Introduction: The management of ICDs towards end of life present considerable challenges with modern day device technology. In particular, there is little data on cardiac resynchronisation therapy (CRT) patients who receive no therapy during the lifetime of the device however are pacing dependant. With the advent of devices which consist of DF-4 RV and IS-4 leads, the options to downgrade to a pacemaker system are further limited.
Case report: A 79-year old gentleman, with a background of ischaemic cardiomyopathy, NSVT and a LVEF of 20% was implanted with an Abbott Quadra Assura CRT-D device. The device consisted of an Abbott DF-4 RV lead and IS-4 Coronary Sinus lead. During the lifetime of the device, the patient became pacing dependent and received no treatment for tachyarrhythmias. Advanced care planning was implemented due to drug refractory heart failure and a decision was made to downgrade to CRT-P. As there was no adapter to convert the DF-4 RV lead to an IS-1 connector, it was suggested to connect the IS-4 Coronary sinus lead to a compatible CRT-P device and pace in an LV only configuration. Prior to generator change, the patient was programmed to a LV only configuration through the current device however this resulted in significant symptoms of pre-syncope and a reduction in systolic BP from baseline. As LV only pacing was not appropriate, a short-dated CRT-D at a reduced price was sourced and ICD therapies were deactivated at the time of generator change.
Discussion: Approximately one-third of patients newly fitted with ICDs in Western countries are 70 years or older (Galder et al., 2011). Although studies have shown an improvement in mortality rates with CRT (Moss, A et al., 2009), there is now a growing number of patients where despite optimal pharmacological and device therapy, prognosis is poor due to refractory symptoms of heart failure. In the setting of Advanced care planning, attempts are made to ensure the patient remains comfortable towards the end of life and although ICD therapy is often deactivated, the expectation is that pacemaker therapy will continue due to unpredictability of life expectancy. There are consensus documents on the withdrawal of ICD therapy, however there is little in the way of guidance for pacing dependant patients. Device battery behaviour varies amongst manufacturers however towards the end life, devices may program themselves into a back-up mode leading to asynchronous pacing which can result in symptoms of pacemaker syndrome. In order to avoid unnecessary distress to the patient, those that are pacing dependent are often required to undergo generator replacement.
Conclusions: The decision to downgrade from a CRT-D to a CRT-P towards the end of life carry ethical, clinical and financial implications, particularly in the elderly. A multidisciplinary approach to decision making is vital which should include discussions of appropriateness of device type. One could speculate that lower risk sub-groups should be implanted with DF-1 rather than DF-4 leads to facilitate potential downgrade to CRT-P. In addition to this, clinicians should put pressure on industry to produce suitable adaptors which will allow the downgrade to avoid unnecessary costs to healthcare providers. The patient described in this case sadly passed away 3 weeks post generator change.