Optimizing Cardiac Resynchronization Therapy: an Update on New Insights and Advancements
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Purpose of Review
This review focuses on the current advancements in optimizing patient response to cardiac resynchronization therapy (CRT).
It has been well known that not every patient will derive benefit from CRT, and of those that do, there are varying levels of response. Optimizing CRT begins well before device implant and involves appropriate patient selection and an understanding of the underlying substrate. After implant, there are different CRT device programming options that can be enabled to help overcome barriers as to why a patient may not respond.
Given the multifaceted components of optimizing CRT and the complex patient population, multi-subspecialty clinics have been developed bringing together specialists in heart failure, electrophysiology, and imaging. Data as to whether this results in better response rates and outcomes shows promise.
KeywordsHeart failure Cardiac resynchronization therapy CRT optimization CRT optimization clinic Electrophysiology EP device management
Compliance with Ethical Standards
Conflict of Interest
Adam Grimaldi and Eiran Z. Gorodeski declare no conflicts of interest. John Rickard reports personal fees from Medtronic and personal fees from Boston scientific, outside the submitted work.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 10.Zareba W, Klein H, Cygankiewicz I, Hall WJ, McNitt S, Brown M, et al. Effectiveness of cardiac Resyncrhonization therapy by QRS morphology in the multicenter automatic defibrillator implantation trial-cardiac resynchronization therapy (MADIT-CRT). Circulation. 2011;123:1061–72.CrossRefPubMedGoogle Scholar
- 12.Fantoni C, Kawabata M, Massaro R, et al. Right and left ventricular activation sequence in patients with heart failure and right bundle branch block: a detailed analysis using three-dimensional non-fluoroscopic electroanatomic mapping system. J Cardiovasc Electrophysiol. 2005;16(2):112–9.CrossRefPubMedGoogle Scholar
- 15.Surawicz B, Childers R, Deal BJ, Gettes LS, Bailey JJ, Gorgels A, et al. AHA/ACCF/HRS recommendations for the standardization and interpretation of the electrocardiogram: part III: intraventricular conduction disturbances: a scientific statement from the American Heart Association electrocardiography and arrhythmias committee, council on clinical cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. Endorsed by the International Society for Computerized Electrocardiology. J Am Coll Cardiol. 2009;53(11):976–81.CrossRefPubMedGoogle Scholar
- 18.Epstein AE, DiMarco JP, Ellenbogen KA, American College of Cardiology Foundation; American Heart Association task force on practice guidelines, Heart Rhythm Society, et al. 2012 ACCF/AHA/HRS focused update incorporated into the ACCF/AHA/HRS 2008 guidelines for device –based therapy of cardiac rhythm abnormalities: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2013;61:6–75.CrossRefGoogle Scholar
- 24.Wilton SB, Shibata MA, Sondergaard R, Cowan K, Semeniuk L, Exner DV. Relationship between left ventricular lead position using a simple radiographic classification scheme and long-term outcome with resynchronization therapy. J Interv Card Electrophysiol. 2008;23(3):219–27.CrossRefPubMedGoogle Scholar
- 26.Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, et al. Dual chamber and VVI implantable defibrillator trial investigators. Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the dual chamber and VVI implantable defibrillator (DAVID) trial. JAMA. 2002;288(24):3115–23.CrossRefPubMedGoogle Scholar
- 27.Boriani G, Kranig W, Donal E, Calo L, Casella M, Delarche N, et al. A randomized double-blind comparison of biventricular versus left ventricular stimulation for cardiac resynchronization therapy: the biventricular versus left Univentricular pacing with ICD back-up in heart failure patients (B-LEFT HF) trial. Am Heart J. 2010;159(6):1052–8.CrossRefPubMedGoogle Scholar
- 28.Martin DO, Lemke B, Birnie D, Krum H, Lee KL, Aonuma K, et al. Adaptive CRT study investigators. Investigation of a novel algorithm for synchronized left-ventricular pacing and ambulatory optimization of cardiac resynchronization therapy: results of the adaptive CRT trial. Heart Rhythm. 2012;9(11):1807–14.CrossRefPubMedGoogle Scholar
- 29.• Tomassoni G, Baker J, Corbisiero R, et al. Rationale and design of a randomized trial to assess the safety and efficacy of MultiPoint Pacing (MPP) in cardiac resynchronization therapy: The MPP Trial. Ann Noninvasive Electrocardiol, 2017;22(6). https://doi.org/10.1111/anec.12448. This study is ongoing and will help to answer wether MPP results in improved CRT response rates.
- 30.Kamath GS, Cotiga D, Koneru JN, Arshad A, Pierce W, Aziz EF, et al. The utility of 12-lead holter monitoring in patients with permanent atrial fibrillation for the identification of nonresponders after cardiac resynchronization therapy. J Am Coll Cardiol. 2009;53(12):1050–5.CrossRefPubMedGoogle Scholar
- 31.• Plummer CJ, Frank CM, Bari Z, et al. A novel algorithm increases the delivery of effective cardiac resynchronization therapy during atrial fibrillation: the CRTee randomized crossover trial. Heart Rhythm. 2017;S1547-5271(17):31240–7. This study shows that with this novel algorithm, there is an increase in effective CRT pacing in patients with AF. More data is needed to see if this means improved response to CRT and clinical outcomes. Google Scholar
- 32.Ellenbogen KA, Gold MR, Meyer TE, Fernndez Lozano I, Mittal S, Waggoner AD, et al. Primary results from the SmartDelay determined AV optimization: a comparison to other AV delay methods in cardiac resynchronization therapy (SMART-AV) trial: a randomized trial comparing empirical, echocardiography-guided, and algorithmic atrioventricular delay programming in cardiac resynchronization therapy. Circulation. 2010;122(25):2660–8.CrossRefPubMedGoogle Scholar
- 33.Boriani G, Muller CP, Seidl KH, et al. Randomized comparison of simultaneous biventricular stimulation versus optimized interventricular delay in cardiac resynchronization therapy. The resynchronization for the HemodYnamic treatment for heart failure management II implantable cardioverter defibrillator (RHYTHM II ICD) study. Am Heart J. 2006;151(5):1050–8.CrossRefPubMedGoogle Scholar
- 34.Weiss R, Malik M, Dinerman J, et al. VV optimization in cardiac resynchronization therapy non-responders: RESPONSE-HF trial results. Abstract AB12–5. Denber (CO): HRS. 2010.Google Scholar