A novel approach for left ventricular lead placement in cardiac resynchronization therapy: Intraprocedural integration of coronary venous electroanatomic mapping with delayed enhancement cardiac magnetic resonance imaging

A novel approach for left ventricular lead placement in cardiac resynchronization therapy: Intraprocedural integration of coronary venous electroanatomic mapping with delayed enhancement cardiac magnetic resonance imaging

Author’s Accepted Manuscript A novel approach for left ventricular lead placement in cardiac resynchronization therapy: Intra-procedural integration o...

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Author’s Accepted Manuscript A novel approach for left ventricular lead placement in cardiac resynchronization therapy: Intra-procedural integration of coronary venous electro-anatomic mapping with delayed enhancement cardiac magnetic resonance imaging Uyên Châu Nguyên, Masih Mafi-Rad, Jean-Paul Aben, Martijn W. Smulders, Elien B. Engels, Antonius M.W. van Stipdonk, Justin G.L.M. Luermans, Sebastiaan C.A.M. Bekkers, Frits W. Prinzen, Kevin Vernooy

PII: DOI: Reference:

www.elsevier.com/locate/buildenv

S1547-5271(16)30798-6 http://dx.doi.org/10.1016/j.hrthm.2016.09.015 HRTHM6865

To appear in: Heart Rhythm Received date: 2 August 2016 Cite this article as: Uyên Châu Nguyên, Masih Mafi-Rad, Jean-Paul Aben, Martijn W. Smulders, Elien B. Engels, Antonius M.W. van Stipdonk, Justin G.L.M. Luermans, Sebastiaan C.A.M. Bekkers, Frits W. Prinzen and Kevin Vernooy, A novel approach for left ventricular lead placement in cardiac resynchronization therapy: Intra-procedural integration of coronary venous electro-anatomic mapping with delayed enhancement cardiac magnetic resonance imaging, Heart Rhythm, http://dx.doi.org/10.1016/j.hrthm.2016.09.015 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

A novel approach for left ventricular lead placement in cardiac

resynchronization

therapy:

intraprocedural

integration of coronary venous electroanatomic mapping with delayed enhancement cardiac magnetic resonance imaging  ›² ŠŸ— ‰—›²ǡ ǡ …ǡͳ ƒ•‹Š ƒˆ‹Ǧƒ†ǡ ǡʹ ‡ƒǦƒ—Ž „‡ǡ …ǡ͵ ƒ”–‹Œ Ǥ —Ž†‡”•ǡ ǡʹ Ž‹‡ Ǥ ‰‡Ž•ǡ …ǡͳ –‘‹—• ǤǤ ˜ƒ –‹’†‘ǡ ǡʹ —•–‹ ǤǤǤ —‡”ƒ•ǡǡŠǡʹ‡„ƒ•–‹ƒƒǤǤǤ‡‡”•ǡǡŠǡʹ ”‹–•Ǥ”‹œ‡ǡŠǡͳ‡˜‹ ‡”‘‘›ǡǡŠʹ  1DepartmentofPhysiology,CardiovascularResearchInstituteMaastricht, 2Departmentof

Cardiology, Maastricht University Medical Center, 3Pie Medical Imaging, Maastricht, the Netherlands  Correspondenceto: ›² ŠŸ— ‰—›²ǡ ‡’ƒ”–‡– ‘ˆ Š›•‹‘Ž‘‰›ǡ ƒ”†‹‘˜ƒ•…—Žƒ” ‡•‡ƒ”…Š •–‹–—–‡ ƒƒ•–”‹…Š–ǡ Ǧ‘š ͸ͳ͸ǡ ͸ʹͲͲǡ –Š‡ ‡–Š‡”Žƒ†•Ǥ ‡ŽǣΪ͵ͳǦͶ͵Ǧ͵ͺͺͳʹͲͲǢ ˆƒšǣΪ͵ͳǦͶ͵Ǧ ͵ͺͺͶͳ͸͸Ǥƒ‹Žǣ…Šƒ—ʹ͹̷‰ƒ‹ŽǤ…‘  Shorttitle: Ž‡ƒ†’Žƒ…‡‡–„›Ǧˆ—•‡†™‹–Š…‘”‘ƒ”›˜‡‘—•  Wordcount:Ͷͻ͵ʹ  Conflict of interest: ǤǤǤ Šƒ• ”‡…‡‹˜‡† ”‡•‡ƒ”…Š ‰”ƒ–• ˆ”‘ ‡†–”‘‹…ǡ –Ǥ —†‡ ‡†‹…ƒŽǡ‘”‹ǡǡƒ†‹‘–”‘‹ǤǤǤ”‡…‡‹˜‡†”‡•‡ƒ”…Š‰”ƒ–•ˆ”‘‡†–”‘‹…ƒ†–Ǥ

—†‡ ‡†‹…ƒŽǤ ǤǤ ‹• ƒ ‡’Ž‘›‡‡ ‘ˆ ‹‡ ‡†‹…ƒŽ ƒ‰‹‰Ǥ ǤǤǤ ”‡…‡‹˜‡† ƒ ”‡•‡ƒ”…Š ‰”ƒ– ˆ”‘ –Š‡ ‡–Š‡”Žƒ†• ‡ƒ”– ‘—†ƒ–‹‘Ǥ ǤǤǤ ”‡…‡‹˜‡† ƒ ‘‘–•–”ƒ ƒŽ‡– ‡ŽŽ‘™•Š‹’ ‰”ƒ– ˆ”‘ ƒƒ•–”‹…Š– ‹˜‡”•‹–›Ǥ ŽŽ ‘–Š‡” ƒ—–Š‘”• †‡…Žƒ”‡ ‘ …‘ˆŽ‹…– ‘ˆ ‹–‡”‡•–Ǥ ͳ 

Abstract Background:Žƒ…‹‰ –Š‡ Ž‡ˆ– ˜‡–”‹…—Žƒ” ȋȌ Ž‡ƒ† ƒ–ƒ •‹–‡ ‘ˆ Žƒ–‡ ‡Ž‡…–”‹…ƒŽ ƒ…–‹˜ƒ–‹‘ ”‡‘–‡ ˆ”‘ •…ƒ” ‹• †‡•‹”‡† –‘ ‹’”‘˜‡ …ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’› ȋȌ ”‡•’‘•‡Ǥ Objective:‘‹–‡‰”ƒ–‡…‘”‘ƒ”›˜‡‘—•‡Ž‡…–”‘Ǧƒƒ–‘‹…ƒ’’‹‰ȋȌ™‹–Š†‡Žƒ›‡† ‡Šƒ…‡‡– …ƒ”†‹ƒ… ƒ‰‡–‹… ”‡•‘ƒ…‡ ȋǦȌ ‡ƒ„Ž‹‰  Ž‡ƒ† ‰—‹†ƒ…‡ –‘ –Š‡ Žƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹”‡‘–‡ˆ”‘•…ƒ”Ǥ Methods:‹‰Š–‡‡  …ƒ†‹†ƒ–‡• ™‹–Š ˆ‘…ƒŽ •…ƒ” ‘ Ǧ ™‡”‡ ’”‘•’‡…–‹˜‡Ž› ‹…Ž—†‡†ǤǦ‹ƒ‰‡•™‡”‡•‡‹Ǧƒ—–‘ƒ–‹…ƒŽŽ›ƒƒŽ›œ‡†Ǥ‘”‘ƒ”›˜‡‘—•™ƒ• ’‡”ˆ‘”‡†‹–”ƒǦ’”‘…‡†—”ƒŽŽ›ƒ†‹–‡‰”ƒ–‡†™‹–ŠǦ–‘‰—‹†‡Ž‡ƒ†’Žƒ…‡‡– ”‡ƒŽǦ–‹‡Ǥ ƒ‰‡ ‹–‡‰”ƒ–‹‘ ƒ……—”ƒ…› ƒ† ‡Ž‡…–”‘‰”ƒ ȋ Ȍ ’ƒ”ƒ‡–‡”• ™‡”‡ ‡˜ƒŽ—ƒ–‡†‘ˆˆŽ‹‡Ǥ Results: –‡‰”ƒ–‹‘ ‘ˆ  ƒ† Ǧ ™ƒ• ƒ…Š‹‡˜‡† —•‹‰ ͺǤͻάʹǤͺ ƒƒ–‘‹…ƒŽ Žƒ†ƒ”• ƒ† ™‹–Š ƒ ƒ……—”ƒ…› ‘ˆ ͶǤ͹άͳǤͳ ȋ‡ƒάȌǤ ƒš‹ƒŽ ‡Ž‡…–”‹…ƒŽ †‡Žƒ› ”ƒ‰‡† „‡–™‡‡ ͹ʹΫͳͻ͹• ȋͷ͹Ϋͳͳ͵Ψ ‘ˆ  †—”ƒ–‹‘Ȍ ƒ† ™ƒ• Š‡–‡”‘‰‡‡‘—•Ž› Ž‘…ƒ–‡† ƒ‘‰ ‹†‹˜‹†—ƒŽ•Ǥ  –™‡Ž˜‡ ’ƒ–‹‡–• –Š‡ Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ™ƒ• Ž‘…ƒ–‡† ‘—–•‹†‡ •…ƒ” ƒ† ’Žƒ…‹‰ –Š‡  Ž‡ƒ† ‹ –Š‡ Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ”‡‘–‡ ˆ”‘ •…ƒ” ™ƒ• ƒ……‘’Ž‹•Š‡†‹–‡ƒ†’”‘Š‹„‹–‡†‹–™‘’ƒ–‹‡–•Ǥ –Š‡‘–Š‡”•‹š’ƒ–‹‡–•–Š‡Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ™ƒ• Ž‘…ƒ–‡† ‹ •…ƒ” ƒ† –ƒ”‰‡–‹‰ ƒŽ–‡”ƒ–‹˜‡ ˜‡‹• ™ƒ• …‘•‹†‡”‡†Ǥ ‹’‘Žƒ” ˜‘Ž–ƒ‰‡• ™‡”‡ ‘ ƒ˜‡”ƒ‰‡ Ž‘™‡” ‹ •…ƒ” …‘’ƒ”‡† –‘ ‘Ǧ•…ƒ” ȋ͸Ǥ͹ͳά͵ǤͶͷ ˜•Ǥ ͺǤͳͺάͶǤͲʹȋ‡†‹ƒά ȌǡpδͲǤͲͲͳȌǡ„—–…‘””‡Žƒ–‡†™‡ƒŽ›™‹–ŠǦ•…ƒ”‡š–‡– ȋǦͲǤͳ͸ͳǡpδͲǤͲͲͳȌǡƒ†˜ƒ”‹‡†™‹†‡Ž›ƒ‘‰‹†‹˜‹†—ƒŽ’ƒ–‹‡–•Ǥ Conclusion: –‡‰”ƒ–‹‘‘ˆ…‘”‘ƒ”›˜‡‘—•™‹–ŠǦ…ƒ„‡—•‡††—”‹‰ ‹’Žƒ–ƒ–‹‘–‘‰—‹†‡Ž‡ƒ†’Žƒ…‡‡––‘–Š‡Žƒ–‡•– ƒ…–‹˜ƒ–‡†˜‡‹”‡‘–‡ ˆ”‘•…ƒ”ǡ ’‘••‹„Ž›‹’”‘˜‹‰Ǥ

 

