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Prediction of reverse remodeling in cardiac resynchronization therapy by acute changes in three-dimensional trajectory of pacing cathode pole in coronary sinus: preliminary results

Session Poster session 2

Speaker Corrado Tomasi

Congress : EHRA 2019

  • Topic : arrhythmias and device therapy
  • Sub-topic : Cardiac Resynchronization Therapy
  • Session type : Poster Session
  • FP Number : P1173

Authors : C Tomasi (Ravenna,IT), S Severi (Cesena,IT), F Zanon (Rovigo,IT), G Molon (Negrar,IT), A Corzani (Cesena,IT), A Rossillo (Vicenza,IT), M Biffi (Bologna,IT), G Zanotto (Legnago,IT), L Marcantoni (Rovigo,IT), A Costa (Negrar,IT), A Dal Monte (Ravenna,IT), L Lanzoni (Negrar,IT), G Piovaccari (Ravenna,IT), C Corsi (Cesena,IT)


C Tomasi1 , S Severi2 , F Zanon3 , G Molon4 , A Corzani5 , A Rossillo6 , M Biffi7 , G Zanotto8 , L Marcantoni3 , A Costa4 , A Dal Monte1 , L Lanzoni4 , G Piovaccari1 , C Corsi2 , 1Santa Maria delle Croci Hospital, Department of Cardiovascular - Ravenna - Italy , 2University of Bologna, Department DEIS - Cesena - Italy , 3General Hospital of Rovigo - Rovigo - Italy , 4Sacred Heart Hospital of Negrar - Negrar-Verona - Italy , 5Ospedale M. Bufalini - Cesena - Italy , 6San Bortolo Hospital - Vicenza - Italy , 7University Hospital Policlinic S. Orsola-Malpighi - Bologna - Italy , 8Legnago Hospital - Legnago - Italy ,


Background: In cardiac resynchronization therapy (CRT) patients, the coronary sinus (CS) lead pacing cathode movements have been proposed as a source of information about left ventricular (LV) mechanic response to CRT. An automated method for 3D reconstruction of CS lead’s pacing cathode trajectory (3DTJ) was described  by our group, and in a small exploratory study we found that trajectory’s geometry at biventricular pacing (BIV) start suddenly changed in CRT responders (R), becoming less eccentric and more multi-directional, as described by the ratio between its two major axes (S1/S2).

Purpose: The TRAJECTORIES study (Trajectory Changes Of Coronary Sinus Lead Tip And Cardiac Resynchronization Therapy Outcome, NCT02340546) is an observational study by seven Italian centers about  the prediction of CRT-induced LV reverse remodeling by means of the acute 3DTJ changes at CRT implant. Preliminary description and results are reported. 
Methods: In CRT implants with standard indications, stable CHF and regular ventricular rhythm,  a fluoroscopic sequence in two standard X-rays views of a few seconds was acquired immediately before (T-1) and after the start of BIV (T0). 3DTJ  at T-1 and T0 were reconstructed using a procedure to track the CS lead cathode pole throughout the cardiac cycle and  applying stereo-photogrammetric rules, and the mean 3DTJ over a cardiac cycle was computed. Geometric features and  shape of mean 3DTJ were then analyzed. Changes of S1/S2 (?S1/S2) between T-1 and T0 were compared with the volumetric response at six-month f.u: the percent negative variation of S1/S2 (?S1/S2<0), marking a more multi-directional shape of 3DTJ, was assumed to predict the response to CRT. Volumetric response was adjudicated by a core-lab using a cut-off reduction = 15% in echocardiographic LV end-systolic volume at f.u.. 
Results:  Out of 119 patients enrolled in 42 months, 39 pts ended f.u. (28 m; age 69±10) and 10 dropped–out. Fluoroscopies were acquired easily and 3DTJ were fully reconstructed. Patients baseline features were: ischemic heart disease (IHD)  24/39 pts; sinus rhythm 35/39 pts; upgrade from PM/ICD 9/39 pts; QRS morphology with LBBB 30/39, intraventricular aspecific delay 3 and  RV pace 6 pts;  LV ejection fraction (EF) 32±10%; QRS duration 162±26 ms. At f.u., volumetric R were 26/39 (66%). Concordance between ?S1/S2 (as either ?S1/S2<0 or ?S1/S2>0) and volumetric response was 79% overall (31/39), 92% in R (24/26), 61% in non-R (8/13). Non-concordant patients were older (73±8),  predominantly with IHD (6/8) and  mostly non-R (5/8), but  no differences in QRS and EF were found. The proposed  3DTJ metric showed sensitivity = 82%, specificity =72%;  positive predictive value = 88%, negative predictive value = 61%.
Conclusions: Metrics of 3DTJ seem promising  to acutely predict CS pacing site-specific response to CRT in long-term, above all in R. 3DTJ might depict aspects of  CRT delivery effects on LV mechanics.

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