Zero-contrast cardiac resynchronization therapy device implantation in heart failure patients with renal impairment

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BACKGROUND Coronary sinus (CS) venography is commonly used during cardiac resynchronization therapy (CRT) to guide left ventricular lead placement; however, iodinated contrast poses a substantial risk of contrast-induced acute kidney injury (CI-AKI) in patients with chronic kidney disease (CKD). Evidence supporting contrast-sparing CRT techniques remains limited. OBJECTIVE To assess the feasibility, safety, and renal outcomes of a zero-contrast CRT implantation strategy in CKD patients. METHODS Consecutive CKD patients (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m 2 ) undergoing CRT at two centers between January 2023 and June 2025 were analyzed. Procedures were initiated using a contrast-free approach, with CS venography reserved as a bail-out strategy. Predictors of ≥20% eGFR decline were evaluated using multivariable logistic regression. Secondary outcomes included increase in left ventricular ejection fraction (LVEF) ≥5 percentage points at 3–6 months and one-year all-cause mortality and heart failure hospitalization (HFH). RESULTS Overall, 113 patients were analyzed. Zero-contrast implantation was successful in 57.5% of cases. Renal function remained stable after zero-contrast implantation (ΔeGFR +3.6 mL/min/1.73 m 2 ; p=0.08), whereas it declined significantly in the contrast group (−7.9 mL/min/1.73 m 2 ; p < 0.001). Post-procedural AKI occurred in 1.5% versus 14.6% of patients, respectively (p = 0.004). Contrast use (odds ratio 6.8, 95% confidence interval 1.5–30.9; p=0.013), lower baseline eGFR, and diabetes independently predicted a ≥20% decline in eGFR. Complication rates, LVEF improvement, and one-year mortality or HFH were similar between groups. CONCLUSION Zero-contrast CRT implantation is feasible, safe, and effective, with better renal preservation in patients with CKD.

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