Repositioning and optimization of left ventricular lead position in nonresponders to cardiac resynchronization therapy is associated with improved ejection fraction, lower NT-proBNP values, and fewer heart failure symptoms

BackgroundObservational data suggest that an anterior or apical left ventricular (LV) position in cardiac resynchronization therapy (CRT) is associated with worse outcome and higher likelihood of “nonresponse.” It is not known whether the benefits of optimizing LV lead position in a second procedure outweighs the procedural risks.ObjectiveTo evaluate the clinical effects of LV lead repositioning.MethodsDuring the period 2015–2020, we identified all patients in whom the indication for the procedure was LV lead repositioning owing to “nonresponse” in combination with suboptimal LV lead position. All patients were followed with a structured visit 6 months post LV lead revision. Heart failure hospitalization and mortality data were gathered from the medical records and cross-checked with the population registry.ResultsA total of 25 patients were identified who fulfilled the inclusion criteria. All procedures were successful in establishing LV lead pacing in a lateral mid or basal location. Median follow-up was 2.5 years [1.1–3.7]. There were improvements in NYHA class (mean -0.5 ± 0.5 class, P < .001), LV ejection fraction (+5 [interquartile range 2–11] absolute %, P = .01), QRS duration (-36 [-44 to -8], P < .001) and N-terminal pro–brain natriuretic peptide (NT-proBNP) (-615 [-2837 to +121] ng/L, P = .03). Clinical outcome was similar to a reference population with CRT (P = ns).ConclusionIn nonresponders to CRT with either an anterior or inferior LV lead position, it was feasible to perform LV lead repositioning in all cases, with a low complication rate. Changing the LV lead position was associated with improved LV ejection fraction, larger QRS reduction, and larger NT-proBNP reduction. Observational data suggest that an anterior or apical left ventricular (LV) position in cardiac resynchronization therapy (CRT) is associated with worse outcome and higher likelihood of “nonresponse.” It is not known whether the benefits of optimizing LV lead position in a second procedure outweighs the procedural risks. To evaluate the clinical effects of LV lead repositioning. During the period 2015–2020, we identified all patients in whom the indication for the procedure was LV lead repositioning owing to “nonresponse” in combination with suboptimal LV lead position. All patients were followed with a structured visit 6 months post LV lead revision. Heart failure hospitalization and mortality data were gathered from the medical records and cross-checked with the population registry. A total of 25 patients were identified who fulfilled the inclusion criteria. All procedures were successful in establishing LV lead pacing in a lateral mid or basal location. Median follow-up was 2.5 years [1.1–3.7]. There were improvements in NYHA class (mean -0.5 ± 0.5 class, P < .001), LV ejection fraction (+5 [interquartile range 2–11] absolute %, P = .01), QRS duration (-36 [-44 to -8], P < .001) and N-terminal pro–brain natriuretic peptide (NT-proBNP) (-615 [-2837 to +121] ng/L, P = .03). Clinical outcome was similar to a reference population with CRT (P = ns). In nonresponders to CRT with either an anterior or inferior LV lead position, it was feasible to perform LV lead repositioning in all cases, with a low complication rate. Changing the LV lead position was associated with improved LV ejection fraction, larger QRS reduction, and larger NT-proBNP reduction.