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  • Review Article
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Strategies to improve cardiac resynchronization therapy

Nature Reviews Cardiology volume 11, pages 481–493 (2014)Cite this article

Subjects

Key Points

  • Cardiac resynchronization therapy (CRT) is widely used to improve cardiac pump function and prolong life in patients with heart failure, but 30–50% do not respond to treatment

  • Appropriate selection of patients, careful positioning of pacing leads, and optimization of resynchronization settings can notably improve response to CRT

  • Patients with left bundle branch block (LBBB), a QRS duration >150 ms, or both, benefit most from CRT; whether mechanical dyssynchrony provides additional useful diagnostic information is disputed

  • Optimal left ventricular lead positions vary considerably between individuals, but scarred regions should be avoided, and selection of a late-activated region is particularly important in patients with non-LBBB morphology

  • The greatest benefit from CRT might come from the optimal placement of one left ventricular pacing lead, rather than the combined effects of pacing at multiple sites

  • Optimization of atrioventricular and interventricular intervals increases acute haemodynamic response, but the lack of an accurate method to measure synchronization has hampered assessment of long-term effects

Abstract

Cardiac resynchronization therapy (CRT) emerged 2 decades ago as a useful form of device therapy for heart failure associated with abnormal ventricular conduction, indicated by a wide QRS complex. In this Review, we present insights into how to achieve the greatest benefits with this pacemaker therapy. Outcomes from CRT can be improved by appropriate patient selection, careful positioning of right and left ventricular pacing electrodes, and optimal timing of electrode stimulation. Left bundle branch block (LBBB), which can be detected on an electrocardiogram, is the predominant substrate for CRT, and patients with this conduction abnormality yield the most benefit. However, other features, such as QRS morphology, mechanical dyssynchrony, myocardial scarring, and the aetiology of heart failure, might also determine the benefit of CRT. No single left ventricular pacing site suits all patients, but a late-activated site, during either the intrinsic LBBB rhythm or right ventricular pacing, should be selected. Positioning the lead inside a scarred region substantially impairs outcomes. Optimization of stimulation intervals improves cardiac pump function in the short term, but CRT procedures must become easier and more reliable, perhaps with the use of electrocardiographic measures, to improve long-term outcomes.

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Figure 1: Sequences of electrical activation and strain curves before and after CRT in a dog with left branch bundle block.
Figure 2
Figure 3: Electrocardiograms showing various criteria for complete LBBB.161
Figure 4: Kaplan–Meier curves for all-cause mortality according to the site of LV pacing in the TARGET study.78
Figure 5: Changes in LVdP/dtmax in dogs with isolated left bundle branch block during LV pacing according to number and location of sites.
Figure 6: Changes in resynchronization and pump function after biventricular cardiac resynchronization therapy.

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Authors and Affiliations

  1. Department of Cardiology, Maastricht University Medical Center, PO Box 5800, Maastricht, 6202 AZ, Netherlands

    Kevin Vernooy & Marc Strik

  2. Department of Physiology, Maastricht University, PO Box 616, Maastricht, 6200 MD, Netherlands

    Caroline J. M. van Deursen & Frits W. Prinzen

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  1. Kevin Vernooy
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K.V. and F.W.P. researched data for the article. All the authors contributed substantially to discussion of content and wrote the manuscript. K.V. and F.W.P. reviewed/edited the article before submission.

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Correspondence to Frits W. Prinzen.

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Competing interests

K.V. has received research grants from Medtronic. F.W.P. has received research grants from Biological Delivery Systems (Johnson & Johnson), EBR Systems, Medtronic, MSD, and Proteus Biomedical; and is an advisor to St. Jude Medical. The other authors declare no competing interests.

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Vernooy, K., van Deursen, C., Strik, M. et al. Strategies to improve cardiac resynchronization therapy. Nat Rev Cardiol 11, 481–493 (2014). https://doi.org/10.1038/nrcardio.2014.67

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