CTR-D without the left lead vs single/dual chamber ICD implantation: a cost saving strategy to avoid future upgrading of the latter?

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Introduction/Background: Implantation of cardioverter defibrillators (ICD) to prevent sudden death is common in patients with left ventricular dysfunction (LVD) (1).However, these devices are expensive and there is increasing controversy about their cost benefit ratio. More agreement is present about the benefits of cardiac resynchronization therapy (CRT) in patients with LVD and concurrent heart failure (HF) and left bundle branch block (LBB) (2). Nevertheless, LVD often presents without one these two conditions which may only develop at follow up. This makes unclear the benefits of CRT at the time of ICD implantation (CRT-D) in these patients. Some have advocated implanting a CRT-D without the left ventricle lead instead of a conventional single/dual chamber ICD which would give the possibility to add CRT pacing without replacing the device generator at follow-up. However, this practice has been never evaluated and it is unclear its potential impact on cost. Methods This study included all CRT devices implanted in our institution since 2005. Patients with LVD but just heart failure (HF) or left bundle branch block (LBB) were considered for CRT-D implantation without the left lead. The number of patients who needed implantation of a LV lead at follow-up was analyzed. Only patients who needed device replacement due to battery depletion were included in the final analysis Results A total of 913 CRT devices were implanted of which 115 (12.59%) were implanted without a left ventricular lead. The left ventricular lead was not implanted due to technical reasons in 46 cases (5%) and electively in the remaining. CRT device replacement (due to Elective Replacement Indicator (ERI) activation) was necessary in 38 patients of the latter and a LV lead had been never implanted in 32 (84.21%) of them during follow-up (7 +/- 2 years). In patients who needed a LV lead added, device replacement (because of battery depletion) was necessary during left ventricular lead implant procedure in 2 (6.25%). Using the average cost of these devices in our institution (22,000 euros), around 384,000 euros could have been saved if the CRT-D had not been implanted until left ventricular lead was. Conclusions Implantation of a CRT-D without the left ventricle lead instead of a conventional single/dual chamber ICD in patient with border line indication for CRT is not cost effective and does not result is significant savings in ICD generators.