Skip to main content

Periprocedural Management of Cardiac Resynchronization Therapy

Current Treatment Options in Cardiovascular Medicine volume 16, Article number: 298 (2014) Cite this article

Opinion Statement

Cardiac resynchronization therapy (CRT) is an important therapy in heart failure but 30 %‒40 % of patients may not respond. Improving this rate is an important goal and requires attention to candidate selection, intraoperative procedure, and postoperative follow-up. Factors to be considered are QRS morphology, duration, and left ventricular lead position with attention to paced effects on QRS. Postprocedure follow-up is critical to correct interfering conditions (eg, anodal capture, loss of 100 % biventricular pacing because of premature ventricular complexes (PVCs) or atrial fibrillation (AF). Echocardiographic improvement following CRT, which may take up to 18 months, is a potent predictor of long-term outcomes. Correcting the status of nonresponders, when possible, is important. Remote monitoring, in conjunction with CRT optimization clinics, may facilitate multidisciplinary follow-up and enable early intervention to improve outcome.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Cazeau S, Leclercq C, Lavergne T, Walker S, Varma C, Linde C, et al. Effects of multisite biventricular pacing in patients with heart failure and intraventricular conduction delay. N Engl J Med. 2001;344(12):873–80.

    CAS  PubMed  Article  Google Scholar 

  2. Abraham WT, Fisher WG, Smith AL, Delurgio DB, Leon AR, Loh E, et al. Cardiac-resynchronization in chronic heart failure. N Engl J Med. 2002;346:1845–53.

    PubMed  Article  Google Scholar 

  3. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, et al. Cardiac resynchronization therapy without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004;350:2140–50.

    CAS  PubMed  Article  Google Scholar 

  4. Cleland JG, Daubert JC, Erdmann E, Freemantle N, Gras D, Kappenberger L, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539–49. Landmark trial showing that CRT imparts survival benefit in heart failure patients.

    CAS  PubMed  Article  Google Scholar 

  5. Linde C, Abraham WT, Gold MR, et al. Randomized trial of resynchronization in mildly symptomatic heart failure patients and in asymptomatic patients with left ventricular dysfunction and previous heart failure symptoms. J Am Coll Cardiol. 2008;52:1834–43.

    PubMed  Article  Google Scholar 

  6. Daubert C, Gold MR, Abraham WT, et al. Prevention of disease progression by cardiac resynchronization therapy in patients with asymptomatic or mildly symptomatic left ventricular dysfunction. J Am Coll Cardiol. 2009;54:1837–46.

    PubMed  Article  Google Scholar 

  7. Moss AJ, Hall WJ, Cannom DS, et al. Cardiac-resynchronization therapy for the prevention of heart failure events. N Engl J Med. 2009;361:1329–38.

    PubMed  Article  Google Scholar 

  8. Tang AS, Wells GA, Talajic M, Arnold MO, Sheldon R, Connolly S. Resynchronization-defibrillation for ambulatory heart failure trial investigators. N Engl J Med. 2010;363:2385–95.

    CAS  PubMed  Article  Google Scholar 

  9. Rickard J, Brennan DM, Martin DO, Hsich E, Tang WH, Lindsay BD, et al. The impact of left ventricular size on response to cardiac resynchronization therapy. Am Heart J. 2011;162:646–53.

    PubMed  Article  Google Scholar 

  10. Birnie DH, Tang AS. The problem of nonresponse to cardiac resynchronization therapy. Curr Opin Cardiol. 2006;219:20–6.

    Article  Google Scholar 

  11. ACC/AHA/HRS. Guidelines for device-based therapy of cardiac rhythm abnormalities. report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 guideline update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;51(21):2085–105.

    Article  Google Scholar 

  12. Rickard J, Kumbhani DJ, Gorodeski EZ, Baranowski B, Wazni O, Martin DO, et al. Cardiac resynchronization therapy in non-left bundle branch block morphologies. Pacing Clin Electrophysiol. 2010;33:590–5.

