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Cardiac resynchronization therapy in heart failure: Implantation and other considerations

Author
Daniel J Cantillon, MD, FACC, HRS
Section Editor
Jonathan Piccini, MD, MHS, FACC, FAHA, FHRS
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

Cardiac resynchronization therapy (CRT) is a treatment for some patients with chronic heart failure with reduced ejection fraction and bundle branch block involving biventricular pacing, or pacing of only the left ventricle [1-6]. CRT can be achieved with a device designed only for pacing (CRT-P) or with the added capability for defibrillation (CRT-D).

The rationale for CRT is that ventricular and atrioventricular dyssynchrony can further impair the function of a failing ventricle. Resynchronization may improve performance and reverse the deleterious process of ventricular remodeling, improve quality of life, reduce heart failure hospitalizations, and improve survival outcomes. CRT does not obviate medical therapy. (See "Rationale for and mechanisms of benefit of cardiac resynchronization therapy".)

The implantation technique for CRT and initial programming considerations will be reviewed here. Indications for CRT and outcomes of CRT in patients in sinus rhythm or with atrial fibrillation and cardiac pacing in patients with heart failure are discussed separately. (See "Cardiac resynchronization therapy in heart failure: Indications" and "Overview of cardiac pacing in heart failure" and "Rationale for and mechanisms of benefit of cardiac resynchronization therapy".)

SYSTEM COMPONENTS

The most common cardiac resynchronization therapy (CRT) pacing configuration involves three leads (right atrial, right ventricular, and left ventricular) with a three-lead pulse generator. Compatibility of the connector pins of all pacing leads into the device header across manufacturers is facilitated by the International Standardization Organization, whereby connections for bipolar and unipolar leads (IS-1), quadripolar leads (IS-4), and defibrillation leads (DF-4) are uniform and interchangeable. Thus, lead and generator technology can be freely mixed among vendors, including epicardial and transvenous leads.

Right atrial lead — An implanted atrial lead is essential for patients in sinus rhythm to synchronize ventricular activation to follow either a spontaneously occurring sinus beat or a pacemaker-delivered atrial beat.

                          

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Literature review current through: Jul 2017. | This topic last updated: Jun 06, 2017.
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