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CRT Non-responder — EECC MCQ

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ModerateCardiac DevicesCRT Non-responderEECC

A 62-year-old man with HFrEF (LVEF 28%) and LBBB (QRS 162 ms) in sinus rhythm received a CRT-D 12 months ago. His LVEF has only improved to 30% and he remains in NYHA class III. Biventricular pacing percentage is 98%. What is the most important next step in optimising CRT response?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Check LV lead position and optimise AV and VV timing intervals under echocardiographic guidance

Approximately 30-40% of CRT recipients are classified as non-responders. Before concluding non-response, the following should be optimised: (1) Confirm LV lead position (lateral or posterolateral wall, avoiding apical pacing and phrenic nerve stimulation); (2) Optimise AV delay (ensuring full LV capture before intrinsic AV conduction) and VV interval (timing between RV and LV pacing) using echocardiographic guidance; (3) Ensure biventricular pacing >98% (already achieved here); (4) Rule out and treat AF (which reduces effective biventricular pacing); (5) Review GDMT adherence and titration. If these measures fail, conduction system pacing (His bundle or LBBAP) may be considered as an alternative to traditional biventricular pacing.

Reference: ESC (2021): Guidelines on Cardiac Pacing and CRT; ESC (2023): HF Guidelines