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Cardiac resynchronization therapy in heart failure: Implantation and other considerations

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


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.

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".)


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: Nov 2017. | This topic last updated: Jun 06, 2017.
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  1. Leclercq C, Kass DA. Retiming the failing heart: principles and current clinical status of cardiac resynchronization. J Am Coll Cardiol 2002; 39:194.
  2. Abraham WT, Hayes DL. Cardiac resynchronization therapy for heart failure. Circulation 2003; 108:2596.
  3. Auricchio A, Abraham WT. Cardiac resynchronization therapy: current state of the art: cost versus benefit. Circulation 2004; 109:300.
  4. Leclercq C, Hare JM. Ventricular resynchronization: current state of the art. Circulation 2004; 109:296.
  5. Jarcho JA. Resynchronizing ventricular contraction in heart failure. N Engl J Med 2005; 352:1594.
  6. Burkhardt JD, Wilkoff BL. Interventional electrophysiology and cardiac resynchronization therapy: delivering electrical therapies for heart failure. Circulation 2007; 115:2208.
  7. Hummel JD, Coppess MA, Osborn JS, et al. Real-World Assessment of Acute Left Ventricular Lead Implant Success and Complication Rates: Results from the Attain Success Clinical Trial. Pacing Clin Electrophysiol 2016; 39:1246.
  8. León AR, Abraham WT, Curtis AB, et al. Safety of transvenous cardiac resynchronization system implantation in patients with chronic heart failure: combined results of over 2,000 patients from a multicenter study program. J Am Coll Cardiol 2005; 46:2348.
  9. Wilkoff BL, Love CJ, Byrd CL, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009; 6:1085.
  10. Poole JE, Gleva MJ, Mela T, et al. Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry. Circulation 2010; 122:1553.
  11. Santini M, Di Fusco SA, Santini A, et al. Prevalence and predictor factors of severe venous obstruction after cardiovascular electronic device implantation. Europace 2016; 18:1220.
  12. Worley SJ. Implant venoplasty: dilation of subclavian and coronary veins to facilitate device implantation: indications, frequency, methods, and complications. J Cardiovasc Electrophysiol 2008; 19:1004.
  13. Abu-El-Haija B, Bhave PD, Campbell DN, et al. Venous Stenosis After Transvenous Lead Placement: A Study of Outcomes and Risk Factors in 212 Consecutive Patients. J Am Heart Assoc 2015; 4:e001878.
  14. van Rooden CJ, Molhoek SG, Rosendaal FR, et al. Incidence and risk factors of early venous thrombosis associated with permanent pacemaker leads. J Cardiovasc Electrophysiol 2004; 15:1258.
  15. Lickfett L, Bitzen A, Arepally A, et al. Incidence of venous obstruction following insertion of an implantable cardioverter defibrillator. A study of systematic contrast venography on patients presenting for their first elective ICD generator replacement. Europace 2004; 6:25.
  16. Gula LJ, Ames A, Woodburn A, et al. Central venous occlusion is not an obstacle to device upgrade with the assistance of laser extraction. Pacing Clin Electrophysiol 2005; 28:661.
  17. Wazni O, Epstein LM, Carrillo RG, et al. Lead extraction in the contemporary setting: the LExICon study: an observational retrospective study of consecutive laser lead extractions. J Am Coll Cardiol 2010; 55:579.
  18. Navia JL, Atik FA. Minimally invasive surgical alternatives for left ventricle epicardial lead implantation in heart failure patients. Ann Thorac Surg 2005; 80:751.
  19. McALOON CJ, Anderson BM, Dimitri W, et al. Long-Term Follow-Up of Isolated Epicardial Left Ventricular Lead Implant Using a Minithoracotomy Approach for Cardiac Resynchronization Therapy. Pacing Clin Electrophysiol 2016; 39:1052.
