Does a 67-year-old lady with preserved Ejection Fraction (EF), low Congestive Heart Failure (CHF) symptom burden, and no Left Bundle Branch Block (LBBB), meet the criteria for a biventricular device?

From the Guidelines

The 67-year-old lady with preserved ejection fraction, low CHF symptom burden, and no left bundle branch block does not meet the criteria for a biventricular device (cardiac resynchronization therapy or CRT). Biventricular devices are primarily indicated for patients with reduced ejection fraction (typically EF ≤35%), significant heart failure symptoms (usually NYHA class II-IV despite optimal medical therapy), and evidence of electrical dyssynchrony, most commonly manifested as LBBB with QRS duration ≥150 ms [ 1 ]. Since this patient has preserved ejection fraction and no LBBB, she lacks the two major criteria that would warrant CRT implantation.

The benefits of CRT are most pronounced in patients with electrical dyssynchrony causing mechanical inefficiency of the heart, which this patient does not appear to have [ 1 ]. Instead, management should focus on optimizing medical therapy for her heart failure with preserved ejection fraction, which typically includes:

• Diuretics for symptom control
• Blood pressure management
• Treatment of underlying conditions such as hypertension, diabetes, or coronary artery disease that may contribute to her heart failure

Key considerations for this patient include:

• The absence of LBBB and preserved ejection fraction make CRT less likely to be beneficial
• The patient's low CHF symptom burden and lack of significant heart failure symptoms reduce the need for advanced device therapy
• Optimal medical therapy should be the primary focus for managing her heart failure with preserved ejection fraction [ 1 ]

In the context of real-life clinical medicine, prioritizing the patient's quality of life and minimizing morbidity and mortality are crucial. Given the current evidence and guidelines, the patient does not meet the criteria for a biventricular device, and alternative management strategies should be explored [ 1 ].

From the Research

Patient Profile

• The patient is a 67-year-old lady with preserved Ejection Fraction (EF) and low Congestive Heart Failure (CHF) symptom burden.
• She has been managed on Jardiance only with PRN Lasix and has not exhibited CHF symptoms until her most recent follow-up.
• Her BNP level was 70 in April, and she has been experiencing progressive bradycardia.
• She does not have Left Bundle Branch Block (LBBB) and has a relatively low A Fib burden (6%) off all b-blocking agents and anti-arrhythmics.

Biventricular Device Criteria

• The patient's profile does not perfectly match the typical criteria for a biventricular device, which usually includes patients with LBBB, wide QRS complex, and reduced EF 2, 3, 4.
• However, some studies suggest that patients with narrow QRS complex may also benefit from biventricular pacing, especially if they have ventricular dyssynchrony 3.
• The patient's preserved EF and low CHF symptom burden may not be typical of patients who would benefit from a biventricular device, but her recent increase in symptoms and progressive bradycardia may indicate a need for closer monitoring and potential intervention.

Device Considerations

• The decision to implant a biventricular device should be based on individual patient characteristics and needs, rather than a one-size-fits-all approach 5, 6.
• The patient's lack of LBBB and relatively low A Fib burden may affect the decision to implant a biventricular device, and alternative treatments or devices may be considered.
• Further evaluation and monitoring of the patient's condition may be necessary to determine the best course of treatment and to ensure that she receives the most appropriate device to minimize her symptom burden and optimize her quality of life.