Keywords ǡŽ‡ƒ†’Žƒ…‡‡–ǡ‡Ž‡…–”‘Ǧƒƒ–‘‹…ƒ’’‹‰ǡ†‡Žƒ›‡†‡Šƒ…‡‡–Ǥ  

 ʹ 

Introduction ‡•’‹–‡–Š‡’”‘˜‡‡ˆˆ‡…–‹˜‡‡••‘ˆ…ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘–Š‡”ƒ’›ȋȌǡ–Š‡ ‹••—‡ ”‡ƒ‹• –Šƒ– ƒ •—„•–ƒ–‹ƒŽ ’”‘’‘”–‹‘ ‘ˆ ’ƒ–‹‡–• ˆƒ‹Ž• –‘ „‡‡ˆ‹–Ǥͳ ƒ”– ‘ˆ –Š‹• ”‡†—…‡† „‡‡ˆ‹–Šƒ• „‡‡ƒ––”‹„—–‡†–‘ƒ•—„‘’–‹ƒŽŽ‡ˆ–˜‡–”‹…—Žƒ”ȋȌŽ‡ƒ† ’‘•‹–‹‘Ǥʹ ‡…‡– •–—†‹‡• Šƒ˜‡ •—‰‰‡•–‡† –Šƒ– ’‘•‹–‹‘‹‰ –Š‡  Ž‡ƒ† ‹ –Š‡ ”‡‰‹‘ ‘ˆ Žƒ–‡•– ‡Ž‡…–”‹…ƒŽ ƒ…–‹˜ƒ–‹‘ ’”‘˜‹†‡• •—’‡”‹‘” ‘—–…‘‡ …‘’ƒ”‡† ™‹–Š –Š‡ …‘˜‡–‹‘ƒŽ ƒƒ–‘‹…ƒŽ ƒ’’”‘ƒ…ŠǤ͵  –Š‡ ‘–Š‡” Šƒ†ǡ ’ƒ…‹‰ ‹ ‘” ‡ƒ” ›‘…ƒ”†‹ƒŽ •…ƒ” †‹‹‹•Š‡• –Š‡ ‡ˆˆ‡…–‹˜‡‡•• ‘ˆ ǤͶ ††‹–‹‘ƒŽŽ›ǡ …‘’—–‡” •‹—Žƒ–‹‘• Šƒ˜‡ †‡‘•–”ƒ–‡† –Šƒ– –Š‡ ƒš‹ƒŽ Š‡‘†›ƒ‹… ‡ˆˆ‡…– ‹• ƒ…Š‹‡˜‡† ™Š‡ –Š‡  Ž‡ƒ† ‹• Ž‘…ƒ–‡† ƒ• ”‡‘–‡ ƒ• ’‘••‹„Ž‡ ˆ”‘•…ƒ”Ǥͷ Š—•ǡ’Žƒ…‹‰–Š‡ Ž‡ƒ†‹–Š‡‡Ž‡…–”‹…ƒŽŽ›Žƒ–‡•– ƒ…–‹˜ƒ–‡† ”‡‰‹‘ ”‡‘–‡ˆ”‘•…ƒ”‹•†‡•‹”‡†–‘‹’”‘˜‡”‡•’‘•‡Ǥ ‘”‘ƒ”› ˜‡‘—• ‡Ž‡…–”‘Ǧƒƒ–‘‹… ƒ’’‹‰ ȋȌ …ƒ ƒ••‡•• –Š‡ ‡Ž‡…–”‹…ƒŽ ƒ…–‹˜ƒ–‹‘ ’ƒ––‡” ‘ˆ –Š‡ …‘”‘ƒ”› ˜‡‘—• •›•–‡ †—”‹‰  ‹’Žƒ–ƒ–‹‘ ƒ† ‰—‹†‡•  Ž‡ƒ† ’Žƒ…‡‡– –‘ –Š‡ Žƒ–‡•– ƒ…–‹˜ƒ–‹‘ ”‡‰‹‘Ǥ͸ ‡Žƒ›‡† ‡Šƒ…‡‡– …ƒ”†‹ƒ… ƒ‰‡–‹… ”‡•‘ƒ…‡ ȋǦȌ ‹• –Š‡ ‰‘Ž† •–ƒ†ƒ”† ˆ‘” ‡˜ƒŽ—ƒ–‹‰ –Š‡ Ž‘…ƒ–‹‘ ƒ† ‡š–‡– ‘ˆ ›‘…ƒ”†‹ƒŽ •…ƒ”Ǥ –‡‰”ƒ–‹‘ ‘ˆ Ǧ ‹ƒ‰‹‰ ™‹–Š …‘”‘ƒ”› ˜‡‘—•  –ƒ‡• ƒ†˜ƒ–ƒ‰‡‘ˆ–Š‡„‡‡ˆ‹–‘ˆ„‘–Š‘†ƒŽ‹–‹‡•„›‡ƒ„Ž‹‰͵˜‹•—ƒŽ‹œƒ–‹‘‘ˆ–Š‡Ž‘…ƒ–‹‘ ‘ˆ–Š‡Žƒ–‡•–ƒ…–‹˜ƒ–‡†”‡‰‹‘™‹–Š‹–Š‡…‘”‘ƒ”›˜‡‹•™‹–Š”‡•’‡…––‘–Š‡†‹•–”‹„—–‹‘ ‘ˆ•…ƒ”ǤŠ‡‘„Œ‡…–‹˜‡•‘ˆ–Š‡’”‡•‡–•–—†›™‡”‡ȋͳȌ–‘‹–‡‰”ƒ–‡’”‡Ǧ’”‘…‡†—”ƒŽ͵•…ƒ” •‡‰‡–ƒ–‹‘ˆ”‘Ǧ‹ƒ‰‡•™‹–Š‹–”ƒǦ’”‘…‡†—”ƒŽ…‘”‘ƒ”›˜‡‘—•ǡȋʹȌ–‘ —•‡–Š‡‹–‡‰”ƒ–‡†͵‹ƒ‰‡ƒ•ƒ”‡ƒŽǦ–‹‡ƒ˜‹‰ƒ–‹‘ƒŽ–‘‘Ž–‘‰—‹†‡Ž‡ƒ†’Žƒ…‡‡– –‘–Š‡Žƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹”‡‘–‡ˆ”‘•…ƒ”†—”‹‰‹’Žƒ–ƒ–‹‘ǡȋ͵Ȍ–‘ƒ••‡••–Š‡ ƒ……—”ƒ…› ‘ˆ –Š‹• ‹–‡‰”ƒ–‹‘ǡ ƒ† ͶȌ –‘ …‘’ƒ”‡ ‡Ž‡…–”‘‰”ƒ ȋ Ȍ —‹’‘Žƒ” ˜‘Ž–ƒ‰‡• ˆ”‘•…ƒ”™‹–Š‘”ƒŽ›‘…ƒ”†‹—Ǥ

Methods Studypopulation ‘•‡…—–‹˜‡’ƒ–‹‡–• ”‡ˆ‡””‡† ˆ‘”  †‡˜‹…‡ ‹’Žƒ–ƒ–‹‘ ™‹–Š ƒ …Žƒ•• Ȁ ƒ ‹†‹…ƒ–‹‘ ƒ……‘”†‹‰ –‘ —”‘’‡ƒ ‘…‹‡–› ‘ˆ ƒ”†‹‘Ž‘‰› ‰—‹†‡Ž‹‡•͹ ƒ† ˆ‘…ƒŽ •…ƒ” ‘ ’”‡Ǧ ’”‘…‡†—”ƒŽ Ǧ ™‡”‡ ’”‘•’‡…–‹˜‡Ž› ‡”‘ŽŽ‡†Ǥ Š‡ ‹•–‹–—–‹‘ƒŽ ‡˜‹‡™ ‘ƒ”† ƒ’’”‘˜‡†–Š‡•–—†›’”‘–‘…‘ŽǤ

͵ 

Cardiacmagneticresonanceimagingandanalysis  ‹ƒ‰‡• ™‡”‡ ƒ…“—‹”‡† †—”‹‰ —Ž–‹’Ž‡ „”‡ƒ–ŠǦŠ‘Ž†• ‘ ƒ ͳǤͷȀ͵ǤͲǦ‡•Žƒ •›•–‡ ȋŠ‹Ž‹’• –‡”ƒȀ ‰‡‹ƒȀ…Š‹‡˜ƒǡ ‡•–Ȍ ™‹–Š ƒ …ƒ”†‹ƒ… •‘ˆ–™ƒ”‡ ’ƒ…ƒ‰‡Ǥ ˆ–‡” •—”˜‡› ‹ƒ‰‡• ƒ† …‘‹Ž …ƒŽ‹„”ƒ–‹‘ǡ  Ǧ‰ƒ–‡† …‹‡ ‹ƒ‰‡• ™‡”‡ ‘„–ƒ‹‡† —•‹‰ ƒ •–‡ƒ†›Ǧ•–ƒ–‡ ˆ”‡‡’”‡…‡••‹‘•‡“—‡…‡ȋ•Ž‹…‡–Š‹…‡••͸Ǧͺǡ•Ž‹…‡‰ƒ’͸ǦͳͲǡȀʹǤͻǦͶǤ͵ȀͳǤͷǦ ͳǤ͹•ǡ ˆŽ‹’ ƒ‰Ž‡ ͷͲǦͺͲιǡ  ͵ʹͲǦ͵ͺͶǡ ƒ–”‹š ʹͷ͸Ǧͷ͸Ͳέʹͷ͸Ǧͷ͸ͲȌ ‹ –Š‡ ˆ‘ŽŽ‘™‹‰ ‘”‹‡–ƒ–‹‘•ǣ •‹‰Ž‡ •Ž‹…‡ –™‘Ǧ…Šƒ„‡”ǡ –Š”‡‡Ǧ…Šƒ„‡”ǡ ˆ‘—”Ǧ…Šƒ„‡”ǡ ƒ† ƒ •Š‘”–Ǧƒš‹• …‘˜‡”‹‰ –Š‡ ‡–‹”‡ Ǥ —„•‡“—‡–Ž›ǡ ƒ ʹ ‹˜‡”•‹‘ ”‡…‘˜‡”› ‰”ƒ†‹‡– ‡…Š‘ •‡“—‡…‡ ™ƒ•—•‡†ˆ‘”†‡Žƒ›‡†‡Šƒ…‡‡–ȋȀͶǤͲǦ͸ǤͳȀͳǤʹǦ͵ǤͲ•ǡ•Ž‹…‡–Š‹…‡••͹ǦͳͲǡ ˆŽ‹’ ƒ‰Ž‡ ͳͲǦʹͷιǡ  ͵ͲͲǦ͵ͺͶǡ ƒ–”‹š ʹͶͲǦͷ͹͸έʹͶͲǦͷ͹͸Ȍǡ ͳͲ‹ ƒˆ–‡” ƒ ‹–”ƒ˜‡‘—• „‘Ž—• ‘ˆ ͲǤͳͷ‘ŽȀ‰ ‰ƒ†‘„—–”‘Ž ȋ ƒ†‘˜‹•– ƒ›‡” …Š‡”‹‰ Šƒ”ƒǡ —”‹…ŠȌǤ  ‹ƒ‰‡• ™‡”‡ ƒƒŽ›œ‡† ‘ˆˆǦŽ‹‡ —•‹‰ …—•–‘‹œ‡† •‘ˆ–™ƒ”‡ ȋ ͵ǤͶǡ ‹‡ ‡†‹…ƒŽ ƒ‰‹‰ǡ ƒƒ•–”‹…Š–ȌǤ  •‹‰Ž‡ ‘„•‡”˜‡” ’‡”ˆ‘”‡† –Š‡  ƒƒŽ›•‹• —†‡” •—’‡”˜‹•‹‘ ‘ˆ ƒ ‡š’‡”‹‡…‡†  ”‡ƒ†‡”Ǥ †‘…ƒ”†‹ƒŽ ƒ† ‡’‹…ƒ”†‹ƒŽ …‘–‘—”• ™‡”‡ ƒ—ƒŽŽ›–”ƒ…‡†‹‡†Ǧ†‹ƒ•–‘Ž‹…ƒ†‡†Ǧ•›•–‘Ž‹…•Š‘”–Ǧƒš‹•…‹‡‹ƒ‰‡•–‘†‡–‡”‹‡ ˆ—…–‹‘ƒŽ ’ƒ”ƒ‡–‡”•ǡ ƒ† ‹ •Š‘”–Ǧƒš‹• Ǧ ‹ƒ‰‡•ǡ ƒ• •Š‘™ ‹ ‹‰—”‡ ͳǡ –‘‰‡–Š‡”™‹–Š–Š‡…‘”‘ƒ”›•‹—•ȋȌ–‘…‘•–”—…–ƒ͵…ƒ”†‹ƒ…‘†‡ŽǤ…ƒ”™ƒ••‡‹Ǧ ƒ—–‘ƒ–‹…ƒŽŽ›“—ƒ–‹ˆ‹‡†—•‹‰–Š‡ˆ—ŽŽǦ™‹†–ŠǦŠƒŽˆƒš‹—‡–Š‘†„›’”‘˜‹†‹‰ƒ•‡‡† ’‘‹–‹–Š‡Š›’‡”‡Šƒ…‡†”‡‰‹‘ƒ†ƒ’’Ž›‹‰ƒ—Ž–‹Ǧ’ƒ••”‡‰‹‘Ǧ‰”‘™‹‰ƒŽ‰‘”‹–ŠǤͺ ƒ…Š Ǧ •Š‘”–Ǧƒš‹• •Ž‹…‡ ™ƒ• •—„†‹˜‹†‡† ‹ ͻ͸Ǧ•‡‰‡–• ƒ† •…ƒ” ˆ”ƒ…–‹‘ ™ƒ• …‘’—–‡† ˆ‘” ‡ƒ…Š •‡‰‡–Ǥ ”ƒ…‡† Ǧ …‘–‘—”• ™‡”‡ …‘˜‡”–‡† ‹–‘ ͵ •—”ˆƒ…‡ ‡•Š‡•ǡƒ••Š‘™‹ ‹‰—”‡ͳǡ—•‹‰…—•–‘•‘ˆ–™ƒ”‡’”‘‰”ƒ‡†‹”ʹͲͳ͵ƒ ȋƒ–Š‘”•ǡƒ–‹…ǡȌ™‹–Šƒˆ‹Ž‡ˆ‘”ƒ––Šƒ–…‘—Ž†„‡‹’‘”–‡†‹–‘‹–‡ƒ˜ȋ–Ǥ

—†‡‡†‹…ƒŽǡ–Ǥƒ—ŽǡȌǤ

Electroanatomicmapping –”ƒǦ’”‘…‡†—”ƒŽ …‘”‘ƒ”› ˜‡‘—•  ™ƒ• ’‡”ˆ‘”‡† ƒ• †‡•…”‹„‡† ’”‡˜‹‘—•Ž›Ǥ͸  ‰—‹†‡™‹”‡ –Šƒ– ’‡”‹–• —‹’‘Žƒ” •‡•‹‰ ƒ† ’ƒ…‹‰ ™ƒ• ‹•‡”–‡† ‹–‘ –Š‡  ƒ† …‘‡…–‡†–‘‹–‡ƒ˜ǤŠ‡‰—‹†‡™‹”‡™ƒ•ƒ‹’—Žƒ–‡†–‘ƒŽŽ–”‹„—–ƒ”‹‡•ǡ…”‡ƒ–‹‰ ƒƒƒ–‘‹…͵ƒ’™Š‹Ž‡•‹—Ž–ƒ‡‘—•Ž›†‡–‡”‹‹‰‡Ž‡…–”‹…ƒŽ†‡Žƒ›†—”‹‰‹–”‹•‹… ˜‡–”‹…—Žƒ” ƒ…–‹˜ƒ–‹‘Ǥ  ”‡’”‡•‡–ƒ–‹˜‡ …‘”‘ƒ”› ˜‡‘—•  ‹• •Š‘™ ‹ ‹‰—”‡ͳǤ Ž‡…–”‹…ƒŽ †‡Žƒ› ™ƒ• ‡ƒ•—”‡† ˆ”‘  ‘•‡– –‘ –Š‡ ’‡ƒ ‡‰ƒ–‹˜‡ •Ž‘’‡ ‘ –Š‡ Ͷ 

—‹’‘Žƒ”‹–”ƒǦ…ƒ”†‹ƒ… ƒ†‡š’”‡••‡†ƒ•’‡”…‡–ƒ‰‡‘ˆ–‘–ƒŽ†—”ƒ–‹‘ȋ†ȌǤ Š‡”‹‰Š–˜‡–”‹…—Žƒ”ȋȌŽ‡ƒ†™ƒ•–ƒ”‰‡–‡†–‘™ƒ”†•–Š‡ƒ’‡šǡ†‡–‡”‹‹‰‹–•’‘•‹–‹‘ —•‹‰ ˆŽ—‘”‘•…‘’›ǡ ƒ† ™ƒ• ‹†‡–‹ˆ‹‡† ‘ –Š‡ Ǥ Š‡  ‘•–‹— ™ƒ• ‹†‡–‹ˆ‹‡† „› ’‘•‹–‹‘‹‰ ƒ ‡Ž‡…–”‘’Š›•‹‘Ž‘‰› …ƒ–Š‡–‡” ȋ–Ǥ —†‡ ‡†‹…ƒŽȌ ‹ –Š‡ ”‹‰Š– ƒ–”‹— ƒ† ƒ†˜ƒ…‹‰ ‹– –‘™ƒ”† –Š‡ Ǥ Š‡ ’‘•‹–‹‘ ƒ– –Š‡ ‘•–‹— ™ƒ• …‘ˆ‹”‡† „› …‘–”ƒ•– ‹Œ‡…–‹‘Ǥ ‘”‘ƒ”› ˜‡‘—• ƒƒ–‘› ™ƒ• ‡˜ƒŽ—ƒ–‡† ‘ …‘”‘ƒ”› ˜‡‘‰”ƒ• ƒ† …Žƒ••‹ˆ‹‡† ƒ……‘”†‹‰ –‘ –Š‡ ‡”‹…ƒ ‡ƒ”– ••‘…‹ƒ–‹‘ ͳ͹Ǧ•‡‰‡– Š‡ƒ”– ‘†‡Ž –‘ ‡•—”‡…‘•‹•–‡…›™‹–Š–Š‡ƒƒ–‘‹……Žƒ••‹ˆ‹…ƒ–‹‘—•‡†‹Ǥͻ

