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Europace Advance Access originally published online on April 16, 2009
Europace 2009 11(5):554-561; doi:10.1093/europace/eup076
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Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org

REVIEWS

Left ventricular lead placement in cardiac resynchronization therapy: where and how?

Fakhar Zaman Khan1, Munmohan Singh Virdee2, Simon Patrick Fynn2 and David Paul Dutka1,*

1 Addenbrooke's Hospital, Level 6 ACCI, Box 110, Hills Road, Cambridge CB2 2QQ, UK; 2 Papworth Hospital, Papworth Everard, Cambridge CB23 8RE, UK

Cardiac resynchronization therapy (CRT) offers proven benefit to patients with refractory symptomatic chronic heart failure (New York Heart Association Class III or IV), severe left ventricular (LV) systolic dysfunction (LV ejection fraction <35%), and LV dyssynchrony (QRS width >120 ms). Cardiac resynchronization therapy has the potential to improve survival and functional capacity, reduce hospital admissions, and promote LV reverse remodelling. Although difficult to truly evaluate, up to 30% of patients do not attain symptomatic benefit. Factors associated with a poor outcome include inappropriate patient selection, inadequate device programming, presence of myocardial scar, and suboptimal LV lead placement. Left ventricular dyssynchrony is an important determinant of CRT response, although at present no reliable single measure to identify patients beyond QRS width has been identified. In this review, we discuss the effect of LV lead placement to pace the region of maximal dyssynchrony, the impact of total scar burden on response, and the relationship between LV lead position and localized scar. Consideration is also given to prospectively defining placement of the LV lead including surgical epicardial lead positioning.

Key Words: Cardiac resynchronization therapy, Left ventricular lead position, Myocardial scar

* Corresponding author. Tel: +44 1223 762583, Fax: +44 1223 331505, Email: dpd24{at}medschl.cam.ac.uk

Manuscript submitted 21 November 2008. Accepted after revision 6 March 2009.


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