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While echocardiographic predictors of response are well described in de novo CRT, evidence in CRT upgrade populations remains limited. We investigated predictors of echocardiographic response in the BUDAPEST-CRT Upgrade trial cohort.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      In this randomized trial, 360 patients with heart failure and reduced ejection fraction (HFrEF) with priorly implanted pacemaker or ICD,\u2009\u2265\u200920% right ventricular (RV) pacing burden, and wide-paced QRS (\u2265\u2009150\u00a0ms) were randomized to CRT-D upgrade (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009215) or ICD upgrade (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u2009145). Echocardiographic response was defined as\u2009\u2265\u200915% reduction in left ventricular end-systolic volume (LVESV) at 12\u00a0months.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Among 275 patients with paired echocardiographic data, 161 (59%) were responders. Responders had fewer HF hospitalizations (0.6% vs. 7.0%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.003), more often received mineralocorticoid receptor antagonists (71% vs. 59%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.038), and showed a higher baseline RV pacing burden (88.9% vs. 83.4%,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.025) than non-responders. Independent predictors of echocardiographic response were randomization to CRT-D (OR 5.57, 95% CI 2.56\u201312.12,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.0001), greater RV pacing burden (OR 1.02 per %, 95% CI 1.00\u20131.04,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.024), non-ischemic cardiomyopathy (OR 2.50, 95% CI 1.15\u20135.26,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.021), and a lateral LV lead position (OR 8.79, 95% CI 1.28\u201360.39,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.027).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In patients with pacing-induced cardiomyopathy, CRT-D upgrade significantly improved echocardiographic outcomes. Non-ischemic etiology, higher RV pacing burden, and lateral LV lead positioning were associated with greater benefit. These results underscore the importance of tailored patient selection and lead placement strategies to optimize CRT-D upgrade outcomes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00392-026-02963-x","type":"journal-article","created":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T07:28:34Z","timestamp":1787124514000},"page":"2206-2215","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Predictors of echocardiographic response in the Budapest-CRT upgrade trial"],"prefix":"10.1007","volume":"115","author":[{"given":"Eperke","family":"Merkel","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rich\u00e1rd","family":"Masszi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"B\u00e1lint","family":"Lakatos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert","family":"Hatala","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bogl\u00e1rka","family":"Veres","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexandra","family":"F\u00e1bi\u00e1n","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Istv\u00e1n","family":"Osztheimer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"L\u00e1szl\u00f3","family":"Gell\u00e9r","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tam\u00e1s","family":"Urb\u00e1n","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Csaba","family":"Horv\u00e1th","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Scott D.","family":"Solomon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Valentina","family":"Kutyifa","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Attila","family":"Kov\u00e1cs","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6514-0723","authenticated-orcid":false,"given":"B\u00e9la","family":"Merkely","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annam\u00e1ria","family":"Kosztin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,8,19]]},"reference":[{"issue":"12","key":"2963_CR1","doi-asserted-by":"publisher","first-page":"2272","DOI":"10.1016\/j.hrthm.2016.09.027","volume":"13","author":"EL Kiehl","year":"2016","unstructured":"Kiehl EL, Makki T, Kumar R, Gumber D, Kwon DH, Rickard JW, Kanj M, Wazni OM, Saliba WI, Varma N, Wilkoff BL, Cantillon DJ (2016) Incidence and predictors of right ventricular pacing-induced cardiomyopathy in patients with complete atrioventricular block and preserved left ventricular systolic function. 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I.O. reports lecture and advisory fees from Abbott, Biotronik, Boston Scientific, Medtronic, and Vitatron and travel grants from Abbott, Biotronik, Boston Scientific, and Medtronic. At.K. reports grants from Bolyai Research Scholarship and FK \u201cOTKA\u201d Research Grant from NKFIH outside the submitted work; stock from CardioSight, Inc. and stock option from Argus Cognitive, Inc. outside the submitted work; and personal fees from Argus Cognitive, Inc. and CardioSight Hungary LLC outside the submitted work. L.G. reports support for the present manuscript from Vitatron Medical, Boston Scientific, Abbott Laboratories, Medtronic Hungary, and Biotronik Hungary; consulting fees from Medtronic Hungary and Abbott Hungary; honoraria; travel grants; participation on a data safety monitoring board or advisory board; and role in other board and committee (FESC, FEHRA, President of the Scientific Committee of the Hungarian Society of Cardiology, Past President of the Working Group on Cardiac Arrhythmias and Pacing, and EHRA Scientific Programme Board). An.K. reports grants from Bolyai Research Scholarship outside the submitted work; consulting fees from Medtronic; honoraria from AstraZeneca, Bayer, Boehringer Ingelheim, Biotronik, Novartis; payment for expert testimony from Boehringer Ingelheim and Boston Scientific; travel grants from AstraZeneca and Novartis; participation on a data safety monitoring board or advisory board for Boehringer Ingelheim and Boston Scientific; and role in other board and committee (committee member of Hungarian Society of Cardiology and secretary of the Working Group on Cardiac Arrhythmias and Pacing, Hungarian Society of Cardiology). S.D.S. reports grants to institution from Actelion, Alnylam, Amgen, AstraZeneca, Bellerophon, Bayer, BMS, Celladon, Cytokinetics, Eidos, Gilead, GSK, Ionis, Lilly, Mesoblast, MyoKardia, NIH\/NHLBI, Neurotronik, Novartis, NovoNordisk, Respicardia, Sanofi Pasteur, Theracos, and US2.AI and consulting fees outside the scope of the current work from Abbott, Action, Akros, Alnylam, Amgen, Arena, AstraZeneca, Bayer, Boehringer Ingelheim, BMS, Cardior, Cardurion, Corvia, Cytokinetics, Daiichi-Sankyo, GSK, Lilly, Merck, Myokardia, Novartis, Roche, Theracos, Quantum Genomics, Cardurion, Janssen, Cardiac Dimensions, Tenaya, Sanofi Pasteur, Dinaqor, Tremeau, CellProThera, Moderna, American Regent, Sarepta, Lexicon, Anacardio, Akros, and Valo. R.H. reports institutional grants from Abbott, Biotronik, and Slovak Research and Development Agency; honoraria from Abbott and Medtronic; and travel grants from the European Society of Cardiology and Pfizer. He is also the president of the Slovak Heart Rhythm Association. E.M. reports grants from Novartis, Boehringer Ingelheim and Biotronik Hungary. V.K. reports grants from Boston Scientific, ZOLL, Biotronik, Spire Inc., and NIH; consulting fees from Biotronik and Zoll; payment or honoraria for lectures from Abbott Medical, Medtronic. The other authors declare no conflict of interest for this contribution.","order":1,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}}]}}