Imageintegration ˆ–‡” –Š‡ ƒ’’‹‰ ’”‘…‡†—”‡ǡ –Š‡ ’”‡Ǧ’”‘…‡†—”ƒŽ Ǧ ͵ ‡•Š‡• ™‡”‡ ‹’‘”–‡† ‹–‘ ‹–‡ ƒ˜ ƒ† ‹–‡‰”ƒ–‡† ™‹–Š –Š‡ …‘”‘ƒ”› ˜‡‘—• Ǥ ‘” –Š‹• ’—”’‘•‡ǡ ƒƒ–‘‹…ƒŽŽƒ†ƒ”•™‡”‡•‡–ƒ––Š‡ƒ’‡šǡ‘•–‹—ǡƒ†–Š‡ƒ–‡”‹‘”ƒ†‹ˆ‡”‹‘” ‹–‡”˜‡–”‹…—Žƒ”˜‡‹•ƒ†•—Ž…‹‘„‘–Š–Š‡ƒ†Ǧ‰‡‘‡–”‹‡•Ǥ—„•‡“—‡–Ž›ǡ –Š‡ …‘‘”†‹ƒ–‡ •›•–‡ ‘ˆ –Š‡ …‘”‘ƒ”› ˜‡‘—•  ™ƒ• ƒ—–‘ƒ–‹…ƒŽŽ› •—’‡”‹’‘•‡† ƒ†ƒ†Œ—•–‡†–‘–Š‡Ǧ†‡”‹˜‡†‰‡‘‡–”›—•‹‰ƒ†›ƒ‹…”‡‰‹•–”ƒ–‹‘ƒŽ‰‘”‹–Šǡ ƒŽŽ‘™‹‰ Ž‘…ƒŽ ”‡ˆ‹‡‡– ™Š‹Ž‡ Ž‡ƒ˜‹‰ ‘–Š‡” ƒ”‡ƒ• —ƒˆˆ‡…–‡†ǤͳͲ  ”‡’”‡•‡–ƒ–‹˜‡ ‹–‡‰”ƒ–‡† ͵ Ǧ ‹ƒ‰‡ ‘ˆ ƒ •–—†› ’ƒ–‹‡– ‹• •Š‘™ ‹ ‹‰—”‡ͳ ƒ† –Š‡ …‘””‡•’‘†‹‰„—ŽŽ•‡›‡Ǧ’Ž‘–‹ ‹‰—”‡ͳǤ

Leftventricularleadplacement •‹‰–Š‡‹–‡‰”ƒ–‡†Ǧ‹ƒ‰‡ǡŽ‡ƒ†’Žƒ…‡‡–™ƒ•–ƒ”‰‡–‡†ƒ––Š‡…‘”‘ƒ”› ˜‡‹™‹–Šƒš‹ƒŽ‡Ž‡…–”‹…ƒŽ†‡Žƒ›Ǥ ˆ–Š‡˜‡‹™‹–Šƒš‹ƒŽ‡Ž‡…–”‹…ƒŽ†‡Žƒ›™ƒ•Ž‘…ƒ–‡† ‹ •…ƒ” ȋ•‡‰‡–ƒŽ •…ƒ” ˆ”ƒ…–‹‘ εͲΨȌǡ ƒ ƒŽ–‡”ƒ–‹˜‡ ˜‡‹ ™ƒ• –ƒ”‰‡–‡† ”‡‘–‡ ˆ”‘ •…ƒ”ǡ ’”‘˜‹†‡† –Šƒ– ‡Ž‡…–”‹…ƒŽ †‡Žƒ› ‹ –Š‹• ˜‡‹ ™ƒ• …‘•‹†‡”‡† •—ˆˆ‹…‹‡–Ž› Žƒ–‡ǡ ’”‡ˆ‡”ƒ„Ž›εͻͷ•‘”εͷͲΨ‘ˆ†ǡ„ƒ•‡†‘…—””‡–‡˜‹†‡…‡ƒ†”‡…‘‡†ƒ–‹‘•Ǥͳͳ Š‡Ž‡ƒ†™ƒ•…‘‡…–‡†–‘‹–‡ƒ˜–‘ƒŽŽ‘™”‡ƒŽǦ–‹‡ƒ˜‹‰ƒ–‹‘‘ˆ–Š‡Ž‡ƒ†–‘ –Š‡ –ƒ”‰‡– ”‡‰‹‘ ‹ –Š‡ ‹–‡‰”ƒ–‡† ‹ƒ‰‡Ǥ ‹’‘Žƒ” ‘” “—ƒ†”‹’‘Žƒ” Ž‡ƒ†• ™‡”‡—•‡†Ǥ Š‡ ’‘Ž‡ ™‹–Š ƒ Ž‘™ ˜‘Ž–ƒ‰‡ –Š”‡•Š‘Ž† ™‹–Š‘—– ’Š”‡‹… ‡”˜‡ •–‹—Žƒ–‹‘ ™ƒ• •‡Ž‡…–‡† ˆ‘” ’ƒ…‹‰Ǥ

ͷ 

Integrationaccuracyevaluation ‘‘”†‹ƒ–‡•‘ˆ–Š‡Ǧ‹ƒ‰‡™‡”‡‡š’‘”–‡†‘ˆˆŽ‹‡ƒˆ–‡”‹’Žƒ–ƒ–‹‘ƒ†™‡”‡ ”‘–ƒ–‡†—•‹‰–Š‡’”‹…‹’ƒŽ…‘’‘‡–ƒƒŽ›•‡•–‘ƒŽ‹‰ƒŽŽ˜‡”–‹…‡•’‡”Ǧ•Ž‹…‡‹ ‘‡ Ǧ’Žƒ‡ ƒ– –Š‡ •ƒ‡ Ǧ˜ƒŽ—‡ ƒ• †‡‘•–”ƒ–‡† ‹ ‹‰—”‡ʹǤ ‘” ‡˜‡”› Ǧ •Š‘”–Ǧƒš‹• •Ž‹…‡ ƒ …‡–”‘Æ ™ƒ• …‘’—–‡† „› ƒ˜‡”ƒ‰‹‰ –Š‡ ‡’‹…ƒ”†‹ƒŽ ˜‡”–‹…‡• ‘ˆ –Š‡ •ƒ‡ Ǧ˜ƒŽ—‡Ǥ ‡” ˜‡‹ ‡†‰‡• ™‡”‡ †‡–‡…–‡† „› •‡Ž‡…–‹‰ ˜‡”–‹…‡• ‡ƒ”‡•– –‘ –Š‡ …‡–”‘ÆǤ –‡‰”ƒ–‹‘‡””‘”•™‡”‡…‘’—–‡†ƒ•–Š‡—…Ž‹†‡ƒ†‹•–ƒ…‡„‡–™‡‡–Š‡Ǧ  ‡’‹…ƒ”†‹—ƒ†–Š‡…‘”‘ƒ”› ˜‡‘—•˜‡”–‡š‡ƒ”‡•––‘–Š‡…‡–”‘Æ’‡”Ǧ •Ž‹…‡ƒ••Š‘™‹ ‹‰—”‡ʹǤ—…Ž‹†‡ƒ†‹•–ƒ…‡•™‡”‡…‘’—–‡†ƒ–—Ž–‹’Ž‡•‹–‡•ˆ‘” ‡˜‡”› Ǧ •Š‘”–Ǧƒš‹• •Ž‹…‡ǡ ƒ• •Š‘™ ‹ ‹‰—”‡ʹǡ ƒ† ƒ˜‡”ƒ‰‡† –‘ …‘’—–‡ –Š‡ ‹ƒ‰‡‹–‡‰”ƒ–‹‘‡””‘”’‡”’ƒ–‹‡–—•‹‰…—•–‘•‘ˆ–™ƒ”‡‹Ǥ

Electrogramanalyses   ’‡ƒǦ–‘Ǧ’‡ƒ —‹’‘Žƒ” ˜‘Ž–ƒ‰‡• ™‡”‡ ƒ—–‘ƒ–‹…ƒŽŽ› …‘’—–‡† —•‹‰ …—•–‘ •‘ˆ–™ƒ”‡‹Ǥ‘…‘’ƒ”‡˜‘Ž–ƒ‰‡•™‹–Š•…ƒ”ǡ‡ƒ…ŠǦ•Š‘”–Ǧƒš‹••Ž‹…‡™ƒ• •—„†‹˜‹†‡† ‹ ͳ͸Ǧ•‡‰‡–• ȋ‹•–‡ƒ† ‘ˆ –Š‡ ͻ͸Ǧ•‡‰‡–• ˆ‘”  Ž‡ƒ† ‰—‹†ƒ…‡ȌǤ   Ž‘…ƒ–‹‘• ™‡”‡ ƒ–…Š‡† ™‹–Š –Š‡ •…ƒ” ˆ”ƒ…–‹‘ ‘ˆ –Š‡ ‡ƒ”‡•– Ǧ •‡‰‡–Ǥ  •‡‰‡–™ƒ•…‘•‹†‡”‡†ƒ•‘Ǧ•…ƒ”™Š‡–Š‡•…ƒ”ˆ”ƒ…–‹‘™ƒ•ͲΨƒ†ƒ••…ƒ”™Š‡ –Š‡•…ƒ”ˆ”ƒ…–‹‘™ƒ•εͲΨǤ

Statisticalanalysis –ƒ–‹•–‹…ƒŽ ƒƒŽ›•‡• ™‡”‡ ’‡”ˆ‘”‡† —•‹‰ ͳͻǤͲ ȋ ‹…Ǥǡ Š‹…ƒ‰‘ǡ ŽŽ‹‘‹•ȌǤ ‘–‹—‘—• ˜ƒ”‹ƒ„Ž‡• ƒ”‡ ‡š’”‡••‡† ƒ• ‡ƒά ‘” ‡†‹ƒά  ƒ† †‹…Š‘–‘‘—• ˜ƒ”‹ƒ„Ž‡•‹ˆ”‡“—‡…‹‡•Ȁ’‡”…‡–ƒ‰‡•Ǥ‘Ž–ƒ‰‡•™‡”‡…‘’ƒ”‡†—•‹‰ƒȂŠ‹–‡› –‡•–•ǡ”—•ƒŽǦƒŽŽ‹•–‡•–•ǡƒ†’ƒ”–‹ƒŽ…‘””‡Žƒ–‹‘ƒƒŽ›•‡•Ǥ‹‰‹ˆ‹…ƒ…‡™ƒ•†‡ˆ‹‡†ƒ• p˜ƒŽ—‡δͲǤͲͷǢ–™‘Ǧ–ƒ‹Ž‡†ƒ’’”‘ƒ…Š‡•™‡”‡—•‡†Ǥ

Results Patientcharacteristics ‹‰Š–‡‡ …‘•‡…—–‹˜‡ ’ƒ–‹‡–• ”‡ˆ‡””‡† ˆ‘”  †‡˜‹…‡ ‹’Žƒ–ƒ–‹‘ ™‹–Š ƒ  …Žƒ•• Ȁ ƒ ‹†‹…ƒ–‹‘ ƒ† ˆ‘…ƒŽ •…ƒ” ‘ ’”‡Ǧ’”‘…‡†—”ƒŽ Ǧ ™‡”‡ ‹…Ž—†‡† ‹ –Š‹• •–—†›Ǥ

͸ 

ƒ–‹‡– …Šƒ”ƒ…–‡”‹•–‹…• ƒ”‡ ‰‹˜‡ ‹ ƒ„Ž‡ͳǤ ‡–ƒ‹Ž‡† Ǧ ƒƒŽ›•‡• ’‡” ’ƒ–‹‡– ƒ”‡ ‰‹˜‡‹ƒ„Ž‡ʹǤ

CRTimplantation  de novo  †‡ˆ‹„”‹ŽŽƒ–‘” ™ƒ• ‹’Žƒ–‡† ‹ •‡˜‡–‡‡ ’ƒ–‹‡–•Ǥ ‡ ’ƒ–‹‡– ™ƒ• —’‰”ƒ†‡† ˆ”‘ ƒ ‹’Žƒ–ƒ„Ž‡ …ƒ”†‹‘˜‡”–‡” †‡ˆ‹„”‹ŽŽƒ–‘” –‘ ƒ  †‡ˆ‹„”‹ŽŽƒ–‘”Ǥ ‡˜‡ ’ƒ–‹‡–•”‡…‡‹˜‡†ƒ„‹’‘Žƒ”Ž‡ƒ†ƒ†‡Ž‡˜‡’ƒ–‹‡–•ƒ“—ƒ†”‹’‘Žƒ”Ž‡ƒ†ǤŠ‡”‡™‡”‡‘ ’”‘…‡†—”ƒŽ…‘’Ž‹…ƒ–‹‘•Ǥ

Electroanatomicmapping –”ƒǦ’”‘…‡†—”ƒŽ …‘”‘ƒ”› ˜‡‘—•  ™ƒ• ƒ……‘’Ž‹•Š‡† ‹ ƒŽŽ ’ƒ–‹‡–• ™‹–Š‘—– …‘’Ž‹…ƒ–‹‘•Ǥ ƒ’’‹‰ –‹‡ ™ƒ• ʹͲάͶ ‹—–‡• ƒ† –‘–ƒŽ ˆŽ—‘”‘•…‘’› –‹‡ ͳͻά͸ ‹—–‡•Ǥ ‘”‘ƒ”› ˜‡‘—• ƒ‰‹‘‰”ƒ’Š› ‹ ƒŽŽ ͳͺ ’ƒ–‹‡–• ”‡˜‡ƒŽ‡† ƒ –‘–ƒŽ ‘ˆ ͸͵  „”ƒ…Š‡•ǡ‘ˆ™Š‹…ŠͻʹΨ™‡”‡ƒ’’‡†ǤŠ‡ƒ’’‡†˜‡‹•’‡”’ƒ–‹‡–ƒ”‡†‡•…”‹„‡†‹ ƒ„Ž‡͵Ǥ ̵• ™‡”‡ ‰‡‡”ƒ–‡† ˆ”‘ ͹͹Ǥ͸άʹ͵Ǥʹ —‹“—‡ ƒƒ–‘‹… ’‘‹–• ’‡” ’ƒ–‹‡–Ǥ ƒš‹ƒŽ ‡Ž‡…–”‹…ƒŽ†‡Žƒ›”ƒ‰‡†„‡–™‡‡͹ʹΫͳͻ͹•ȋͷ͹Ϋͳͳ͵Ψ‘ˆ†Ȍǡƒ•‰‹˜‡‹ƒ„Ž‡͵ǡƒ† ™ƒ•†‹˜‡”•‡Ž›ƒƒ–‘‹…ƒŽŽ›†‹•–”‹„—–‡†ƒ••Š‘™‹ ‹‰—”‡͵Ǥ

