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PVC Burden Reducing CRT Efficacy — EECC MCQ

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HardCardiac DevicesPVC Burden Reducing CRT EfficacyEECC

A 62-year-old man with a CRT-D has biventricular pacing percentage of only 85% on device interrogation. He has frequent PVCs (18% burden on Holter). His LVEF has not improved from 30% despite 6 months of CRT. What is the most likely reason for suboptimal CRT response and the recommended action?

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Correct answer: A — High PVC burden is reducing effective biventricular pacing; catheter ablation of the PVC focus should be considered to improve CRT delivery

Biventricular pacing percentage >98% is essential for optimal CRT benefit. A pacing percentage of 85% is suboptimal and often caused by: (1) frequent PVCs (which are sensed beats, not paced — reducing BiV pacing percentage), (2) AF with rapid ventricular response, or (3) device programming issues. In this case, an 18% PVC burden directly accounts for the reduced pacing percentage. Catheter ablation of the PVC focus (if monomorphic and from a single site) can restore effective biventricular pacing and is associated with improved CRT response. Studies have shown that patients with high PVC burden who undergo successful ablation have similar CRT outcomes to those without PVCs.

Reference: ESC (2021): Guidelines on Cardiac Pacing and CRT; HRS Expert Consensus on CRT Optimisation