defibrillator Therapy in Patients with Heart Failure” (2009-2013) and of an American Heart Association Career Development Award (2002-2006). She is a Co-Principal Investigator on an NHLBI-funded T-32 Postdoctoral Training in Cardiovascular Clinical Research and is a co-investigator on several NIH-funded projects. She has more than 350 publications in peer-reviewed journals. She has established several collaborative research efforts both within and outside her institution. The goals of these collaborations are to synergize efforts aimed at improving the survival and quality of life of patients at risk for sudden cardiac death and those with atrial and ventricular arrhythmias through clinical trials and outcomes-based research and to evaluate study design and data analysis in order to improve the quality of research done in these arenas. Dr. Al-Khatib is a Senior Associate Editor for Circulation and is on the Editorial Board for Circulation: Arrhythmia and Electrophysiology, Heart Rhythm, Journal of Cardiovascular Electrophysiology, JACC:EP, the Cardiovascular Digital Health Journal, and the American Heart Journal. Dr. Al-Khatib has served on multiple national committees including the Heart Rhythm Society Board of Trustees (current), the Heart Rhythm Society Finance Committee (current), the Heart Rhythm Society Audit Committee (current), the Heart Rhythm Society Health Policy committee (past), the Heart Rhythm Society Legislative subcommittee (past), and the Heart Rhythm Society Program Planning committee (past). She chaired the 2017 AHA/ACC/HRS Guideline for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. 

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