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CRT Non-responder Evaluation — EECC MCQ

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HardHeart FailureCRT Non-responder EvaluationEECC

A 60-year-old man with HFrEF (LVEF 28%) and a CRT-D in situ has persistent symptoms (NYHA III) despite optimal GDMT. His device interrogation shows 98% biventricular pacing with appropriate lead positions on CXR. What factors should be evaluated in a CRT non-responder?

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Correct answer: D — Assess: LV lead position (target lateral/posterolateral vein, not anterior or apical), biventricular pacing percentage (target >98%), AV and VV timing optimisation, ongoing myocardial ischaemia, and non-cardiac causes of dyspnoea

CRT non-response (failure to improve ≥1 NYHA class or ≥5% absolute improvement in LVEF) occurs in approximately 30% of patients. The ESC 2021 Pacing/CRT Guidelines recommend systematic evaluation: (1) LV lead position — lateral/posterolateral veins are optimal; anterior or apical positions yield worse outcomes (repositioning may be needed); (2) biventricular pacing percentage — must be >98% (AF with rapid rate, PVCs, and inappropriate ICD therapies all reduce effective BiV pacing); (3) AV delay optimisation — echocardiography-guided to maximise LV filling; (4) VV timing optimisation — sequential biventricular pacing may improve haemodynamics; (5) scar at the LV lead site (LGE on CMR); (6) residual ischaemia; (7) non-cardiac causes. Upgrade to conduction system pacing (His bundle or LBBAP) may be considered.

Reference: ESC (2021): Cardiac Pacing and CRT Guidelines