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

BACKGROUND Coronary sinus venography is commonly used dur- ing cardiac resynchronization therapy (CRT) to guide left ventricu- lar (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 pa- tients with CKD. METHODS Consecutive patients with CKD (estimated glomerular filtration rate [eGFR] ,60 mL/min/1.73 m 2 ) undergoing CRT at 2 centers between January 2023 and June 2025 were analyzed. Pro- cedures were initiated using a contrast-free approach, with coro- nary 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 ejec- tion 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 implan- tation was successful in 57.5% of cases. Renal function remained sta- ble after zero-contrast implantation (change in eGFR 13.6 mL/min/ 1.73 m 2 ; P 5 .08), whereas it declined significantly in the contrast group (27.9 mL/min/1.73 m 2 ; P , .001). Postprocedural acute kid- ney injury occurred in 1.5% vs 14.6% of patients, respectively (P 5 .004). Contrast use (odds ratio 6.8, 95% confidence interval 1.5– 30.9; P 5 .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 hospitali- zation were similar between groups. CONCLUSION Zero-contrast CRT implantation is feasible, safe, and effective, with better renal preservation in patients with CKD.