Imageintegration ‘•–”—…–‹‰ –Š‡ ͵ •—”ˆƒ…‡ ‡•Š‡• ‘—– ‘ˆ Ǧ †ƒ–ƒ ’”‡Ǧ’”‘…‡†—”ƒŽŽ› –‘‘ ʹͷάͷ ‹—–‡•Ǥ ƒ‰‡ ‹–‡‰”ƒ–‹‘ †—”‹‰ –Š‡ ’”‘…‡†—”‡ –‘‘ ͳͲάͷ ‹—–‡• —•‹‰ ͺǤͻάʹǤͺ ƒƒ–‘‹…ƒŽ Žƒ†ƒ”•Ǥ ƒ‰‡ ‹–‡‰”ƒ–‹‘ ƒ……—”ƒ…› ™ƒ• ’‡”ˆ‘”‡† ™‹–Š ƒ —…Ž‹†‡ƒ †‹•–ƒ…‡‡ƒ‘ˆͶǤ͹άͳǤͳƒ†‘ˆ͵Ǥ͵άͲǤͻǡƒ†™ƒ•‡ƒ•—”‡†ƒ–ʹͷǤ͵ά͸Ǥ͵•‹–‡• ’‡”’ƒ–‹‡–Ǥ

Leftventricularleadplacement ƒ„Ž‡͵‰‹˜‡•ƒ‘˜‡”˜‹‡™‘ˆ–Š‡’‘•‹–‹‘‘ˆ–Š‡Žƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹•ǡ–Š‡ƒ’’‡†˜‡‹• Ž‘…ƒ–‡† ‘—–•‹†‡ •…ƒ”ǡ ƒ† –Š‡ ˆ‹ƒŽ  Ž‡ƒ† ’‘•‹–‹‘ ’‡” ’ƒ–‹‡–Ǥ • ƒ††‹–‹‘ƒŽŽ› …ƒ „‡ •‡‡ ‹ –Š‡ †‡…‹•‹‘ ƒ‹‰ ˆŽ‘™…Šƒ”– ‘ˆ  Ž‡ƒ† ’Žƒ…‡‡– ‹ ‹‰—”‡ ͵ǡ –Š‡ Žƒ–‡•– ƒ…–‹˜ƒ–‡†˜‡‹™ƒ•Ž‘…ƒ–‡†‘—–•‹†‡•…ƒ”‹–™‡Ž˜‡’ƒ–‹‡–•Ǥˆ–Š‡•‡’ƒ–‹‡–•ǡ–Š‡Ž‡ƒ† ™ƒ• ’Žƒ…‡† ‘—–•‹†‡ •…ƒ” ‹ –Š‡ Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ‹ –‡ ’ƒ–‹‡–•ǡ ˆ”‘ ™Š‹…Š ‘‡ ”‡’”‡•‡–ƒ–‹˜‡‹••Š‘™‹ ‹‰—”‡ͶǤ –™‘’ƒ–‹‡–•–Š‹•™ƒ•Šƒ’‡”‡†Ǣ‹’ƒ–‹‡–‘Ǥͺ †—‡–‘ƒ•ƒŽŽ˜‡‹ƒ••Š‘™‹ ‹‰—”‡Ͷǡƒ†Š‡”‡–Š‡Ž‡ƒ†™ƒ•ˆ‹ƒŽŽ›’Žƒ…‡†‹–Š‡ ͹ 

•‡…‘†Žƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹‘—–•‹†‡•…ƒ”ǡƒ†‹’ƒ–‹‡–‘Ǥͳͺ†—‡–‘Ž‡ƒ†‹•–ƒ„‹Ž‹–›ƒ† Š‡”‡–Š‡Ž‡ƒ†™ƒ•ˆ‹ƒŽŽ›’Žƒ…‡†‹–Š‡ƒ’‹…ƒŽ•‡‰‡–‘ˆ–Š‡Žƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹‹ •…ƒ”Ǥ •‹š’ƒ–‹‡–•ǡ–Š‡Žƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹™ƒ•Ž‘…ƒ–‡†‹•…ƒ”Ǥ –Š‡•‡’ƒ–‹‡–•ǡ–Š‡ Ž‡ƒ† ™ƒ•’Žƒ…‡† ‹–Š‡ •‡…‘† Žƒ–‡•–ƒ…–‹˜ƒ–‡† ˜‡‹ ‘—–•‹†‡ •…ƒ”ȋnαʹǡ’ƒ–‹‡–‘Ǥͷ ƒ† ‘Ǥ͹Ȍ ƒ• •Š‘™ ‹ –Š‡ ”‡’”‡•‡–ƒ–‹˜‡ ’ƒ–‹‡– ‘ˆ ‹‰—”‡ͳǡ ‘” •–‹ŽŽ ‹ –Š‡ Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ‹ •…ƒ” ƒ• ƒŽŽ ƒŽ–‡”ƒ–‹˜‡ ˜‡‹• ™‡”‡ ƒŽ•‘ Ž‘…ƒ–‡† ‹ •…ƒ” ȋnαʹǡ ’ƒ–‹‡– ‘ǤͳͲ ƒ† ‘ǤͳͳȌƒ••Š‘™‹ ‹‰—”‡Ͷǡ‘”‘–•—ˆˆ‹…‹‡–Ž›‡Ž‡…–”‹…ƒŽŽ›†‡Žƒ›‡†ȋnαʹǡ’ƒ–‹‡–‘Ǥͳʹ ƒ†‘ǤͳͷȌƒ••Š‘™‹ ‹‰—”‡ͶǤ

Electrogramvoltages –‘–ƒŽ‘ˆͳͲͳͷ ̵•™‡”‡ƒƒŽ›œ‡†ˆ”‘‘Ǧ•…ƒ”ȋn=ͷͲͶȌƒ†•…ƒ”ȋnαͷͳͳȌǤ‘Ž–ƒ‰‡• ™‡”‡ ͺǤͳͺάͶǤͲʹ  ȋ‡†‹ƒά Ȍ ‹ ‘Ǧ•…ƒ” ƒ† ͸Ǥ͹ͳά͵ǤͶͷ  ‹ •…ƒ” ȋƒȂ Š‹–‡›ǦpζͲǤͲͲͳȌǤŠ‡”‡™ƒ•ƒ•‹‰‹ˆ‹…ƒ–„—–™‡ƒ…‘””‡Žƒ–‹‘„‡–™‡‡˜‘Ž–ƒ‰‡•ƒ† Ǧ •…ƒ” ˆ”ƒ…–‹‘ ȋ’ƒ”–‹ƒŽ …‘””‡Žƒ–‹‘  ǦͲǤͳ͸ͳǡ pδͲǤͲͲͳȌǤ ‘Ž–ƒ‰‡• ™‡”‡ Š‹‰ŠŽ› †‹ˆˆ‡”‡–„‡–™‡‡’ƒ–‹‡–•™Š‹Ž‡†‹ˆˆ‡”‡…‡•™‹–Š‹‡ƒ…Š’ƒ–‹‡–„‡–™‡‡˜‘Ž–ƒ‰‡•ˆ”‘ ‘Ǧ•…ƒ”˜•Ǥ•…ƒ”™‡”‡ƒ„•‡–‘”•ƒŽŽǡƒ••Š‘™‹–Š‡˜‘Ž–ƒ‰‡†‹•–”‹„—–‹‘„‘š’Ž‘–•’‡” ‹†‹˜‹†—ƒŽ ’ƒ–‹‡– ‹ ‹‰—”‡ͷǤ ˜‡ ‘Ǧ•…ƒ” ˜‘Ž–ƒ‰‡• ˜ƒ”‹‡† ™‹†‡Ž› ȋ”—•ƒŽǦƒŽŽ‹• pζͲǤͲͲͳȌ ƒ‘‰ ‹†‹˜‹†—ƒŽ•ǡ †‹•…‘—”ƒ‰‹‰ –Š‡ —•‡ ‘ˆ ˜‘Ž–ƒ‰‡ …”‹–‡”‹ƒ ˆ‘” †‡Ž‹‡ƒ–‹‘ ‘ˆ •…ƒ”Ǥ

Discussion –Š‹••–—†›ǡ™‡†‡‘•–”ƒ–‡ƒ‘˜‡Žƒ’’”‘ƒ…Š‘ˆ’”‡Ǧ’”‘…‡†—”ƒŽǦ‹–‡‰”ƒ–‹‘ ™‹–Š…‘”‘ƒ”›˜‡‘—•–‘‰—‹†‡Ž‡ƒ†’Žƒ…‡‡–”‡ƒŽǦ–‹‡–‘–Š‡Žƒ–‡•–‡Ž‡…–”‹…ƒŽŽ› ƒ…–‹˜ƒ–‡†…‘”‘ƒ”›˜‡‹”‡‘–‡ˆ”‘•…ƒ”Ǥ –™‘Ǧ–Š‹”†•‘ˆ‘—”’ƒ–‹‡–•ǡƒ‘’–‹ƒŽ Ž‡ƒ†’‘•‹–‹‘™ƒ•‡Ž‡…–”‘Ǧƒƒ–‘‹…ƒŽŽ›’”‡•‡–ƒ†…‘—Ž†„‡ƒ…Š‹‡˜‡†‹–Š‡ƒŒ‘”‹–›‘ˆ …ƒ•‡•—•‹‰–Š‹•̶‰—‹†‡†̶ƒ’’”‘ƒ…ŠǤ –Š‡‘–Š‡”‘‡Ǧ–Š‹”†ǡ–Š‡Žƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹™ƒ• Ž‘…ƒ–‡†‹•…ƒ”ƒ†ƒƒŽ–‡”ƒ–‹˜‡˜‡‹™ƒ•–ƒ”‰‡–‡†Ǥ……—”ƒ…›‘ˆ‹ƒ‰‡‹–‡‰”ƒ–‹‘™ƒ• ͶǤ͹άͳǤͳ  ‹ …‘…‘”†ƒ…‡ ™‹–Š ’”‡˜‹‘—• •–—†‹‡•Ǥͳʹ ‹‰‹ˆ‹…ƒ– †‹ˆˆ‡”‡…‡• „‡–™‡‡ ‹†‹˜‹†—ƒŽ   ˜‘Ž–ƒ‰‡• ˆ”‘ ‘Ǧ•…ƒ” ˜•Ǥ •…ƒ” ™‡”‡ ƒ„•‡– ‹ ƒ •—„•–ƒ–‹ƒŽ ‰”‘—’ ‘ˆ ’ƒ–‹‡–•ƒ†˜‘Ž–ƒ‰‡†‹•–”‹„—–‹‘•„‡–™‡‡’ƒ–‹‡–•˜ƒ”‹‡†‰”‡ƒ–Ž›ǡƒ‹‰Ǧ•–‹ŽŽ –Š‡’”‡ˆ‡””‡†‡–Š‘†ˆ‘”•…ƒ”†‡Ž‹‡ƒ–‹‘Ǥ

ͺ 

Leftventricularleadplacement Žƒ…‹‰–Š‡Ž‡ƒ†‹ƒƒ”‡ƒ™‹–ŠŽ‘‰‡Ž‡…–”‹…ƒŽ†‡Žƒ›™ƒ•ƒ••‘…‹ƒ–‡†™‹–Š”‡†—…‡†  Š‘•’‹–ƒŽ‹œƒ–‹‘• ƒ† ƒŽŽǦ…ƒ—•‡ ‘”–ƒŽ‹–› ‹ ƒ ‘„•‡”˜ƒ–‹‘ƒŽ •–—†› ‘ˆ ͳͶͶ ’ƒ–‹‡–•Ǥ͵ ‘”‘ƒ”› ˜‡‘—•  –‘ –ƒ”‰‡– –Š‡ Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ™ƒ• ƒ††‹–‹‘ƒŽŽ› …ƒ””‹‡† ‹ ƒ …‘Š‘”– ‘ˆ ʹͷ ƒ† ͵ʹ ’ƒ–‹‡–• ƒ† †‡‘•–”ƒ–‡†ǡ •‹‹Žƒ” ‹ ‘—” •–—†›ǡ –Šƒ– –Š‡ •‹–‡ ‘ˆ Žƒ–‡•– ƒ…–‹˜ƒ–‹‘ ‹• Š‡–‡”‘‰‡‡‘—•Ž› †‹•–”‹„—–‡†Ǥ Žƒ…‹‰ –Š‡  Ž‡ƒ† ƒ– ƒ •‹–‡ ‘ˆ Žƒ–‡ ‡Ž‡…–”‹…ƒŽƒ…–‹˜ƒ–‹‘‹•–Š‡”‡ˆ‘”‡†‡•‹”‡†–‘‹’”‘˜‡”‡•’‘•‡Ǥ ”‘ ƒ ‡Ž‡…–”‘’Š›•‹‘Ž‘‰‹…ƒŽ ’‡”•’‡…–‹˜‡ǡ ’ƒ…‹‰ ‹ •…ƒ” ‹• ƒŽ•‘ Ž‡•• ‡ˆˆ‡…–‹˜‡ǡ ƒ• •Ž‘™ …‘†—…–‹‘†‹•–—”„•”‡•›…Š”‘‹œƒ–‹‘Ǥ‘…‘”†ƒ–Ž›ǡ’ƒ…‹‰‹•…ƒ”‹ƒ…‘Š‘”–‘ˆͷͷͻ ’ƒ–‹‡–• Ž‡† –‘ ƒ Š‹‰Š‡” ”‹• ‘ˆ …ƒ”†‹‘˜ƒ•…—Žƒ” †‡ƒ–Šǡ •—††‡ …ƒ”†‹ƒ… †‡ƒ–Šǡ ƒ† Ž‘™‡” ‡…Š‘…ƒ”†‹‘‰”ƒ’Š‹…”‡•’‘•‡…‘’ƒ”‡†–‘’ƒ…‹‰‘—–•‹†‡•…ƒ”ǤʹŽƒ…‹‰–Š‡Ž‡ƒ† ‹•…ƒ”•Š‘—Ž†–Š‡”‡ˆ‘”‡„‡ƒ˜‘‹†‡†™Š‡’‘••‹„Ž‡Ǥ

