Background Left ventricular (LV) lead upgrade in patients with implantable cardioverter defibrillators (ICD) or bradycardia pacemakers may reverse pacing induced cardiomyopathy or reduced heart failure hospitalisations, but complication rates are higher than new implants.
Purpose To report the indications and outcomes of LV lead upgrades to cardiac resynchronisation (CRT).
Methods We retrospectively studied consecutive patients undergoing CRT upgrades from January 2014 to August 2021. 3345 pacing procedures were performed of which 347 were de novo CRT implants (10.4%) and 160 were CRT upgrades (4.7%).
Results Of the 160 upgrades mean age was 75±11 and 129 were male (81%). There were 3 indications for upgrade; to treat (90) or prevent (26) pacing-induced cardiomyopathy, specifically prior to atrioventricular (AV) node ablation in (5/26), and conventional CRT indication with left bundle branch block and ejection fraction <35% (43). The types of devices upgraded can be found in table 1.Upgrade was prompted by symptoms 95 (60%), box change 42 (26%), ventricular arrhythmias in 9 (6%), routine follow up echo or surveillance in 12 (7%), or a new RV lead 2 (1%). Beta blockers were prescribed in 97 (61%), angiotensin converting enzyme inhibitors in 78 (49%) or angiotensin receptor blockers in 41 (26%).Median time from implant to upgrade was 6.9 years (2.7–11). 43% had a normal ejection fraction (EF) at implant. Mean change from implant to upgrade was -13% ± 10 and mean EF at upgrade was 30% ±9.57% were responders to CRT with a mean change in EF of 16% ± 6. 33% did not respond and 12% deteriorated further. 26 (16%) had a heart failure hospitalisation (HFH) pre upgrade of which only 6 had further HFH. 26 (16%) patients had a HFH after upgrade, of which 6 had prior admissions with HF.LV lead placement was unsuccessful in 2 (1%). 16 procedural complications occurred in 15 patients (9%), mostly driven by lead displacement. No patient had a pneumothorax. 4 had a complication during follow up (3%) (Table 2), infection (2), LV lead failure (1), LV lead displaced (1). Further intervention was required in 2 cases. Extraction for infection (1), LV lead re-do (1). 25% died at a median follow up of 2.7 years (1.7–5).
Conclusion Upgrading devices to CRT in an elderly population was achieved in 99% of cases. The major complication rate is low and it is associated with an improvement in EF in 57%.
Conflict of Interest Nil
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