Decision making for upgrading or downgrading a CRT device regarding ethical, medical, and economic issues

There are limited data about the management of patients presenting for elective generator replacements in the setting of previously implanted implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT) devices that are nearing end of life. Over a patient's life span, clinical situations evolve and previously present conditions that merited CRT implantation may change. The individual patient's clinical status and concomitant illnesses may evolve so that considerations may include not only replacement of the pulse generator but also potentially changing the type of device [e.g., downgrading CRT-defibrillator (CRT-D) to CRT-pacemaker (CRT-P) or ICD or upgrading of CRT-P to CRT-D]. Moreover, the clinical evidence for CRT-D/CRT-P placement may evolve over time, with ongoing research and availability of new trial data. In this review we discuss the ethical, medical, and financial implications related to CRT generator replacements and the need for additional clinical trials to better understand which patients should undergo downgrading or upgrading.

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