Rethinking atrial pacing support in cardiac resynchronization therapy: insights from the CRT-NEXT trial

Area of Science:

• Cardiology
• Medical Devices
• Clinical Trials

Background:

• Traditional cardiac resynchronization therapy defibrillators (CRT-D) use three leads, including one for atrial pacing.
• The necessity of routine atrial pacing in CRT recipients without sinus node dysfunction is debated.
• Additional leads increase procedural complexity and risk of lead-related complications.

Purpose of the Study:

• To evaluate the non-inferiority of a simplified two-lead CRT-DX system (atrial sensing only) compared to conventional three-lead CRT-D.
• To assess if eliminating routine atrial pacing impacts clinical outcomes and complications.

Main Methods:

• A randomized non-inferiority trial (CRT-NEXT) comparing CRT-DX to conventional CRT-D.
• Participants were CRT candidates without sinus node dysfunction.
• Primary endpoint: composite of all-cause mortality, cardiovascular hospitalization, and lead-related complications at 12 months.

Main Results:

• The CRT-DX system met the non-inferiority criterion for the composite endpoint.
• Mortality, cardiovascular hospitalization, arrhythmic outcomes, reverse remodeling, and functional capacity were similar between groups.
• CRT-DX showed shorter procedure times and fewer atrial lead complications, with reliable atrial sensing.

Conclusions:

• A simplified two-lead CRT-DX system without routine atrial pacing is a viable alternative for selected CRT-D candidates.
• Reliable atrial sensing may suffice for most patients without sinus node dysfunction, challenging the need for routine atrial pacing.
• This simplification can reduce procedural complexity and lead-related issues in CRT therapy.