Upgrading to cardiac resynchronisation therapy: Concordance of real-world experience with clinical guidelines

Abstract

Objective: Revision to cardiac resynchronisation therapy (CRT) in patients with existing pacemakers with worsening heart failure (HF) can improve symptoms and cardiac function. We identify factors that predict improvement in left ventricular ejection fraction (LVEF) within a year of CRT revision. Methods: We performed a retrospective study of 146 consecutive patients (16% female, mean age 73 ± 11 years, mean LVEF 27 ± 8%) undergoing revision to CRT (January 2012 to May 2018) in a single tertiary centre. LVEF was measured pre-revision and 3, 6 and 12 months post-upgrade. Results: At 6 months, 68% of patients demonstrated improvement in LVEF (mean ΔLVEF + 6.7% ± 9.6). Compared to patients in atrial fibrillation (AF), patients with sinus rhythm had a greater improvement in LVEF at 6 months (sinus 8.4 ± 10.3% vs. AF 4.2 ± 8.0%, p = 0.02). Compared to ischaemic cardiomyopathy (ICM), patients with non-ischaemic cardiomyopathy (NICM) had a greater improvement in LVEF at 6 months (NICM 8.4 ± 9.8% vs ICM 4.8 ± 9.2%, p = 0.05). Patients with RV pacing ≥40% at baseline had a greater improvement in LVEF at 6 months (≥40% RV pacing 9.3 ± 10.2 vs. < 40% RV pacing 4.0 ± 7.4%, p = 0.01). All improvements were sustained over 12 months post-revision. There was no significant difference between genders, years between initial implant and revision, or previous device type. Conclusions: Our real-world experience supports current guidelines on CRT revision. NICM, ≥40% RV pacing and sinus rhythm are the main predictors of improvement in LVEF in patients who underwent CRT revision.

Keywords

• Heart failure
• HFrEF
• Cardiac resynchronisation therapy
• CRT upgrade
• CRT revision