Optimizing CRT Lead Placement Accuracy With CMR-Guided On-Screen Targeting: A Randomized Controlled Trial (ADVISE-CRT III).

Summary

In a multicenter RCT of 131 CRT candidates, CMR- and AI-guided on-screen targeting significantly increased LV lead placement in the intended activation target and reduced scar placement versus conventional implantation. Overall LVESV reduction did not differ significantly, but patients with myocardial scar achieved a greater LVESV reduction with image guidance.

Key Findings

• Target-area LV lead placement: 66.7% (image-guided) vs 29.2% (conventional), P<0.001
• Scar placement reduced: 7.1% vs 36.4%, P=0.006
• Greater mean LVESV reduction overall in image-guided group (43.2% vs 37.6%, P=0.166), significant benefit in myocardial scar subgroup (40.7% vs 27.7%, P=0.028)

Clinical Implications

Pre-procedural CMR and on-screen targeting can be integrated into CRT workflows to improve target-site placement, particularly in patients with myocardial scar, potentially enhancing remodeling.

Limitations

• Modest sample size may limit power to detect overall LVESV differences
• 6-month follow-up may be insufficient to capture hard clinical endpoints

Future Directions

Larger, longer-term trials should evaluate clinical endpoints (mortality, HF hospitalization), cost-effectiveness, and broader generalizability across health systems and device platforms.