title: Cardiac resynchronization therapy (CRT) device replacement considerations: upgrade or downgrade? A complex decision in the current clinical setting.
abstract: There are limited data about the management of patients presenting for elective generator replacements in the setting of previously implanted cardiac resynchronization therapy (CRT) devices that are nearing end-of-life. The individual patient's clinical status and concomitant morbidities may evolve so that considerations may include not only replacement of the pulse generator, but also potentially changing the type of device [e.g. downgrading CRT-defibrillator (CRT-D) to CRT-pacemaker (CRT-P) or ICD or upgrading of CRT-P to CRT-D]. Moreover, the clinical evidence for CRT-D/CRT-P implantation may change over time, with ongoing research and availability of new trial data. In this review we discuss the ethical, clinical and financial implications related to CRT generator replacements and the need for additional clinical trials to better understand which patients should undergo CRT device downgrading or upgrading at the time of battery depletion.
authors.affiliation: University Hospital of Heraklion, PO box 1352, Stavrakia, Heraklion Crete, Greece.
authors.forename: Eleni S
authors.initials: ES
authors.lastname: Nakou
authors.affiliation: University Hospital of Heraklion, PO box 1352, Stavrakia, Heraklion Crete, Greece.
authors.forename: Emmanuel N
authors.initials: EN
authors.lastname: Simantirakis
authors.affiliation: University Hospital of Heraklion, PO box 1352, Stavrakia, Heraklion Crete, Greece.
authors.forename: Eleftherios M
authors.initials: EM
authors.lastname: Kallergis
authors.affiliation: University Hospital of Heraklion, PO box 1352, Stavrakia, Heraklion Crete, Greece.
authors.forename: Konstantinos S
authors.initials: KS
authors.lastname: Nakos
authors.affiliation: University Hospital of Heraklion, PO box 1352, Stavrakia, Heraklion Crete, Greece.
authors.forename: Panos E
authors.initials: PE
authors.lastname: Vardas
mesh_terms: D000368:Aged; D058406:Cardiac Resynchronization Therapy / Q000706:statistics & numerical data*; D058409:Cardiac Resynchronization Therapy Devices / Q000706:statistics & numerical data*; D000066491:Clinical Decision-Making / Q000379:methods*; D020878:Device Removal / Q000706:statistics & numerical data*; D019544:Equipment Failure Analysis / Q000379:methods* / Q000706:statistics & numerical data; D019317:Evidence-Based Medicine; D005260:Female; D006333:Heart Failure / Q000517:prevention & control*; D006801:Humans; D008297:Male; D016896:Treatment Outcome
keywords: Cardiac resynchronization therapy; Cost-effectiveness; Downgrading; Super-responders; Upgrading