  20. Jaroszewski DE, Altemose GT, Scott LR, et al. Nontraditional surgical approaches for implantation of pacemaker and cardioverter defibrillator systems in patients with limited venous access. Ann Thorac Surg 2009; 88:112.
  21. Antonelli D, Freedberg NA, Turgeman Y. Supraclavicular vein approach to overcoming ipsilateral chronic subclavian vein obstruction during pacemaker-ICD lead revision or upgrading. Europace 2010; 12:1596.
  22. Aleksic I, Kottenberg-Assenmacher E, Kienbaum P, et al. The innominate vein as alternative venous access for complicated implantable cardioverter defibrillator revisions. Pacing Clin Electrophysiol 2007; 30:957.
  23. Borek PP, Wilkoff BL. Pacemaker and ICD leads: strategies for long-term management. J Interv Card Electrophysiol 2008; 23:59.
  24. Fox DJ, Petkar S, Davidson NC, Fitzpatrick AP. Upgrading patients with chronic defibrillator leads to a biventricular system and reducing patient risk: contralateral LV lead placement. Pacing Clin Electrophysiol 2006; 29:1025.
  25. Rickard J, Johnston DR, Price J, et al. Reverse ventricular remodeling and long-term survival in patients undergoing cardiac resynchronization with surgically versus percutaneously placed left ventricular pacing leads. Heart Rhythm 2015; 12:517.
  26. Gold MR, Leman RB, Wold N, et al. The effect of left ventricular electrical delay on the acute hemodynamic response with cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2014; 25:624.
  27. Zanon F, Baracca E, Pastore G, et al. Determination of the longest intrapatient left ventricular electrical delay may predict acute hemodynamic improvement in patients after cardiac resynchronization therapy. Circ Arrhythm Electrophysiol 2014; 7:377.
  28. Kaypakli O, Koç M, Gözübüyük G, Şahin DY. High Left Ventricular Lead Sensing Delay Predicts QRS Narrowing and Good Response to Cardiac Resynchronization Therapy. Pacing Clin Electrophysiol 2016; 39:1317.
  29. Chatterjee NA, Gold MR, Waggoner AD, et al. Longer Left Ventricular Electric Delay Reduces Mitral Regurgitation After Cardiac Resynchronization Therapy: Mechanistic Insights From the SMART-AV Study (SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy). Circ Arrhythm Electrophysiol 2016; 9.
  30. Bleeker GB, Kaandorp TA, Lamb HJ, et al. Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy. Circulation 2006; 113:969.
  31. Lardo AC, Abraham TP, Kass DA. Magnetic resonance imaging assessment of ventricular dyssynchrony: current and emerging concepts. J Am Coll Cardiol 2005; 46:2223.
  32. Chalil S, Stegemann B, Muhyaldeen S, et al. Intraventricular dyssynchrony predicts mortality and morbidity after cardiac resynchronization therapy: a study using cardiovascular magnetic resonance tissue synchronization imaging. J Am Coll Cardiol 2007; 50:243.
  33. Murphy RT, Sigurdsson G, Mulamalla S, et al. Tissue synchronization imaging and optimal left ventricular pacing site in cardiac resynchronization therapy. Am J Cardiol 2006; 97:1615.
  34. Bax JJ, Bleeker GB, Marwick TH, et al. Left ventricular dyssynchrony predicts response and prognosis after cardiac resynchronization therapy. J Am Coll Cardiol 2004; 44:1834.
  35. Kapetanakis S, Kearney MT, Siva A, et al. Real-time three-dimensional echocardiography: a novel technique to quantify global left ventricular mechanical dyssynchrony. Circulation 2005; 112:992.
  36. Cho GY, Song JK, Park WJ, et al. Mechanical dyssynchrony assessed by tissue Doppler imaging is a powerful predictor of mortality in congestive heart failure with normal QRS duration. J Am Coll Cardiol 2005; 46:2237.
  37. Penicka M, Bartunek J, De Bruyne B, et al. Improvement of left ventricular function after cardiac resynchronization therapy is predicted by tissue Doppler imaging echocardiography. Circulation 2004; 109:978.