Imageguidedcardiacresynchronizationtherapy ‡˜‡”ƒŽ‹ƒ‰‡Ǧ‰—‹†‡†–‡…Š‹“—‡•–‘’Žƒ…‡–Š‡Ž‡ƒ†ƒ–ƒ•‹–‡‘ˆŽƒ–‡ƒ…–‹˜ƒ–‹‘”‡‘–‡ ˆ”‘•…ƒ”Šƒ˜‡„‡‡†‡•…”‹„‡†Ǥ ”‘•’‡…–‹˜‡Ž› –ƒ”‰‡–‹‰ –Š‡  Ž‡ƒ† –‘™ƒ”†• –Š‡ Žƒ–‡•– •‡‰‡– ‘ˆ …‘–”ƒ…–‹‘ ‘—–•‹†‡ •…ƒ”—•‹‰’”‡Ǧ’”‘…‡†—”ƒŽ‡…Š‘…ƒ”†‹‘‰”ƒ’Š‹…•’‡…Ž‡Ǧ–”ƒ…‹‰ʹ”ƒ†‹ƒŽ•–”ƒ‹‹ƒ‰‹‰ Šƒ•„‡‡’‡”ˆ‘”‡†‹–Š‡ –”‹ƒŽǤͳ͵ –Š‹••–—†›ʹʹͲ’ƒ–‹‡–•™‡”‡”ƒ†‘‹œ‡† ͳǣͳ‹ƒ ‘”ƒ—‰—‹†‡†‰”‘—’Ǥ –Š‡ ‰”‘—’ǡ–Š‡”‡™ƒ•ƒ‰”‡ƒ–‡” ’”‘’‘”–‹‘ ‘ˆ ”‡•’‘†‡”• ‹ …‘’ƒ”‹•‘ ™‹–Š –Š‡ —‰—‹†‡† ‰”‘—’ ȋ͹ͲΨ ˜•Ǥ ͷͷΨǡ pα ͲǤͲ͵ͳȌǤ Š‡  Ž‡ƒ† ™ƒ• ’Žƒ…‡† •‹‰‹ˆ‹…ƒ–Ž› ‘”‡ ‹ –Š‡ Žƒ–‡•– ‡…Šƒ‹…ƒŽ •‡‰‡–Ǥ ‡˜‡”–Š‡Ž‡•• –Š‡ ’”‡•‡…‡ ‘ˆ •…ƒ” ƒ– –Š‡  Ž‡ƒ† ™ƒ• ‘– •‹‰‹ˆ‹…ƒ–Ž› †‹ˆˆ‡”‡– ‹ –Š‡  ˜•Ǥ…‘–”‘Ž‰”‘—’Ǥ‡…ƒ‹ƒ‰‹‡–Šƒ–™Š‡–Š‡˜‡‘—•ƒƒ–‘›‹•Ž‹‹–‡†–‘ •…ƒ”ǡ’‘•‹–‹‘‹‰–Š‡Ž‡ƒ†‹•…ƒ”‹•‹‡˜‹–ƒ„Ž‡ǡƒ•–Š‹•™ƒ•ƒŽ•‘–Š‡…ƒ•‡‹’ƒ”–‘ˆ‘—” ’‘’—Žƒ–‹‘ǤŠ‡ƒŽŽǦ…ƒ—•‡‘”–ƒŽ‹–›‘–Š‡Ž‘‰Ǧ–‡”™ƒ•ˆ—”–Š‡”‘”‡”‡†—…‡†™Š‡–Š‡ Ž‡ƒ†™ƒ•’Žƒ…‡†‹–Š‡Žƒ–‡•–ƒ…–‹˜ƒ–‡†•‡‰‡–ȋͷΨȌ˜•Ǥƒƒ†Œƒ…‡–ȋͻΨȌ‘””‡‘–‡ ȋʹͶΨȌ•‡‰‡–ǤŠ‡ƒŽŽǦ…ƒ—•‡‘”–ƒŽ‹–›ˆ”‘’ƒ–‹‡–•™‹–Š•…ƒ”ƒ––Š‡’ƒ…‹‰•‹–‡™ƒ• —…Š Š‹‰Š‡” …‘’ƒ”‡† –‘ ’ƒ–‹‡–• ™‹–Š‘—– •…ƒ” ƒ– –Š‡  ’ƒ…‹‰ •‹–‡ ȋʹͻΨ ˜•Ǥ ͸Ψ ”‡•’‡…–‹˜‡Ž›Ȍǡ‹ŽŽ—•–”ƒ–‹‰–Š‡‹’‘”–ƒ…‡‘ˆ’ƒ…‹‰‘—–•‹†‡•…ƒ”Ǥͳ͵ ǡ ǡƒ†‡…Š‘…ƒ”†‹‘‰”ƒ’Š›™‡”‡‹–‡‰”ƒ–‡†–‘…”‡ƒ–‡’”‡Ǧ’”‘…‡†—”ƒŽ„—ŽŽ•‡›‡ƒ’• ™‹–Š ‹ˆ‘”ƒ–‹‘ ‘ –Š‡ ‡…Šƒ‹…ƒŽ †‡Žƒ›ǡ …‘”‘ƒ”› ˜‡‹•ǡ ƒ† •…ƒ” ‹ ͵ͻ ’ƒ–‹‡–• „› ƒ‘•‡–ƒŽǤͳͶŽ‡ƒ†–ƒ”‰‡–•‡‰‡–•™‡”‡‹†‡–‹ˆ‹‡†’”‹‘”–‘‹’Žƒ–ƒ–‹‘Ǥ ”‘—‰ŠŽ› ͻ 

ŠƒŽˆ ‘ˆ –Š‡ ’ƒ–‹‡–•ǡ ‘ …‘”‘ƒ”› ˜‡‹ ‹ –Š‡ •‡‰‡– ™‹–Š –Š‡ Žƒ–‡•– ‡…Šƒ‹…ƒŽ †‡Žƒ› ™ƒ• ’”‡•‡–ǡ ‹†‹…ƒ–‹‰ –Š‡ ‹’‘”–ƒ…‡ ‘ˆ ‘Ž› †‡–‡…–‹‰ †‡Žƒ›• ‹ ƒ”‡ƒ• ‘ˆ …‘”‘ƒ”› ˜‡‘—•ƒƒ–‘›Ǥ  Ž‡ƒ† ‰—‹†ƒ…‡ ™ƒ• ƒŽ•‘ ’‡”ˆ‘”‡† „› ‘˜‡”Žƒ›‹‰ ’”‡Ǧ’”‘…‡†—”ƒŽ Ǧ†‡”‹˜‡† ƒƒ–‘‹…ƒŽǦ‡…Šƒ‹…ƒŽƒ’•™‹–Š‹–”ƒǦ’”‘…‡†—”ƒŽˆŽ—‘”‘•…‘’›–‘‰—‹†‡–Š‡Ž‡ƒ†–‘ –Š‡‡…Šƒ‹…ƒŽŽ›Žƒ–‡•–•‡‰‡–™‹–ŠδͷͲΨ•…ƒ”Ǥͳͷ•‹‰–Š‹•ƒ’’”‘ƒ…Š–Š‡›™‡”‡ƒ„Ž‡–‘ ‰—‹†‡–Š‡Ž‡ƒ†–‘ƒ•‡‰‡–™‹–ŠδͷͲΨ•…ƒ”ƒ†—’–‘–Š‹”†Žƒ–‡•–‡…Šƒ‹…ƒŽ†‡Žƒ›‹ ͳͷȀʹͲ ’ƒ–‹‡–•Ǥ ”‘ –Š‡ ‡…Š‘…ƒ”†‹‘‰”ƒ’Š‹…  ”‡•’‘†‡”•ǡ ͻʹΨ ™ƒ• ’ƒ…‡† ‹ –Š‡  –ƒ”‰‡– •‡‰‡– ˜•Ǥ ͷͲΨ ‹ –Š‡ ‘Ǧ”‡•’‘†‡”•ǡ …‘ˆ‹”‹‰ –Šƒ– Š‡‘†›ƒ‹… ”‡•’‘•‡™ƒ•‘”‡ˆ”‡“—‡–Ž›ƒ……‘’ƒ‹‡†™‹–Šƒ…‘…‘”†ƒ–Ž‡ƒ†’‘•‹–‹‘Ǥ • ’”‹‘” •–—†‹‡• ‘  Ž‡ƒ† ‰—‹†ƒ…‡ ƒ‹Ž› ˆ‘…—•‡† ‘ ‹–‡‰”ƒ–‹‰ Ǧ ™‹–Š ‡…Šƒ‹…ƒŽ ƒ…–‹˜ƒ–‹‘ ƒ’• †‡”‹˜‡† ˆ”‘ ‡…Š‘…ƒ”†‹‘‰”ƒ’Š› ‘” ǡ ‘—” •–—†› ‹• –Š‡ ˆ‹”•––Šƒ–‹…‘”’‘”ƒ–‡•‡Ž‡…–”‘Ǧƒƒ–‘‹…ƒŽ‹ˆ‘”ƒ–‹‘ˆ”‘–Š‡…‘”‘ƒ”›˜‡‹•ƒ…“—‹”‡† „›™Š‹…Š‹•”‡Ž‡˜ƒ–ƒ•Ž‡ƒ†’Žƒ…‡‡–‹•Ž‹‹–‡†–‘…‘”‘ƒ”›˜‡‘—•ƒƒ–‘›Ǥ •‹‰‹–”ƒǦ’”‘…‡†—”ƒŽ‹–‡‰”ƒ–‹‘‹•–‡ƒ†‘ˆ’”‡Ǧ’”‘…‡†—”ƒŽ„—ŽŽ•‡›‡Ǧƒ’•ƒ††‹–‹‘ƒŽŽ› Šƒ•–Š‡ƒ†˜ƒ–ƒ‰‡‘ˆƒŽŽ‘™‹‰”‡ƒŽǦ–‹‡Ž‡ƒ†ƒ˜‹‰ƒ–‹‘Ǥ

Clinicalimplications Ǧ –‘ ‡˜ƒŽ—ƒ–‡ •…ƒ” ’”‹‘” –‘  ‹’Žƒ–ƒ–‹‘ ‹• „‡‹‰ ‹…”‡ƒ•‹‰Ž› ƒ†‘’–‡† ƒ• •–ƒ†ƒ”†…ƒ”‡‹ƒ›…‡–‡”•Ǥ††‹–‹‘ƒŽŽ›ǡ‘•–˜‡†‘”•Šƒ˜‡ƒŽ”‡ƒ†›ƒ†‘’–‡†ƒ –‘‘Ž–‘‹–‡‰”ƒ–‡‘”Ǧ„ƒ•‡†‰‡‘‡–”‹‡•ǡƒ•‹ƒ‰‡‹–‡‰”ƒ–‹‘‹•ƒŽ”‡ƒ†›…‘‘ ’”ƒ…–‹…‡‹‘–Š‡”‡Ž‡…–”‘’Š›•‹‘Ž‘‰‹…ƒŽˆ‹‡Ž†•Ǥš’ƒ†‹‰‹–•ƒ’’Ž‹…ƒ–‹‘‹ƒ›Šƒ˜‡ ’‘–‡–‹ƒŽ‹’ƒ…–‘–Š‡’”‘‰‘•‹•‘ˆ–Š‹•’ƒ–‹‡–’‘’—Žƒ–‹‘Ǥ  ‘—” ‡š’‡”‹‡…‡ǡ •…ƒ” ‹• –›’‹…ƒŽŽ› ‘– ƒ ™‡ŽŽǦ†‡ˆ‹‡† –”ƒ•—”ƒŽ ‡–‹–›ǡ „—– ‹• ‘”‡ Š‡–‡”‘‰‡‡‘—•Ž› •’”‡ƒ†ǡ ƒ‹‰ ‹– ‘”‡ …ŠƒŽŽ‡‰‹‰ –‘†‡–‡”‹‡™Š‡–Š‡”–Š‡ ˜‡‘—• ƒƒ–‘› ‹• ‡„‡††‡† ‹ •…ƒ”Ǥ •‹‰ ”‡ƒŽǦ–‹‡ ‹–‡‰”ƒ–‹‘ ‹• –Š‡”‡ˆ‘”‡ ’ƒ”–‹…—Žƒ”Ž› ‘ˆ ƒ††‡†˜ƒŽ—‡‹’ƒ–‹‡–•™‹–ŠŽƒ–‡”ƒŽ•…ƒ”ǡƒ•–ƒ”‰‡–˜‡‹•ƒ”‡‘ˆ–‡Ž‘…ƒ–‡†‹–Š‹•ƒ”‡ƒǤ ‘”‘ƒ”› ˜‡‘—•  Šƒ• ’”‘˜‡ ‹–•‡Žˆ ƒ• ƒ •ƒˆ‡ –‡…Š‹“—‡ ”‡“—‹”‹‰ ”‡ƒ•‘ƒ„Ž‡ ’”‘…‡†—”ƒŽ –‹‡•Ǥ͸ǡͳ͸ ŽŽ ’”‘…‡†—”‡• ‹ ‘—” •–—†› ‘……—””‡† ™‹–Š‘—– …‘’Ž‹…ƒ–‹‘• ƒ† ‹ƒ‰‡ ‹–‡‰”ƒ–‹‘ †‹† ‘– ’”‘Ž‘‰ –Š‡ ‹’Žƒ–ƒ–‹‘ –‹‡ǡ ƒ‹Ž› „‡…ƒ—•‡ …‘•–”—…–‹‰ –Š‡ Ǧ ‡•Šǡ –Š‡ ‘•– –‹‡Ǧ…‘•—‹‰ ƒ•’‡…–ǡ ™ƒ• ’‡”ˆ‘”‡† ’”‹‘” –‘ –Š‡ ’”‘…‡†—”‡Ǥ