    PubMed  Article  Google Scholar 

  13. Adelstein E, Saba S. Usefulness of baseline electrocardiographic QRS complex pattern to predict response to cardiac resynchronization. Am J Cardiol 2008; 238‒42.

  14. Tompkins C, Kutyifa V, McNitt S, Polonsky B, Klein HU, Moss AJ, Zareba W. Effect on cardiac function of cardiac resynchronization therapy in patients with right bundle branch block (from the Multicenter Automatic Defibrillator Implantation trial with Cardiac Resynchronization Therapy [MADIT-CRT] Trial) 2013;112:525‒9.

    Google Scholar 

  15. Rickard J, Bassiouny M, Cronin EM, Martin DO, Varma N, Niebauer MJ, et al. Predictors of response to cardiac resynchronization therapy in patients with a non-left bundle branch block morphology. Am J Cardiol. 2011;108:1576–80.

    PubMed  Article  Google Scholar 

  16. Epstein AE, DiMarco JP, Ellenbogen KA, Estes III NA, Freedman RA, Gettes LS, et al. American College of Cardiology Foundation; American Heart Association Task Force on practice guidelines; Heart Rhythm Society. 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(3):e6–e75.

    PubMed  Article  Google Scholar 

  17. Cuoco FA, Gold MR. Optimization of cardiac resynchronization therapy: importance of programmed parameters. J Cardiovasc Electrophysiol. 2012;23:110–8.

    PubMed  Article  Google Scholar 

  18. Worley SJ. CRT delivery systems based on guide support for LV lead placement. Heart Rhythm. 2009;6:1383–7.

    PubMed  Article  Google Scholar 

  19. Blendea D, Singh JP. Lead positioning strategies to enhance response to cardiac resynchronization therapy. Heart Fail Rev. 2011;16:291–303.

    PubMed  Article  Google Scholar 

  20. Heist EK, Fan D, Mela T, et al. Radiographic left ventricular-right ventricular interlead distance predicts the acute hemodynamic response to cardiac resynchronization therapy. Am J Cardiol. 2005;96:685–90.

    PubMed  Article  Google Scholar 

  21. Singh JP, Fan D, Heist EK, et al. Left ventricular lead electrical delay predicts response to cardiac resynchronization therapy. Heart Rhythm. 2006;3:1285–92.

    PubMed  Article  Google Scholar 

  22. Becker M, Franke A, Breithardt OA, et al. Impact of left ventricular lead position on the efficacy of cardiac resynchronization therapy: a two-dimensional strain echocardiography study. Heart. 2007;93:1197–203.

    PubMed Central  PubMed  Article  Google Scholar 

  23. Singh JP, Klein HU, Huang DT, Reek S, Kuniss M, Quesada A, et al. Left ventricular lead position and clinical outcome in the Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT) trial. Circulation. 2011;22:1159–66. Nonapical LV lead position were associated with negative outcomes to CRT.

    Article  Google Scholar 

  24. Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, et al. Dual Chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) trial. JAMA. 2002;288:3115–23.

    PubMed  Article  Google Scholar 

  25. 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;23:219–27.

    PubMed  Article  Google Scholar 

  26. Rademakers LM, van Kerckhoven R, van Deursen CJ, et al. Myocardial infarction does not preclude electrical and hemodynamic benefits of cardiac resynchronization therapy in dyssynchronous canine hearts. Circ Arrythm Electrophysiol. 2010;3:361–58.

    Article  Google Scholar 

  27. Bleeker GB, Kaandorp TA, Lamb HJ, Boersma E, Steendijk P, de Roos A, et al. Effect of posterolateral scar tissue on clinical and echocardiographic improvement after cardiac resynchronization therapy. Circulation. 2006;113:969–76.