  38. Bordachar P, Lafitte S, Reuter S, et al. Echocardiographic parameters of ventricular dyssynchrony validation in patients with heart failure using sequential biventricular pacing. J Am Coll Cardiol 2004; 44:2157.
  39. Yu CM, Fung JW, Zhang Q, et al. Tissue Doppler imaging is superior to strain rate imaging and postsystolic shortening on the prediction of reverse remodeling in both ischemic and nonischemic heart failure after cardiac resynchronization therapy. Circulation 2004; 110:66.
  40. Notabartolo D, Merlino JD, Smith AL, et al. Usefulness of the peak velocity difference by tissue Doppler imaging technique as an effective predictor of response to cardiac resynchronization therapy. Am J Cardiol 2004; 94:817.
  41. Mele D, Pasanisi G, Capasso F, et al. Left intraventricular myocardial deformation dyssynchrony identifies responders to cardiac resynchronization therapy in patients with heart failure. Eur Heart J 2006; 27:1070.
  42. Suffoletto MS, Dohi K, Cannesson M, et al. Novel speckle-tracking radial strain from routine black-and-white echocardiographic images to quantify dyssynchrony and predict response to cardiac resynchronization therapy. Circulation 2006; 113:960.
  43. Miyazaki C, Powell BD, Bruce CJ, et al. Comparison of echocardiographic dyssynchrony assessment by tissue velocity and strain imaging in subjects with or without systolic dysfunction and with or without left bundle-branch block. Circulation 2008; 117:2617.
  44. Achilli A, Sassara M, Ficili S, et al. Long-term effectiveness of cardiac resynchronization therapy in patients with refractory heart failure and "narrow" QRS. J Am Coll Cardiol 2003; 42:2117.
  45. Bleeker GB, Holman ER, Steendijk P, et al. Cardiac resynchronization therapy in patients with a narrow QRS complex. J Am Coll Cardiol 2006; 48:2243.
  46. Yu CM, Chan YS, Zhang Q, et al. Benefits of cardiac resynchronization therapy for heart failure patients with narrow QRS complexes and coexisting systolic asynchrony by echocardiography. J Am Coll Cardiol 2006; 48:2251.
  47. Kass DA. Predicting cardiac resynchronization response by QRS duration: the long and short of it. J Am Coll Cardiol 2003; 42:2125.
  48. Bax JJ, Abraham T, Barold SS, et al. Cardiac resynchronization therapy: Part 1--issues before device implantation. J Am Coll Cardiol 2005; 46:2153.
  49. Adelstein EC, Saba S. Scar burden by myocardial perfusion imaging predicts echocardiographic response to cardiac resynchronization therapy in ischemic cardiomyopathy. Am Heart J 2007; 153:105.
  50. Sweeney MO, van Bommel RJ, Schalij MJ, et al. Analysis of ventricular activation using surface electrocardiography to predict left ventricular reverse volumetric remodeling during cardiac resynchronization therapy. Circulation 2010; 121:626.
  51. Fox M, Mealing S, Anderson R, et al. The clinical effectiveness and cost-effectiveness of cardiac resynchronisation (biventricular pacing) for heart failure: systematic review and economic model. Health Technol Assess 2007; 11:iii.
  52. Duray GZ, Israel CW, Pajitnev D, Hohnloser SH. Upgrading to biventricular pacing/defibrillation systems in right ventricular paced congestive heart failure patients: prospective assessment of procedural parameters and response rate. Europace 2008; 10:48.
  53. Swindle JP, Rich MW, McCann P, et al. Implantable cardiac device procedures in older patients: use and in-hospital outcomes. Arch Intern Med 2010; 170:631.
  54. Rickard J, Cheng A, Spragg D, et al. Survival in octogenarians undergoing cardiac resynchronization therapy compared to the general population. Pacing Clin Electrophysiol 2014; 37:740.