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ƒ„‘—–‘‡Ǧ–Š‹”†‘ˆ‘—”’‘’—Žƒ–‹‘ǡ–Š‡Žƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹™ƒ•Ž‘…ƒ–‡†‹•…ƒ”–‹••—‡ǡ ’”‘Š‹„‹–‹‰‘’–‹ƒŽŽ‡ƒ†’Žƒ…‡‡–Ǥ–‹ŽŽǡ™‡„‡Ž‹‡˜‡–Šƒ–…‘”‘ƒ”›˜‡‘—•™‹–Š Ǧ ‹–‡‰”ƒ–‹‘ ƒ› ‡˜‡ ‹ –Š‡•‡ ’ƒ–‹‡–• „‡ ‘ˆ ƒ††‡† ˜ƒŽ—‡Ǥ ˆ‘”ƒ–‹‘ ‘ –Š‡ ˆ‹ƒŽ  Ž‡ƒ† ’‘•‹–‹‘ ”‡‰ƒ”†‹‰ •…ƒ” ƒ† ‡Ž‡…–”‹…ƒŽ ƒ…–‹˜ƒ–‹‘ ƒ› „‡ —•‡ˆ—Ž ‹ ’ƒ–‹‡– ˆ‘ŽŽ‘™Ǧ—’ƒ†’”‘˜‹†‡•ƒ††‹–‹‘ƒŽ‹•‹‰Š–‹ȋ‘ǦȌ”‡•’‘•‡ƒˆ–‡”Ǥ

Limitations —” •–—†› ‹• •‹‰Ž‡Ǧ…‡–‡”‡† —•‹‰ ‘Ž› ƒ •ƒŽŽ ’‘’—Žƒ–‹‘Ǥ ƒ› ˆƒ…–‘”• ƒˆˆ‡…– –Š‡ ’”‘‰‘•‹• ‘ˆ  ƒ† ƒ• –Š‡•‡ ’ƒ–‹‡–• ƒ”‡ Š‡–‡”‘‰‡‡‘—•ǡ Žƒ”‰‡” ’‘’—Žƒ–‹‘• ƒ”‡ ”‡“—‹”‡† –‘ ‡˜ƒŽ—ƒ–‡ –Š‡ •—’‡”‹‘”‹–› ‘ˆ ‘—” ̶‰—‹†‡†̶ ƒ’’”‘ƒ…Š …‘’ƒ”‡† –‘ –Š‡ …‘˜‡–‹‘ƒŽƒ’’”‘ƒ…Š”‡‰ƒ”†‹‰”‡•’‘•‡–‘Ǥ ‘”‘ƒ”›˜‡‘—•”‡“—‹”‡•’”ƒ…–‹…‡ˆ”‘–Š‡‡Ž‡…–”‘’Š›•‹‘Ž‘‰‹•–ǡƒŽ–Š‘—‰Š‹–…ƒ„‡ ’‡”ˆ‘”‡†™‹–Š‹”‡ƒ•‘ƒ„Ž‡–‹‡•™Š‡ƒ†‡“—ƒ–‡Ž›•‹ŽŽ‡†Ǥ͸ǡͳ͸ Š‡‹–‡‰”ƒ–‹‘’”‘…‡••‹‘—”•–—†›™ƒ•…‘’Ž‹…ƒ–‡†ƒ•–™‘ƒƒ–‘‹‡•™‡”‡ˆ—•‡†ƒ† Ǧ ‹ƒ‰‡• ™‡”‡ ƒ…“—‹”‡† †—”‹‰ ‡†Ǧ†‹ƒ•–‘Ž‡ ™Š‹Ž‡ –Š‡  ‰‡‡”ƒ–‹‘ ™ƒ•̵–  Ǧ–”‹‰‰‡”‡†Ǥ ‡˜‡”–Š‡Ž‡••ǡ ”‘–ƒ–‹‘ ‡””‘”• ™‡”‡ ‹‹‹œ‡† „› ƒ’’‹‰ –Š‡  ƒ’‡š ƒ†‘•–‹—…”‡ƒ–‹‰ƒ††‹–‹‘ƒŽƒ–…Š‹‰’‘‹–•‘„‘–Š‰‡‘‡–”‹‡•Ǥ

Conclusion ‡ †‡‘•–”ƒ–‡ ƒ ‘˜‡Ž ‹ƒ‰‡Ǧ‰—‹†‡†  ƒ’’”‘ƒ…Š ™‹–Š ‹–‡‰”ƒ–‹‘ ‘ˆ ‹–”ƒǦ ’”‘…‡†—”ƒŽ …‘”‘ƒ”› ˜‡‘—•  ™‹–Š Ǧ ‡ƒ„Ž‹‰ ”‡ƒŽǦ–‹‡  Ž‡ƒ† ƒ˜‹‰ƒ–‹‘Ǥ Š‹• ‹ƒ‰‡Ǧ‰—‹†‡† ƒ’’”‘ƒ…Š …ƒ „‡ ‹’Ž‡‡–‡† —•‹‰ •–ƒ†ƒ”† Ǧ •…ƒ• ƒ† ‹ƒ‰‡‹–‡‰”ƒ–‹‘–‘‘Ž•–Šƒ–ƒ”‡ƒŽ”‡ƒ†›‹…‘”’‘”ƒ–‡†‹‘•–•›•–‡•ǤǦ‹• •–‹ŽŽ–Š‡’”‡ˆ‡””‡†‡–Š‘†ˆ‘”•…ƒ”†‡Ž‹‡ƒ–‹‘ǡƒ• ˜‘Ž–ƒ‰‡•…‘””‡Žƒ–‡†’‘‘”Ž›™‹–Š Ǧ•…ƒ”Ǥ

Acknowledgement Š‡ ƒ—–Š‘”• ‰”ƒ–‡ˆ—ŽŽ› ƒ…‘™Ž‡†‰‡ ‡–‡” ƒ‡” ƒ† ”Œƒ ‡‹ ˆ”‘ –Ǥ —†‡ ‡†‹…ƒŽˆ‘”–Š‡‹”–‡…Š‹…ƒŽ•—’’‘”–†—”‹‰–Š‡’”‘…‡†—”‡•Ǥ

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10. 11.

ͳʹ 

‡›˜ƒ ǡ ‘Ž‡› ǡ ŠƒŽ‹Ž ǡ ƒ–‹„ ǡ ‹–Š ǡ ”‹œ‡ ǡ —”‹……Š‹‘ Ǥ ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’› ‰—‹†‡† „› Žƒ–‡ ‰ƒ†‘Ž‹‹—Ǧ‡Šƒ…‡‡– …ƒ”†‹‘˜ƒ•…—Žƒ” ƒ‰‡–‹… ”‡•‘ƒ…‡Ǥ ‘—”ƒŽ ‘ˆ …ƒ”†‹‘˜ƒ•…—Žƒ” ƒ‰‡–‹… ”‡•‘ƒ…‡ǣ‘ˆˆ‹…‹ƒŽŒ‘—”ƒŽ‘ˆ–Š‡‘…‹‡–›ˆ‘”ƒ”†‹‘˜ƒ•…—Žƒ”ƒ‰‡–‹…‡•‘ƒ…‡ ʹͲͳͳǢͳ͵ǣʹͻǤ ƒ†ƒŽƒ ǡ’ƒ†Š›ƒ› ǡŽ–ƒǡƒ”•ǡ”‡…‘Ž‡ǡ‡Žƒǡ‡˜‹ ‡‹•–ǡ ‹‰Š Ǥ‘”’Š‘Ž‘‰›ǡŽ‡ˆ–˜‡–”‹…—Žƒ”Ž‡ƒ†Ž‘…ƒ–‹‘ǡƒ†…Ž‹‹…ƒŽ‘—–…‘‡‹ ’ƒ–‹‡–• ”‡…‡‹˜‹‰ …ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’›Ǥ —” ‡ƒ”–  —‰ ʹͲͳ͵Ǣ͵ͶǣʹʹͷʹǦʹʹ͸ʹǤ ‘‰ ǡ‡‡ǡ–‹””ƒ– ǡ‡–ƒŽǤ ˆŽ—‡…‡‘ˆ’ƒ…‹‰•‹–‡…Šƒ”ƒ…–‡”‹•–‹…•‘”‡•’‘•‡ –‘ …ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’›Ǥ ‹”…—Žƒ–‹‘ ƒ”†‹‘˜ƒ•…—Žƒ” ‹ƒ‰‹‰ —Ž ʹͲͳ͵Ǣ͸ǣͷͶʹǦͷͷͲǤ —–Œ‡•ǡƒŽ•Ž‡› ǡŽ‘—šǡ‘”†ƒ…Šƒ”ǡ”‹œ‡ ǡ‡ŽŠƒƒ•ǡ—‡• Ǥ ˆŽ—‡…‡‘ˆŽ‡ˆ–˜‡–”‹…—Žƒ”Ž‡ƒ†’‘•‹–‹‘”‡Žƒ–‹˜‡–‘•…ƒ”Ž‘…ƒ–‹‘‘”‡•’‘•‡–‘ …ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’›ǣ ƒ ‘†‡Ž •–—†›Ǥ —”‘’ƒ…‡ ǣ —”‘’‡ƒ ’ƒ…‹‰ǡ ƒ””Š›–Š‹ƒ•ǡ ƒ† …ƒ”†‹ƒ… ‡Ž‡…–”‘’Š›•‹‘Ž‘‰› ǣ Œ‘—”ƒŽ ‘ˆ –Š‡ ™‘”‹‰ ‰”‘—’• ‘ …ƒ”†‹ƒ… ’ƒ…‹‰ǡ ƒ””Š›–Š‹ƒ•ǡ ƒ† …ƒ”†‹ƒ… …‡ŽŽ—Žƒ” ‡Ž‡…–”‘’Š›•‹‘Ž‘‰› ‘ˆ –Š‡ —”‘’‡ƒ‘…‹‡–›‘ˆƒ”†‹‘Ž‘‰›‘˜ʹͲͳͶǢͳ͸—’’ŽͶǣ‹˜͸ʹǦ‹˜͸ͺǤ ƒ† ǡ Žƒƒ—™ ǡ ‹Š ǡ ‹•‘ ǡ ”‹Œ• ǡ ”‹œ‡ ǡ ‡”‘‘› Ǥ ‡ˆ– ˜‡–”‹…—Žƒ” Ž‡ƒ† ’Žƒ…‡‡– ‹ –Š‡ Žƒ–‡•– ƒ…–‹˜ƒ–‡† ”‡‰‹‘ ‰—‹†‡† „› …‘”‘ƒ”› ˜‡‘—•‡Ž‡…–”‘ƒƒ–‘‹…ƒ’’‹‰Ǥ—”‘’ƒ…‡ǣ—”‘’‡ƒ’ƒ…‹‰ǡƒ””Š›–Š‹ƒ•ǡƒ† …ƒ”†‹ƒ… ‡Ž‡…–”‘’Š›•‹‘Ž‘‰› ǣ Œ‘—”ƒŽ ‘ˆ –Š‡ ™‘”‹‰ ‰”‘—’• ‘ …ƒ”†‹ƒ… ’ƒ…‹‰ǡ ƒ””Š›–Š‹ƒ•ǡ ƒ† …ƒ”†‹ƒ… …‡ŽŽ—Žƒ” ‡Ž‡…–”‘’Š›•‹‘Ž‘‰› ‘ˆ –Š‡ —”‘’‡ƒ ‘…‹‡–› ‘ˆ ƒ”†‹‘Ž‘‰› ƒʹͲͳͷǢͳ͹ǣͺͶǦͻ͵Ǥ —”‘’‡ƒ ‘…‹‡–› ‘ˆ ǡ —”‘’‡ƒ ‡ƒ”– Š›–Š ǡ ”‹‰‘Ž‡ ǡ ‡– ƒŽǤ ʹͲͳ͵  ‰—‹†‡Ž‹‡• ‘ …ƒ”†‹ƒ… ’ƒ…‹‰ ƒ† …ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’›ǣ –Š‡ –ƒ• ˆ‘”…‡‘…ƒ”†‹ƒ…’ƒ…‹‰ƒ†”‡•›…Š”‘‹œƒ–‹‘–Š‡”ƒ’›‘ˆ–Š‡—”‘’‡ƒ‘…‹‡–›‘ˆ ƒ”†‹‘Ž‘‰› ȋȌǤ ‡˜‡Ž‘’‡† ‹ …‘ŽŽƒ„‘”ƒ–‹‘ ™‹–Š –Š‡ —”‘’‡ƒ ‡ƒ”– Š›–Š ••‘…‹ƒ–‹‘ ȋ ȌǤ —”‘’ƒ…‡ ǣ —”‘’‡ƒ ’ƒ…‹‰ǡ ƒ””Š›–Š‹ƒ•ǡ ƒ† …ƒ”†‹ƒ… ‡Ž‡…–”‘’Š›•‹‘Ž‘‰›ǣŒ‘—”ƒŽ‘ˆ–Š‡™‘”‹‰‰”‘—’•‘…ƒ”†‹ƒ…’ƒ…‹‰ǡƒ””Š›–Š‹ƒ•ǡ ƒ†…ƒ”†‹ƒ……‡ŽŽ—Žƒ”‡Ž‡…–”‘’Š›•‹‘Ž‘‰›‘ˆ–Š‡—”‘’‡ƒ‘…‹‡–›‘ˆƒ”†‹‘Ž‘‰›—‰ ʹͲͳ͵ǢͳͷǣͳͲ͹ͲǦͳͳͳͺǤ ƒ†‘ ǡ ‡”„‡” ǡ —’–ƒ ǡ ‡––ƒ ǡ œƒ”ˆ ǡ …Š‘… ǡ ƒ•‹” ǡ ”ƒ‹–…Šƒ ǡ ‹ƒ Ǥ ……—”ƒ–‡ ƒ† ‘„Œ‡…–‹˜‡ ‹ˆƒ”…– •‹œ‹‰ „› …‘–”ƒ•–Ǧ ‡Šƒ…‡† ƒ‰‡–‹… ”‡•‘ƒ…‡ ‹ƒ‰‹‰ ‹ ƒ …ƒ‹‡ ›‘…ƒ”†‹ƒŽ ‹ˆƒ”…–‹‘ ‘†‡ŽǤ