    PubMed  Article  Google Scholar 

  28. White JA, Yee R, Yuan X, Krahn A, Skanes A, Parker M, et al. Delayed enhancement magnetic resonance imaging predicts response to cardiac resynchronization therapy in patients with intraventricular dyssynchrony. J Am Coll Cardiol. 2006;48:1953–60.

    PubMed  Article  Google Scholar 

  29. Marsan NA, Westenberg JJ, Ypenburg C, van Bommel RJ, Roes S, Delgado V, et al. Magnetic resonance imaging and response to cardiac resynchronization therapy: relative merits of left ventricular dyssynchrony and scar tissue. Eur Heart J. 2009;30:2360–7.

    PubMed  Article  Google Scholar 

  30. Varma N. Cardiac resynchronization therapy and the electrical substrate in heart failure: what does the QRS conceal ? Heart Rhythm. 2009;6:1059–62.

    PubMed  Article  Google Scholar 

  31. Varma N. Variegated left ventricular electrical activation in response to a novel quadripolar electrode-visualization by noninvasive electrocardiographic imaging. J Electrocard. 2013; 47: 66–74

    Google Scholar 

  32. van Rees JB, de Bie MK, Thijssen J, Borleffs CJ, Schalij MJ, van Erven L. Implantation-related complications of implantable cardioverter-defibrillators and cardiac resynchronization therapy devices. J Am Coll Cardiol. 2011;58:995–1000.

    PubMed  Article  Google Scholar 

  33. Tomassoni G, Baker J, Corbisiero R, Love C, Martin D, Niazi I, et al. Postoperative performance of the Quartet® left ventricular heart lead. J Cardiovasc Electrophysiol. 2013;24:449–56.

    Google Scholar 

  34. Reynolds MR, Cohen DJ, Kugelmass AD, et al. The frequency and incremental cost of major complications among Medicare beneficiaries receiving Implantable Cardioverter-Defibrillators. J Am Coll Cardiol. 2006;47:2493–7.

    PubMed Central  PubMed  Article  Google Scholar 

  35. Poole JE, Gleva MJ, Mela T, Chung MK, Uslan DZ, Borge R, et al. Complication rates associated with pacemaker or Implantable Cardioverter-Defibrillator generator replacements and upgrade procedures: results from the REPLACE registry. Circulation. 2010;122:1553–61.

    Google Scholar 

  36. Birnie DH, Healey JS, Wells GA, Verma A, Tang AS, Krahn AD, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368:208–93.

    Article  Google Scholar 

  37. Rowley CP, Bernard ML, Brabham WW, Netzler PC, Sidney DS, Cuoco F, et al. Safety of continuous anticoagulation with dabigatran during implantation of cardiac rhythm devices. Am J Cardiol. 2013;111:1165–8.

    CAS  PubMed  Article  Google Scholar 

  38. Rickard J, Jackson G, Spragg DD, Cronin EM, Baranowski B, Tang WH, et al. QRS prolongation induced by cardiac resynchronization therapy correlates with deterioration in left ventricular function. Heart Rhythm. 2012;9(10):1674–8.

    PubMed  Article  Google Scholar 

  39. Rickard J, Cheng A, Spragg D, Cantillon D, Chung MK, Wilson Tang W, et al. QRS narrowing is associated with reverse remodeling in patients with chronic right ventricular pacing upgraded to cardiac resynchronization therapy. Heart Rhythm. 2013;10:55–60. 37 and 38 describe the value of CRT paced ECGs in predicting outcome.

    PubMed Central  PubMed  Article  Google Scholar 

  40. Hayes DL, Boehmer JP, Day JD, Gilliam III FR, Heidenreich PA, Seth M, et al. Cardiac resynchronization therapy and the relationship of percent biventricular pacing to symptoms and survival. Heart Rhythm. 2011;8:1469–75.

    PubMed  Article  Google Scholar 

  41. 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 used 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;122:2660–8.

    PubMed  Article  Google Scholar 

  42. Boriani G, Müller CP, Seidl KH, Grove R, Vogt J, Danschel W, 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;15:1050–8.

