Cardiac resynchronization therapy with or without defibrillation requires a patient-tailored approach based on age, comorbidities, and arrhythmia risk, pending future randomized controlled trials.
Does CRT-D compared to CRT-P improve outcomes in patients with severe left ventricular dysfunction and intraventricular conduction disturbances?
The decision to implant a CRT-D versus a CRT-P should be individualized based on factors like age, comorbidities, and etiology of heart failure, balancing the prevention of arrhythmic death against higher complication rates and costs.
Cardiac resynchronization therapy (CRT) was shown to improve cardiac function, reduce heart failure hospitalizations, improve quality of life and prolong survival in patients with severe left ventricular dysfunction and intraventricular conduction disturbances, mainly left bundle branch block, on optimal medical therapy with ACE-inhibitors, β-blockers and mineralocorticoid receptor antagonists up-titrated to maximum tolerated evidence-based doses. CRT can be achieved by means of pacemaker systems (CRT-P) or devices with defibrillation capabilities (CRT-D). CRT-Ds offer an undoubted advantage in the prevention of arrhythmic death, but such an advantage may be of lesser degree in nonischemic heart failure etiologies. Moreover, the higher CRT-D hardware complexity compared to CRT-P may predispose to device/lead malfunctions and the higher current drainage may cause a shorter battery duration with consequent premature replacements and the well-known incremental complications. In a period of financial constraints, also device costs should be carefully evaluated, with recent reports suggesting that CRT-Ps may be favored over CRT-Ds in patients with nonischemic cardiomyopathy and no prior history of cardiac arrhythmias from a cost-effectiveness point of view. The choice between a CRT-P or a CRT-D device should be patient-tailored whenever straightforward defibrillator indications are not present. The Goldenberg score may facilitate this decision-making process in ambiguous settings. Age, comorbidities, kidney disease, atrial fibrillation, advanced functional class, inappropriate therapy risk, implantable device infections, and malfunctions are factors potentially reducing the expected benefit from defibrillating capabilities. In the future, prospective randomized controlled trials are warranted to directly compare the efficacy and safety of CRT-Ps and CRT-Ds.
Golzio et al. (Fri,) conducted a review in Heart failure with severe left ventricular dysfunction and intraventricular conduction disturbances. Cardiac resynchronization therapy with defibrillation (CRT-D) vs. Cardiac resynchronization therapy pacemaker (CRT-P) was evaluated. Cardiac resynchronization therapy with or without defibrillation requires a patient-tailored approach based on age, comorbidities, and arrhythmia risk, pending future randomized controlled trials.