Comparing Three Types of Specialist Pacemakers to Improve Heart Function and Reduce Rhythm Problems in Heart Failure

Randomised Investigation of Physiological, Conventional and Optimised Resynchronisation Therapy in Heart Failure With Prolonged QRS Duration (RIPCORD-CRT)

The goal of this clinical trial is to find out which type of specialist pacemaker-known as cardiac resynchronisation therapy (CRT)-works best for people with heart failure and a delay in how the lower chambers of the heart beat together (called electrical dyssynchrony).

The main aims of the study are:

To compare the effects of conventional biventricular pacing (BVP), conduction system pacing (CSP) and left-bundle optimised CRT (LOT-CRT) on heart failure symptoms and heart rhythm problems over six months.

To explore how these pacing methods affect heart muscle strength, electrical activity, and overall heart function.

Participants will:

Attend four hospital visits over a six-month period.

At Visit 1, meet a member of the research team to discuss the study and have screening tests to check eligibility. Participants will also have a smartphone app installed and receive training on how to record their daily heart failure symptoms.

At Visit 2, have a CRT pacemaker implanted. The type of pacemaker will be chosen at random, with a 1 in 3 chance of receiving:

• Biventricular pacing (BVP); the current standard treatment
• Conduction system pacing (CSP)
• LOT-CRT (Left-bundle optimised CRT); a combination of both

At Visit 3 (around 12 weeks after implantation) and Visit 4 (6 months after implantation), take part in routine follow-up assessments to check the pacemaker and heart function.

At Visits 2 and 4, also undergo non-invasive electrical mapping tests, including wearing a specialised vest and having a low-dose CT scan of the chest. These tests help researchers understand how the heart's electrical system responds to different pacing methods.

Inclusion Criteria:

Patients referred/scheduled for a CRT procedure (new implant or upgrade) who have:

• Symptomatic heart failure (NYHA II-IV)
• Reduced ejection fraction (LVEF≤40%)
• Prolonged QRS duration (≥130ms) and left bundle branch block ECG morphology or very prolonged QRS duration (>150ms) and non-left bundle branch block ECG
• Optimal medical therapy for HF

Exclusion Criteria:

• Unable to provide informed consent
• <18 years old
• Pregnant patients (with female patients of childbearing age requiring a negative urine BHCG)