Successful CRT Upgrade Following Less-invasive Ventricular Enhancement Therapy with the Revivent TC Transcatheter System in a patient with a left ventricular aneurysm.

Introduction: 

In selected patients with heart failure (HF) and ischaemic cardiomyopathy, surgical ventricular reconstruction (SVR) has been shown to be an effective therapy. Excluding nonviable or scarred myocardium by reducing LV size and conically reshaping the chamber can improve LV function and HF. The epicardial Revivent TC System allows LV reconstruction on the beating heart without the need for ventriculotomy. The scarred lateral LV wall is attached to the septal scar using paired anchors placed through epicardial transmural catheters. We present a case report of a patient with ischaemic cardiomyopathy (ICM) who underwent CRT upgrade after less invasive ventricular enhancement therapy with the Revivent TC system. 

Case report: 

The 71-year-old patient presented to our hospital in 2024 with acute heart failure on optimal medical therapy (OMT). Following an anterior myocardial infarction in 1998, the patient developed an anteroseptal aneurysm.  Due to recurrent ventricular tachycardia (VT), the patient underwent endocardial VT ablation in 2020 and LV reconstruction including epicardial cryoablation in 2021. Transthoracic echocardiography (TTE) showed a moderately reduced ejection fraction after reconstruction of the LV. The ECG and the ICD telemetry showed a 2nd degree atrioventricular block with continuous right ventricular pacing. Despite the altered anatomy, we decided to perform a CRT upgrade. The CS ostium was posteriorly located and could be intubated with an AL1 diagnostic catheter. To place a rigid J-wire in the coronary sinus and to insert the CS catheter into the great cardiac vein, a 5F diagnostic catheter (AL1) was required. The quadripolar LV lead could be positioned postero-laterally and showed good electrical data despite its proximity to the anchors. The day after the procedure, radiographs excluded pneumothorax and showed good lead position. Three months later, there was significant clinical improvement, and the patient has had no cardiac decompensation since.  

Conclusion: 

The Revivent TC System can be used to treat patients with a LV aneurysm. This can be an obstacle to successful CRT implantation due to changes in cardiac anatomy. To our knowledge, this is the first case report demonstrating the feasibility of CRT upgrade following minimally invasive LV reconstruction and both endo- and epicardial VT ablation.