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

Background Coronary sinus venography is commonly used during cardiac resynchronization therapy (CRT) to guide left ventricular (LV) lead placement; however, iodinated contrast poses a substantial risk of contrast-induced acute kidney injury in patients with chronic kidney disease (CKD). Evidence supporting contrast-sparing CRT techniques remains limited. Objective This study aimed to assess the feasibility, safety, and renal outcomes of a zero-contrast CRT implantation strategy in patients with CKD. Methods Consecutive patients with CKD (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m2) undergoing CRT at 2 centers between January 2023 and June 2025 were analyzed. Procedures were initiated using a contrast-free approach, with coronary sinus venography reserved as a bailout strategy. Predictors of ≥20% eGFR decline were evaluated using multivariable logistic regression. Secondary outcomes included an increase in an LV ejection fraction of ≥5 percentage points at 3–6 months and 1-year all-cause mortality and heart failure hospitalization. Results Overall, 113 patients were analyzed. Zero-contrast implantation was successful in 57.5% of cases. Renal function remained stable after zero-contrast implantation (change in eGFR +3.6 mL/min/1.73 m2; P = .08), whereas it declined significantly in the contrast group (−7.9 mL/min/1.73 m2; P < .001). Postprocedural acute kidney injury occurred in 1.5% vs 14.6% of patients, respectively (P = .004). Contrast use (odds ratio 6.8, 95% confidence interval 1.5–30.9; P = .013), lower baseline eGFR, and diabetes independently predicted a ≥20% decline in eGFR. Complication rates, LV ejection fraction improvement, and 1-year mortality or heart failure hospitalization were similar between groups. Conclusion Zero-contrast CRT implantation is feasible, safe, and effective, with better renal preservation in patients with CKD.