CRT-D to CRT-P Downgrade Decision — EECC MCQ

Correct answer: D — Device replacement strategy should be individualised by the Heart Team — consider: if LVEF has improved to >35% and there have been no ventricular arrhythmias, downgrading to CRT-P may be reasonable; if ischaemic aetiology or arrhythmic risk factors persist, CRT-D replacement is generally favoured; the RESET-CRT trial aims to address this question

Generator replacement at ERI is an opportunity to reassess the appropriateness of continued ICD therapy. The 2022 ESC VA/SCD Guidelines recommend individualised assessment: FACTORS FAVOURING CRT-D: (1) ischaemic aetiology (higher ongoing SCD risk); (2) prior appropriate ICD therapies; (3) LVEF still ≤35%; (4) arrhythmogenic genotype (LMNA, FLNC). FACTORS FAVOURING DOWNGRADE TO CRT-P: (1) LVEF improved to >35% on CRT; (2) non-ischaemic aetiology (DANISH trial: weaker ICD evidence); (3) no arrhythmias over the device lifetime; (4) significant comorbidities limiting life expectancy; (5) patient preference. The RESET-CRT trial is a prospective randomised trial specifically addressing CRT-D vs CRT-P at generator replacement in patients with improved LVEF. Currently, this decision is Heart Team-based with shared decision-making. Battery longevity: CRT-P lasts longer than CRT-D (no ICD circuitry/capacitors), reducing future replacement procedures.

Reference: ESC (2022): VA/SCD; ESC (2021): Pacing/CRT