‘—”ƒŽ‘ˆ–Š‡‡”‹…ƒ‘ŽŽ‡‰‡‘ˆƒ”†‹‘Ž‘‰›‡…ʹͳʹͲͲͶǢͶͶǣʹ͵ͺ͵Ǧʹ͵ͺͻǤ ‡”“—‡‹”ƒ ǡ ‡‹••ƒ  ǡ ‹Ž•‹œ‹ƒ ǡ ƒ…‘„• ǡ ƒ—Ž ǡ ƒ•‡› ǡ ‡‡ŽŽ  ǡ—„‡”‰‡” ǡ›ƒǡ‡”ƒ‹Ǥ–ƒ†ƒ”†‹œ‡†›‘…ƒ”†‹ƒŽ•‡‰‡–ƒ–‹‘ƒ† ‘‡…Žƒ–—”‡ ˆ‘” –‘‘‰”ƒ’Š‹… ‹ƒ‰‹‰ ‘ˆ –Š‡ Š‡ƒ”–Ǥ  •–ƒ–‡‡– ˆ‘” Š‡ƒŽ–Š…ƒ”‡ ’”‘ˆ‡••‹‘ƒŽ• ˆ”‘ –Š‡ ƒ”†‹ƒ… ƒ‰‹‰ ‘‹––‡‡ ‘ˆ –Š‡ ‘—…‹Ž ‘ Ž‹‹…ƒŽ ƒ”†‹‘Ž‘‰›‘ˆ–Š‡‡”‹…ƒ ‡ƒ”–••‘…‹ƒ–‹‘Ǥ‹”…—Žƒ–‹‘ ƒʹͻʹͲͲʹǢͳͲͷǣͷ͵ͻǦ ͷͶʹǤ  Ǥ‹–‡ —•‹‘›ƒ‹…‡‰‹•–”ƒ–‹‘‘‘ŽǤ—’’Ž‡‡––‘–Š‡‹–‡•›•–‡ •–”—…–‹‘•ˆ‘”•‡ –‡”ƒ–‹‘ƒŽ†‹–‹‘ǣ–Ǥ —†‡‡†‹…ƒŽǢʹͲͲ͹Ǥ

‘Ž†ǡ‹”‰‡”•†‘––‡”Ǧ ”‡‡ǡ‹‰Š ǡŽŽ‡„‘‰‡ǡ—ǡ‡›‡”ǡ‡–Šǡ …Š‘—  Ǥ Š‡ ”‡Žƒ–‹‘•Š‹’ „‡–™‡‡ ˜‡–”‹…—Žƒ” ‡Ž‡…–”‹…ƒŽ †‡Žƒ› ƒ† Ž‡ˆ– ˜‡–”‹…—Žƒ””‡‘†‡ŽŽ‹‰ ™‹–Š…ƒ”†‹ƒ…”‡•›…Š”‘‹œƒ–‹‘–Š‡”ƒ’›Ǥ—” ‡ƒ”– …– ʹͲͳͳǢ͵ʹǣʹͷͳ͸ǦʹͷʹͶǤ

12.

13.

14.

15.

16.



‹ŒƒƒŽ‡ǡ˜ƒ†‡” ‡‡•– ǡ˜ƒ —Ž•˜ƒƒš‹• ǡ‹‡„‡Ž‹ ǡ”‘ˆ– ǡ ƒš

ǡ‡‹„‡” ǡ…ŠƒŽ‹Œ ǡ‡’’‡ˆ‡Ž†Ǥ ‡ƒ†Ǧ–‘ǦŠ‡ƒ†…‘’ƒ”‹•‘‘ˆ…‘–”ƒ•–Ǧ ‡Šƒ…‡†ƒ‰‡–‹…”‡•‘ƒ…‡‹ƒ‰‹‰ƒ†‡Ž‡…–”‘ƒƒ–‘‹…ƒŽ˜‘Ž–ƒ‰‡ƒ’’‹‰–‘ ƒ••‡••’‘•–Ǧ‹ˆƒ”…–•…ƒ”…Šƒ”ƒ…–‡”‹•–‹…•‹’ƒ–‹‡–•™‹–Š˜‡–”‹…—Žƒ”–ƒ…Š›…ƒ”†‹ƒ•ǣ ”‡ƒŽǦ–‹‡ ‹ƒ‰‡ ‹–‡‰”ƒ–‹‘ ƒ† ”‡˜‡”•‡† ”‡‰‹•–”ƒ–‹‘Ǥ —” ‡ƒ”–  ƒ ʹͲͳͳǢ͵ʹǣͳͲͶǦͳͳͶǤ Šƒ ǡ‹”†‡‡ǡƒŽ‡”ǡ—‰Š ǡ̵ ƒŽŽ‘”ƒǡŽ•‹ǡ‡ƒ†ǡ‡‰Ž‡›ǡ › ǡ —–ƒ Ǥ ƒ”‰‡–‡† Ž‡ˆ– ˜‡–”‹…—Žƒ” Ž‡ƒ† ’Žƒ…‡‡– –‘ ‰—‹†‡ …ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’›ǣ –Š‡   •–—†›ǣ ƒ ”ƒ†‘‹œ‡†ǡ …‘–”‘ŽŽ‡† –”‹ƒŽǤ

‘—”ƒŽ‘ˆ–Š‡‡”‹…ƒ‘ŽŽ‡‰‡‘ˆƒ”†‹‘Ž‘‰›’”ʹͶʹͲͳʹǢͷͻǣͳͷͲͻǦͳͷͳͺǤ ƒ‘• ǡ ƒ”•–ƒ† ǡ •–‡ˆ‡Ž† ǡ ƒ”Ž••‘ ǡ ‘‹Œ‡” ǡ ‘”‰“—‹•– Ǥ ‘„‹‡† ’”‡‘’‡”ƒ–‹˜‡ ‹ˆ‘”ƒ–‹‘ —•‹‰ ƒ „—ŽŽ•‡›‡ ’Ž‘– ˆ”‘ •’‡…Ž‡ –”ƒ…‹‰ ‡…Š‘…ƒ”†‹‘‰”ƒ’Š›ǡ …ƒ”†‹ƒ…  •…ƒǡ ƒ†   •…ƒǣ –ƒ”‰‡–‡† Ž‡ˆ– ˜‡–”‹…—Žƒ” Ž‡ƒ† ‹’Žƒ–ƒ–‹‘ ‹ ’ƒ–‹‡–• ”‡…‡‹˜‹‰ …ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’›Ǥ —”‘’‡ƒ Š‡ƒ”–Œ‘—”ƒŽ…ƒ”†‹‘˜ƒ•…—Žƒ” ƒ‰‹‰ƒ›ʹͲͳͶǢͳͷǣͷʹ͵Ǧͷ͵ͳǤ Š‡––› ǡ —…‡––  ǡ ‹• ǡ ‡– ƒŽǤ ƒ”†‹ƒ… ƒ‰‡–‹… ”‡•‘ƒ…‡Ǧ†‡”‹˜‡† ƒƒ–‘›ǡ •…ƒ”ǡ ƒ† †›••›…Š”‘› ˆ—•‡† ™‹–Š ˆŽ—‘”‘•…‘’› –‘ ‰—‹†‡  Ž‡ƒ† ’Žƒ…‡‡– ‹ …ƒ”†‹ƒ… ”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’›ǣ ƒ …‘’ƒ”‹•‘ ™‹–Š ƒ…—–‡ Šƒ‡‘†›ƒ‹…‡ƒ•—”‡•ƒ†‡…Š‘…ƒ”†‹‘‰”ƒ’Š‹…”‡˜‡”•‡”‡‘†‡ŽŽ‹‰Ǥ—”‘’‡ƒ Š‡ƒ”–Œ‘—”ƒŽ…ƒ”†‹‘˜ƒ•…—Žƒ” ƒ‰‹‰ —ŽʹͲͳ͵ǢͳͶǣ͸ͻʹǦ͸ͻͻǤ ‹ƒœ‹ ǡ ›— ǡ ‘‘† ǡ Š‘—†Š—”‹ ǡ Š–ƒ” Ǥ Š”‡‡Ǧ†‹‡•‹‘ƒŽ ‡Ž‡…–”‘ƒƒ–‘‹…ƒ’’‹‰‘ˆ–Š‡…‘”‘ƒ”›˜‡‹•†—”‹‰…ƒ”†‹ƒ…”‡•›…Š”‘‹œƒ–‹‘ –Š‡”ƒ’› ‹’Žƒ–ǣ ˆ‡ƒ•‹„‹Ž‹–› ƒ† ’‘••‹„Ž‡ ƒ’’Ž‹…ƒ–‹‘•Ǥ ‘—”ƒŽ ‘ˆ ‹–‡”˜‡–‹‘ƒŽ …ƒ”†‹ƒ… ‡Ž‡…–”‘’Š›•‹‘Ž‘‰› ǣ ƒ ‹–‡”ƒ–‹‘ƒŽ Œ‘—”ƒŽ ‘ˆ ƒ””Š›–Š‹ƒ• ƒ† ’ƒ…‹‰ ‘˜ʹͲͳͶǢͶͳǣͳͶ͹Ǧͳͷ͵Ǥ



  Table1 ƒ–‹‡–…Šƒ”ƒ…–‡”‹•–‹…• ‡‘‰”ƒ’Š‹…•  ƒ–‹‡–‘Ǥ  ‰‡ȋ›‡ƒ”•Ȍ  ƒŽ‡   ȋ‰ȀʹȌ  •…Š‡‹……ƒ”†‹‘›‘’ƒ–Š›  ‹Žƒ–‡†…ƒ”†‹‘›‘’ƒ–Š›   ȋ Ȁ Ȍ ˆ—…–‹‘   ȋΨȌ  ȋŽȌ  ȋŽȌ  ȋŽȌ  …Šƒ”ƒ…–‡”‹•–‹…•  ‹—•”Š›–Š  –”‹ƒŽˆ‹„”‹ŽŽƒ–‹‘

ͳ͵ 

ͳͺ ͸ͻǤʹάͺǤͲ ͳ͸ȋͺͻȌ ʹͺάͶ ͳ͹ȋͻͶȌ ͳȋ͸Ȍ ͳʹȋ͸͹ȌȀ͸ȋ͵͵Ȍ ʹͶǤͶά͸ǤͶ ʹͻ͹ǤͺάͺʹǤͷ ʹʹͺά͹ͶǤͻ ͸ͻǤͲάͳͺǤ͸ ͳ͹ȋͻͶȌ ͳȋ͸Ȍ

 †—”ƒ–‹‘ȋ•Ȍ     ‡†‹…ƒ–‹‘  –‹’Žƒ–‡Ž‡–  ‘—ƒ”‹•  ‡–ƒǦ„Ž‘…‡”•  ƒŽ…‹—ƒ–ƒ‰‘‹•–•  …‡Ǧ‹Š‹„‹–‘”Ȁ  ‹–”ƒ–‡•  ‹—”‡–‹…•  –ƒ–‹

ͳͷ͹ǤͶάʹ͵Ǥͺ ͳʹȋ͸͹Ȍ ͸ȋ͵͵Ȍ ͳͳȋ͸ͳȌ ͹ȋ͵ͻȌ ͳ͹ȋͻͶȌ ͶȋʹʹȌ ͳͷȋͺ͵Ȍ ͹ȋ͵ͻȌ ͳͷȋͺ͵Ȍ ͳͶȋ͹ͺȌ

ƒŽ—‡•ƒ”‡‡ƒά‘”nȋΨȌǤ ა‰‹‘–‡•‹Ǧ…‘˜‡”–‹‰Ǧ‡œ›‡ǡ ა‰‹‘–‡•‹Ǧ Ǧ”‡…‡’–‘”Ǧ„Ž‘…‡”ǡ  α„‘†›Ǧ ƒ••Ǧ‹†‡šǡ α…ƒ”†‹ƒ… ƒ‰‡–‹… ”‡•‘ƒ…‡ǡ ᇐ†Ǧ†‹ƒ•–‘Ž‹… ˜‘Ž—‡ǡ ᇐ†Ǧ •›•–‘Ž‹… ˜‘Ž—‡ǡ ዐ–‡”˜‡–”‹…—Žƒ” …‘†—…–‹‘ †‹•–—”„ƒ…‡ǡ αŽ‡ˆ– „—†Ž‡ „”ƒ…Š „Ž‘…ǡ αŽ‡ˆ– ˜‡–”‹…—Žƒ”ǡ  α ‡Œ‡…–‹‘ ˆ”ƒ…–‹‘ǡ  ᇙ ‘” ‡ƒ”– ••‘…‹ƒ–‹‘ǡα•–”‘‡˜‘Ž—‡Ǥ

ͳͶ 

 Table2 Ǧ‹˜‡•–‹‰ƒ–‹‘• ƒ–‹‡– ‘Ǥ  ͳ ʹ ͵ Ͷ ͷ ͸ ͹ ͺ ͻ ͳͲ ͳͳ ͳʹ ͳ͵ ͳͶ ͳͷ ͳ͸ ͳ͹ ͳͺ

ƒ••ȋ‰Ȍ …ƒ” ȋ؏ƒ••Ȍ   ͳʹͳ ͹ ͳͲʹ ͳͷ ͳͶͳ Ͷ ʹ͵Ͳ ͳͶ ͳʹͺ ͳ͵ ʹͶ͸ ͻ ͳ͸͸ ʹͲ ͳ͸Ͷ ͳͺ ͳͲͳ ͳ͸ ͳ͵ͺ ͳ͹ ͳ͵͹ ʹͷ ͳͳͺ ͻ ʹʹ͹ ͳʹ ͳͶͷ ͵ ͳͻͺ ͳͲ ͳͷ͹ ͳ͸ ʹͳ͵ ʹͶ ͳͺͲ ʹͲ

 Ž‘…ƒŽ‹œƒ–‹‘‘ˆ •…ƒ” ƒ•ƒŽ Ȁ Ȁ  Ȁ Ȁ Ȁ Ǧ Ȁ Ȁ Ȁ Ȁ  Ȁ Ȁ Ȁ Ǧ Ȁ Ȁ  ŽŽ Ȁ Ȁ Ȁ Ȁ Ȁ Ȁ Ȁ Ȁ Ȁ Ȁ  Ȁ Ȁ  Ȁ ȀȀ Ȁ Ȁ  Ȁ Ȁ Ȁ Ȁ 

‹† Ȁ Ȁ  Ȁ  Ȁ Ȁ Ȁ Ȁ Ȁ  Ȁ  ȀȀȀ  ȀȀȀ ȀȀ Ȁ Ȁ  Ȁ Ȁ ȀȀ Ȁ Ȁ  Ȁ Ȁ Ȁ Ȁ  Ȁ Ȁ Ȁ Ȁ Ȁ  Ȁ Ȁ Ȁ  Ȁ 

’‹…ƒŽ  Ǧ Ȁ ȀȀ  Ȁ Ȁ Ȁ ŽŽ ŽŽ ŽŽ  ŽŽ  ŽŽ  Ȁ  ŽŽ ŽŽ

’‡š Ǧ Ǧ Ǧ Ǧ Ǧ Ǧ ’‡š ’‡š Ǧ Ǧ ’‡š Ǧ Ǧ Ǧ Ǧ Ǧ ’‡š Ǧ

ა–‡”‹‘”ǡ  Ꮗ”‹…ƒ ‡ƒ”– ••‘…‹ƒ–‹‘ǡ ა–‡”‘Žƒ–‡”ƒŽǡ ა–‡”‘•‡’–ƒŽǡ Ǧ ᆇŽƒ›‡† ‡Šƒ…‡‡– …ƒ”†‹ƒ… ƒ‰‡–‹… ”‡•‘ƒ…‡ǡ ዐˆ‡”‹‘”ǡ ዐˆ‡”‘Žƒ–‡”ƒŽǡ ዐˆ‡”‘•‡’–ƒŽǡαŽƒ–‡”ƒŽǡαŽ‡ˆ–˜‡–”‹…—Žƒ”ǡᕇ’–ƒŽǤ  

