Procedural Success of Left Ventricular Lead Placement for Cardiac Resynchronization Therapy: A Meta-Analysis
James H P Gamble1, Neil Herring1, Matthew Ginks1
1Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, United Kingdom.
Insights
Transvenous left ventricular lead placement for cardiac resynchronization therapy (CRT) has become more successful over time. Recent failures are increasingly due to unsuitable coronary venous anatomy, not procedural difficulty.
Area of Science:
- Cardiology
- Medical Devices
- Interventional Procedures
Background:
- Cardiac resynchronization therapy (CRT) improves outcomes in select patients.
- Left ventricular (LV) lead placement via the coronary sinus (CS) is technically demanding.
Purpose of the Study:
- To evaluate historical and contemporary success rates of transvenous LV lead placement for CRT.
- To analyze changes in success rates and reasons for failure over time.
Main Methods:
- A meta-analysis of 164 studies involving 29,503 patients was performed.
- Literature search identified studies reporting LV lead placement success rates via the CS route.
Main Results:
- Overall LV lead implantation failure rate was 3.6%.
- Failure rates significantly decreased from 5.4% before 2005 to 2.4% from 2005 onward (p < 0.001).
- Reasons for failure shifted from CS cannulation issues to unsuitable coronary venous anatomy.
Conclusions:
- Transvenous LV lead placement success for CRT has improved significantly.
- Unsuitable coronary venous anatomy is an increasing cause of lead placement failure.
Objectives:
The goal of this study was to assess the contemporary and historical success rates of transvenous left ventricular (LV) lead placement for cardiac resynchronization therapy (CRT), their change over time, and the reasons for failure.
Background:
In selected patients, CRT improves morbidity and mortality, but the placement of the LV lead can be technically challenging.
Methods:
A literature search was used to identify all studies reporting success rates of LV lead placement for CRT via the coronary sinus (CS) route. A total of 164 studies were identified, and a meta-analysis was performed.
Results:
The studies included 29,503 patients: 74% (95% confidence interval [CI]: 72% to 76%) were male; their mean age was 66 years (95% CI: 65 to 67); their mean New York Heart Association functional class was 2.8 (95% CI: 2.7 to 2.9); the mean LV ejection fraction was 26% (95% CI: 25% to 28%); and the mean QRS duration was 155 ms (95% CI: 150 to 160). The overall rate of failure of implantation of an LV lead was 3.6% (95% CI: 3.1 to 4.3). The rate of failure in studies commencing before 2005 was 5.4% (95% CI: 4.4% to 6.5%), and from 2005 onward it was 2.4% (95% CI: 1.9% to 3.1%; p < 0.001). Causes of failure (reported for 39% of failures) also changed over time. Failure to cannulate and navigate the CS decreased from 53% to 30% (p = 0.01), and the absence of any suitable, acceptable vein increased from 39% to 64% (p = 0.007). The proportion of leads in a lateral or posterolateral final position (reported for 26% of leads) increased from 66% to 82% (p = 0.004).
Conclusions:
The reported rate of failure to place an LV lead via the CS has decreased steadily over time. A greater proportion of failures in recent studies are due to coronary venous anatomy that is unsuitable for this technique.
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