AIMS: Several studies have evaluated the use of electrically- or imaging-guided left ventricular (LV) lead placement in cardiac resynchronization therapy (CRT) recipients. We aimed to assess evidence for a guided strategy that targets LV lead position to the site of latest LV activation. METHODS AND RESULTS: A systematic review and meta-analysis was performed for randomized controlled trials (RCTs) until March 2023 that evaluated electrically- or imaging-guided LV lead positioning on clinical and echocardiographic outcomes. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization, and secondary endpoints were quality of life, 6-min walk test (6MWT), QRS duration, LV end-systolic volume, and LV ejection fraction. We included eight RCTs that comprised 1323 patients. Six RCTs compared guided strategy (n = 638) to routine (n = 468), and two RCTs compared different guiding strategies head-to-head: electrically- (n = 111) vs. imaging-guided (n = 106). Compared to routine, a guided strategy did not significantly reduce the risk of the primary endpoint after 12-24 (RR 0.83, 95% CI 0.52-1.33) months. A guided strategy was associated with slight improvement in 6MWT distance after 6 months of follow-up of absolute 18 (95% CI 6-30) m between groups, but not in remaining secondary endpoints. None of the secondary endpoints differed between the guided strategies. CONCLUSION: In this study, a CRT implantation strategy that targets the latest LV activation did not improve survival or reduce heart failure hospitalizations.

1st Department of Internal Medicine Cardiology and Angiology University Hospital Hradec Králové Czech Republic

Arrhythmia Section Skaane University Hospital Lund Sweden

Department of Cardiac Surgery Na Homolce Hospital Prague Czech Republic

Department of Cardiology Aalborg University Hospital Aalborg Denmark

Department of Cardiology Aarhus University Hospital Palle Juul Jensens Boulevard 99 8200 Aarhus N Denmark

Department of Cardiology Institute for Clinical and Experimental Medicine Prague Czech Republic

Department of Cardiology Kristianstad Hospital Kristianstad Sweden

Department of Clinical Medicine Aarhus University Palle Juul Jensens Boulevard 11 8200 Aarhus N Denmark

Diagnostic Center Silkeborg Regional Hospital Falkevej 1A 8600 Silkeborg Denmark

Faculty of Medicine Charles University Hradec Králové Czech Republic

Faculty of Medicine Hebrew University Jerusalem Israel

Heart and Vascular Institute Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA

Jesselson Integrated Heart Center Shaare Zedek Medical Center Jerusalem Israel

Leviev Heart Institute The Chaim Sheba Medical Center Tel Hashomer Israel

Sackler School of Medicine Tel Aviv University Tel Aviv Israel

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