ͳͷ 

 Table3 Ž‡…–”‘Ǧƒƒ–‘‹…ƒ’’‹‰‹˜‡•–‹‰ƒ–‹‘•  ‘ Ǥ

ƒ’’‡† ƒ–‡•– Ž‡…–”‹…ƒŽ ˜‡‹• ƒ…–‹˜ƒ †‡Žƒ›Žƒ–‡•– ƒ…–‹˜ƒ–‡† –‡† ˜‡‹ ˜‡‹• ȋΨ†Ȍ

ͳ ǡ ǡ  ʹ ǡ ͵ ǡǡ  Ͷ ǡǡ  ͷ ǡǡ  ͸ ǡǡ  ͹ ǡʹš ǡ  ͺ ǡǡ ʹš  ͻ ǡǡ  ͳ ǡǡ Ͳ  ͳ ǡǡ ͳ ǡ  ͳ ǡ ǡ ʹ  ͳ ǡǡ ͵  ͳ ǡ ǡ Ͷ  ͳ ǡǡ ͷ ǡ  ͳ ǡǡ ͸ ǡ  ͳ ǡǡ ͹  ͳ ǡǡ ͺ 

ƒ•ƒŽǦ  ƒ•ƒŽǦ  ‹†Ǧ  ƒ•ƒŽǦ  ‹†Ǧ  ƒ•ƒŽǦ  ƒ•ƒŽǦ  ‹†Ǧ  ‹†Ǧ  ‹†Ǧ  ‹†Ǧ  ƒ•ƒŽǦ  ‹†Ǧ  ƒ•ƒŽǦ  ‹†Ǧ  ‹†Ǧ  ‹†Ǧ  ‹†Ǧ 

ͳͶ͵ȋͻʹȌ ͳͻ͹ȋͳͳ͵Ȍ ͳʹͳȋ͹ʹȌ ͳ͹Ͷȋͺ͵Ȍ ͳ͸͹ȋͺͻȌ ͳͷʹȋͻͳȌ ͳͳͻȋͺͳȌ ͳ͵ͲȋͺͳȌ ͳͲ͹ȋ͹ͷȌ ͻͷȋ͹ʹȌ ͺ͹ȋ͸͸Ȍ ͻͲȋ͸ͶȌ ͹ʹȋͷ͹Ȍ ͳ͹ͺȋͳͳ͵Ȍ ͳͲͷȋ͹͹Ȍ ͳ͹ͳȋͻʹȌ ͳͺͺȋͻͻȌ

Ž‡ƒ†‘—–•‹†‡•…ƒ” ‹Žƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹

‡• ‡•

 ǡ   ǡ

‡•

ƒ•ƒŽǦ  ‹†Ǧ

ǡ 

‡•

‹†Ǧ 

‡•

ǡ

‡•

‡•

ǡ

‘

ƒ•ƒŽǦ  ‹†Ǧ

ǡ

‡•

ʹšǡ 

‘

ǡ ʹ

‡•



‡•

ƒ•ƒŽǦ ‡•  ‹†Ǧ ‘ǣ‹ʹ†‘—–•‹†‡•…ƒ” ʹ ‹†Ǧ ʹ ‘ǣ‹ʹ†‘—–•‹†‡•…ƒ” ȋ•ƒŽŽ˜‡‹Ȍ ‹†Ǧ ‡•

Ǧ

‘

‹†Ǧ

Ǧ

‘

‹†Ǧ 



‘

ǡ

‡•

’‹…ƒŽǦ  ‹†Ǧ

‘ǣ‹‹•…ƒ”ȋƒŽŽ˜‡‹•‹ •…ƒ”Ȍ ‘ǣ‹‹•…ƒ”ȋƒŽŽ˜‡‹•‹ •…ƒ”Ȍ ‘ǣ‹‹•…ƒ”ȋ‘–Š‡”˜‡‹• Ž‘™‡Ž‡…–”‹…ƒŽ†‡Žƒ›Ȍ ‡•

ǡ 

‡•

‹†Ǧ 

‡•

ǡ

‘

‹†Ǧ 

ǡǡ  

‡•

‹†Ǧ 

‘ǣ‹‹•…ƒ”ȋ‘–Š‡”˜‡‹• Ž‘™‡Ž‡…–”‹…ƒŽ†‡Žƒ›Ȍ ‡•

‡•

‹†Ǧ

‡•

‡•

’‹…ƒŽǦ 

‘ǣ‹ ‹•…ƒ”ȋŽ‡ƒ† ‹•–ƒ„‹Ž‹–›Ȍ

ƒ•ƒŽȀ‹ †Ǧ

ͳ͸ͺȋͻͻȌ

‹ƒŽ Ž‡ƒ† ’‘•‹–‹‘

ƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ Ž‘…ƒ–‡† ‘—–•‹†‡ •…ƒ” ‡•

Ǧ ˜‡‹• ‘—–•‹†‡ •…ƒ”

‘ǣ‹ʹ†‘—–•‹†‡•…ƒ”

ა–‡”‹‘” ˜‡‹ǡ ა–‡”‘Žƒ–‡”ƒŽ ˜‡‹ǡ ǦᆇŽƒ›‡† ‡Šƒ…‡‡– …ƒ”†‹ƒ… ƒ‰‡–‹…”‡•‘ƒ…‡ǡα‡Ž‡…–”‘Ǧƒƒ–‘‹…ƒ’’‹‰ǡ ዐˆ‡”‹‘”˜‡‹ǡ ዐˆ‡”‘Žƒ–‡”ƒŽ ˜‡‹ǡαŽƒ–‡•–ƒ…–‹˜ƒ–‡†˜‡‹ǡαŽ‡ˆ–˜‡–”‹…—Žƒ”ǡ†α†—”ƒ–‹‘Ǥ  

ͳ͸ 



Figure1

 ͳ͹ 

Figure2

ͳͺ 

Figure3



ͳͻ 

Figure4

  ʹͲ 

Figure5

 Figure1 ƒ‰‡‹–‡‰”ƒ–‹‘™‘”ˆŽ‘™‘ˆ’ƒ–‹‡–‘ǤͷǤǦ•‡‰‡–ƒ–‹‘•ȋȌ™‡”‡…ƒ””‹‡†‘—– ’”‡Ǧ’”‘…‡†—”ƒŽŽ›–‘…‘•–”—…–͵‡•Š‡•ȋȌǤ‘”‘ƒ”›˜‡‘—•ȋȌ™ƒ•‹–‡‰”ƒ–‡† ™‹–Š –Š‡ Ǧ ‡•Š ‹–”ƒǦ’”‘…‡†—”ƒŽŽ› ȋȌǤ ‘””‡•’‘†‹‰ „—ŽŽ•‡›‡Ǧ’Ž‘– ȋȌ ™Š‡”‡ –Š‡  ™ƒ• Žƒ–‡•– ƒ…–‹˜ƒ–‡† ƒ† Ž‘…ƒ–‡† ‹ •…ƒ”Ǥ Š‡”‡ˆ‘”‡ǡ –Š‡  Ž‡ƒ† ™ƒ• –ƒ”‰‡–‡† –‘™ƒ”†• –Š‡ •‡…‘† Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ȋȌ ”‡‘–‡ ˆ”‘ •…ƒ”Ǥ  ა–‡”‘Žƒ–‡”ƒŽ ˜‡‹ǡ ა–‡”‹‘” ˜‡‹ǡ α…‘”‘ƒ”›  •‹—•ǡ ǦᆇŽƒ›‡† ‡Šƒ…‡‡– …ƒ”†‹ƒ… ƒ‰‡–‹…”‡•‘ƒ…‡ǡα‡Ž‡…–”‘Ǧƒƒ–‘‹…ƒ’’‹‰ǡ ዐˆ‡”‘Žƒ–‡”ƒŽ˜‡‹ǡ ዐˆ‡”‹‘” ˜‡‹ǡ αŽ‡ˆ– ƒ–‡”‹‘” ‘„Ž‹“—‡ǡ αŽ‡ˆ– ˜‡–”‹…Ž‡ǡ  †α †—”ƒ–‹‘ǡ α”‹‰Š– ƒ–‡”‹‘”‘„Ž‹“—‡ǡα”‹‰Š–˜‡–”‹…Ž‡Ǥ  Figure2 ƒ‰‡ ‹–‡‰”ƒ–‹‘ ƒ……—”ƒ…› …‘’—–ƒ–‹‘ ‹ Ǥ ͵ …‘‘”†‹ƒ–‡• ™‡”‡ ”‘–ƒ–‡†ǡ ƒŽ‹‰‹‰ ƒŽŽ ˜‡”–‹…‡• „‡Ž‘‰‹‰ –‘ ƒ  •Ž‹…‡ –‘ –Š‡ •ƒ‡ ǦŠ‡‹‰Š– ȋȌǤ Š‡ —…Ž‹†‡ƒ †‹•–ƒ…‡™ƒ•‡ƒ•—”‡†„‡–™‡‡–Š‡‡’‹…ƒ”†‹—ƒ†–Š‡˜‡”–‹…‡•‘ˆ–Š‡˜‡‹•‡ƒ”‡•––‘ –Š‡…‡–”‘ÆȋȌǤ –Š‹•’ƒ–‹‡–‡ƒ•—”‡‡–•™‡”‡’‡”ˆ‘”‡†ƒ–͵Ͳ•‹–‡•ȋȌǤ  ʹͳ 

Figure3 ƒ–‘‹…ƒŽ †‹•–”‹„—–‹‘ ‘ˆ Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ȋȌǤ ƒ…Š …‹”…Ž‡† —„‡” ”‡’”‡•‡–• ƒ ’ƒ–‹‡–Ǥ Š‹–‡ …‹”…Ž‡• ”‡’”‡•‡– Ž‘…ƒ–‹‘• ‘—–•‹†‡ •…ƒ”ǡ ™Š‹Ž‡ „Žƒ… ”‡’”‡•‡– ‹ •…ƒ”Ǥ ა–‡”‹‘”ǡ

ა–‡”‘Žƒ–‡”ƒŽǡ

ა–‡”‘•‡’–ƒŽǡ

ዐˆ‡”‹‘”ǡ

ዐˆ‡”‘Žƒ–‡”ƒŽǡ

ዐˆ‡”‘•‡’–ƒŽǡαŽƒ–‡”ƒŽǡᕇ’–ƒŽǤ ‡…‹•‹‘ƒ‹‰ˆŽ‘™…Šƒ”–‘ˆŽ‡ƒ†’‘•‹–‹‘ȋȌǤ ‘‡Ǧ–Š‹”†‘ˆ–Š‡’ƒ–‹‡–•–Š‡Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ™ƒ• Ž‘…ƒ–‡† ‹ •…ƒ”ǡ ’”‘Š‹„‹–‹‰ ‘’–‹ƒŽ  Ž‡ƒ† ’‘•‹–‹‘•Ǥ αŽƒ–‡•– ƒ…–‹˜ƒ–‡†˜‡‹Ǥ  Figure4 šƒ’Ž‡• ‘ˆ ‹–‡‰”ƒ–‡† ‹ƒ‰‡• ƒ† …‘””‡•’‘†‹‰ „—ŽŽ•‡›‡Ǧ’Ž‘–•Ǥ ”ƒ…‡† Ǧ …‘–‘—”•‹†‹…ƒ–‡‡†‘…ƒ”†‹—ƒ†•…ƒ”Ǥ ’ƒ–‹‡–‘Ǥ͸ȋȌ–Š‡Ž‡ƒ†™ƒ•‹–Š‡Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ȋȌ ‘—–•‹†‡ •…ƒ”Ǥ  ’ƒ–‹‡– ‘Ǥͺ ȋȌ ‘’–‹ƒŽ  ’Žƒ…‡‡– ™ƒ• Šƒ’‡”‡†ƒ•–Š‡™ƒ•–‘‘•ƒŽŽƒ†Š‡”‡–Š‡Ž‡ƒ†™ƒ•’Žƒ…‡†‹–Š‡•‡…‘†Žƒ–‡•– ƒ…–‹˜ƒ–‡† ˜‡‹ ȋ ʹȌǤ  ’ƒ–‹‡– ‘ǤͳͲ ȋȌ ƒŽŽ –ƒ”‰‡– ˜‡‹• ™‡”‡ •—””‘—†‡† „› •…ƒ” ’”‘Š‹„‹–‹‰ƒ†‘’–‹ƒŽŽ‡ƒ†’‘•‹–‹‘Ǥ ƒ–‹‡–‘ǤͳʹȋȌ–Š‡Ž‡ƒ†™ƒ•’Žƒ…‡†‹ –Š‡ ‹•…ƒ”ƒ•ƒŽŽƒŽ–‡”ƒ–‹˜‡˜‡‹•™‡”‡‡ƒ”Ž›ƒ…–‹˜ƒ–‡†Ǥ„„”‡˜‹ƒ–‹‘•ƒ”‡†‡•…”‹„‡† ‹–Š‡…ƒ’–‹‘‘ˆ ‹‰—”‡ͳǤ  Figure5 ‘š’Ž‘–• ‘ˆ   —‹’‘Žƒ” ˜‘Ž–ƒ‰‡• ‹ ‘Ǧ•…ƒ” ˜•Ǥ •…ƒ” ’‡” ‹†‹˜‹†—ƒŽ’ƒ–‹‡–Ǥ PǦ˜ƒŽ—‡• ƒ”‡„ƒ•‡†‘ƒȂŠ‹–‡›–‡•–•Ǥᗐ‹’‘Žƒ”˜‘Ž–ƒ‰‡Ǥ          

”ƒ’Š‹…ƒŽƒ„•–”ƒ…– ʹʹ 

TV Ring

HBP lead

MVR

Selective His Bundle Pacing

TV Ring

HBP lead

MVR

HIS BUNDLE PACING IN A PATIENT WITH MVR AND TV RING

Graphical Abstract