  55. Oswald H, Asbach S, Köbe J, et al. Effectiveness and Reliability of Selected Site Pacing for Avoidance of Phrenic Nerve Stimulation in CRT Patients with Quadripolar LV Leads: The EffaceQ Study. Pacing Clin Electrophysiol 2015; 38:942.
  56. Bristow MR, Saxon LA, Boehmer J, et al. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med 2004; 350:2140.
  57. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352:1539.
  58. McAlister FA, Ezekowitz J, Hooton N, et al. Cardiac resynchronization therapy for patients with left ventricular systolic dysfunction: a systematic review. JAMA 2007; 297:2502.
  59. Perisinakis K, Theocharopoulos N, Damilakis J, et al. Fluoroscopically guided implantation of modern cardiac resynchronization devices: radiation burden to the patient and associated risks. J Am Coll Cardiol 2005; 46:2335.
  60. Fish JM, Brugada J, Antzelevitch C. Potential proarrhythmic effects of biventricular pacing. J Am Coll Cardiol 2005; 46:2340.
  61. Brenyo A, Kutyifa V, Moss AJ, et al. Atrioventricular delay programming and the benefit of cardiac resynchronization therapy in MADIT-CRT. Heart Rhythm 2013; 10:1136.
  62. Meluzín J, Novák M, Müllerová J, et al. A fast and simple echocardiographic method of determination of the optimal atrioventricular delay in patients after biventricular stimulation. Pacing Clin Electrophysiol 2004; 27:58.
  63. Rickard J, Cheng A, Spragg D, et al. QRS narrowing is associated with reverse remodeling in patients with chronic right ventricular pacing upgraded to cardiac resynchronization therapy. Heart Rhythm 2013; 10:55.
  64. Hsing JM, Selzman KA, Leclercq C, et al. Paced left ventricular QRS width and ECG parameters predict outcomes after cardiac resynchronization therapy: PROSPECT-ECG substudy. Circ Arrhythm Electrophysiol 2011; 4:851.
  65. Singh JP, Klein HU, Huang DT, et al. Left ventricular lead position and clinical outcome in the multicenter automatic defibrillator implantation trial-cardiac resynchronization therapy (MADIT-CRT) trial. Circulation 2011; 123:1159.
  66. van Gelder BM, Bracke FA, Meijer A, et al. Effect of optimizing the VV interval on left ventricular contractility in cardiac resynchronization therapy. Am J Cardiol 2004; 93:1500.
  67. Auricchio A, Stellbrink C, Sack S, et al. Long-term clinical effect of hemodynamically optimized cardiac resynchronization therapy in patients with heart failure and ventricular conduction delay. J Am Coll Cardiol 2002; 39:2026.
  68. Rao RK, Kumar UN, Schafer J, et al. Reduced ventricular volumes and improved systolic function with cardiac resynchronization therapy: a randomized trial comparing simultaneous biventricular pacing, sequential biventricular pacing, and left ventricular pacing. Circulation 2007; 115:2136.
  69. Boriani G, Kranig W, Donal E, 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; 159:1052.
  70. Thibault B, Ducharme A, Harel F, et al. Left ventricular versus simultaneous biventricular pacing in patients with heart failure and a QRS complex ≥120 milliseconds. Circulation 2011; 124:2874.
  71. Birnie D, Lemke B, Aonuma K, et al. Clinical outcomes with synchronized left ventricular pacing: analysis of the adaptive CRT trial. Heart Rhythm 2013; 10:1368.
  72. Starling RC, Krum H, Bril S, et al. Impact of a Novel Adaptive Optimization Algorithm on 30-Day Readmissions: Evidence From the Adaptive CRT Trial. JACC Heart Fail 2015; 3:565.
  73. Zanon F, Marcantoni L, Baracca E, et al. Optimization of left ventricular pacing site plus multipoint pacing improves remodeling and clinical response to cardiac resynchronization therapy at 1 year. Heart Rhythm 2016; 13:1644.