Abstract
AimsCardiac resynchronization therapy (CRT) upgrades may be less likely to improve following intervention. Leadless left ventricular (LV) endocardial pacing has been used for patients with previously failed CRT or high-risk upgrades. We compared procedural and long-term outcomes in patients undergoing coronary sinus (CS) CRT upgrades with high-risk and previously failed CRT upgrades undergoing LV endocardial upgrades.Method and resultsProspective consecutive CS upgrades between 2015 and 2019 were compared with those undergoing WiSE-CRT implantation. Cardiac resynchronization therapy response at 6 months was defined as improvement in clinical composite score (CCS) and a reduction in LV end-systolic volume (LVESV) ≥15%. A total of 225 patients were analysed; 121 CS and 104 endocardial upgrades. Patients receiving WiSE-CRT tended to have more comorbidities and were more likely to have previous cardiac surgery (30.9% vs. 16.5%; P = 0.012), hypertension (59.2% vs. 34.7%; P < 0.001), chronic obstructive airways disease (19.4% vs. 9.9%; P = 0.046), and chronic kidney disease (46.4% vs. 21.5%; P < 0.01) but similar LV ejection fraction (30.0 ± 8.3% vs. 29.5 ± 8.6%; P = 0.678). WiSE-CRT upgrades were successful in 97.1% with procedure-related mortality in 1.9%. Coronary sinus upgrades were successful in 97.5% of cases with a 2.5% rate of CS dissection and 5.6% lead malfunction/displacement. At 6 months, 91 WiSE-CRT upgrades and 107 CS upgrades had similar improvements in CCS (76.3% vs. 68.5%; P = 0.210) and reduction in LVESV ≥15% (54.2% vs. 56.3%; P = 0.835). ConclusionDespite prior failed upgrades and high-risk patients with more comorbidities, WiSE-CRT upgrades had high rates of procedural success and similar improvements in CCS and LV remodelling with CS upgrades.
Highlights
Cardiac resynchronization therapy (CRT) is an important intervention in symptomatic patients with severe left ventricular (LV) systolic impairment,[1] with CRT upgrades accounting for 28% of all implantations.[2]
Left ventricular (LV) endocardial pacing can be used in patients with previously failed CRT or high-risk upgrades
WiSE-CRT upgrades were successful in 97.1% of cases with procedure-related mortality in 1.9% and no acute strokes
Summary
Cardiac resynchronization therapy (CRT) is an important intervention in symptomatic patients with severe left ventricular (LV) systolic impairment,[1] with CRT upgrades accounting for 28% of all implantations.[2]. Endocardial pacing may overcome many of these limitations allowing access to faster endocardial conduction and optimal pacing site selection avoiding myocardial scar and targeting areas of latest electrical or mechanical activation.[7,8] Endocardial pacing has been shown to improve both left and right ventricular function.[9] The WiSE-CRT system (EBR systems, USA) is capable of providing leadless LV endocardial pacing to achieve CRT. It consists of three separate components: a subcutaneous transmitter connected only to a subcutaneous battery and a leadless electrode within the left ventricle. We set out to compare procedural and long-term outcomes in patients undergoing CS CRT upgrades with patients with previously failed CRT or high-risk CRT upgrades receiving endocardial CRT upgrades with the WiSE-CRT system
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