    Article  Google Scholar 

  43. Rao RK, Kumar UN, Schafer J, Viloria E, De LD, Foster E. Reduced volumes and improved systolic function with cardiac resynchronization therapy: a randomized controlled trial comparing simultaneous biventricular pacing, sequential biventricular pacing, and left ventricular pacing. Circulation. 2007;115:2136–44.

    PubMed  Article  Google Scholar 

  44. Mullens W, Grimm RA, Verga T, Dresing T, Starling RC, Wilkoff BL, et al. Insights from a cardiac resynchronization optimization clinic as part of a heart failure disease management program. J Am Coll Cardiol. 2009;53:765–73. This outlines the positive effect of a multidisciplinary clinic for follow-up of CRT patients.

    PubMed  Article  Google Scholar 

  45. Weiss, Raul, et al. V-V optimization in cardiac resynchronization therapy nonresponders: Response-HF trial results. Abstract AB12-5, HRS 2010, Denver, Colorado.

  46. Ritter P, Padeletti L, Gillio-Meina L, Gaggini G. Determination of the optimal atrioventricular delay in DDD pacing. comparison between echo and peak endocardial acceleration measurements. Europace. 1999;2:126–30.

    Article  Google Scholar 

  47. Nayer V, Khan FZ, Pugh PJ. Optimizing atrioventricular and interventricular intervals following cardiac resynchronization therapy. Expert Rev Cardiovasc Ther. 2011;9:185–97.

    Article  Google Scholar 

  48. Colocousis JS, Huntsman LL, Curreri PW. Estimation of stroke volume changes by ultrasonic Doppler. Circulation. 1977;56:914–7.

    CAS  PubMed  Article  Google Scholar 

  49. Sogaard P, Egeblad H, Pedersen AK, Kim WY, Kristensen BO, Hansen PS, et al. Systemic versus simultaneous biventricular resynchronization for severe heart failure: evaluation by tissue Doppler imaging. Circulation. 2002;106:2078–84.

    PubMed  Article  Google Scholar 

  50. Ranjan R, Chiamvimon N, Thakor N, Tomaselli G, Marban E. Mechanism of anode stimulation in the heart. Biophys J. 1998;74:1850–63.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  51. Dendy KF, Poweel BD, Cha YM, Espinosa RE, Friedman PA, Rea RF, et al. Anodal stimulation: an under-recognized cause of nonresponders to cardiac resynchronization therapy. Indian Pacing Electrophysiol. 2011;11:64–72.

    Google Scholar 

  52. Tamborero D, Mont L, Alanis R, Berruezo A, Tolosana JM, Sitges M, et al. Anodal capture in cardiac resynchronization therapy implications for device programming. PACE. 2006;29:940–5.

    PubMed  Article  Google Scholar 

  53. Ghio S, Freemantle N, Scelsi L, Serio A, Magrini G, Pasotti M, et al. Long-term left ventricular reverse remodelling with cardiac resynchronization therapy: results from the CARE-HF trial. Eur J Heart Fail. 2009;11:480–8.

    PubMed  Article  Google Scholar 

  54. Solomon SD, Foster E, Bourgoun M, Shah A, Viloria E, Brown MW, et al. Effect of cardiac resynchronization therapy on reverse remodeling and relation to outcome: Multicenter Automatic Defibrillator Implantation Trial: cardiac resynchronization therapy. Circulation. 2010;122:985–92. Outlines the relation between remodeling and outcome in CRT treated patients.

    PubMed  Article  Google Scholar 

  55. Rickard J, Kumbhani DJ, Popovic Z, Verhaert D, Manne M, Sraow D, et al. Characterization of super-response to cardiac resynchronization therapy. Heart Rhythm. 2010;7:885–9.

    PubMed  Article  Google Scholar 

  56. Hsu JC, Solomon SD, Bourgoun M, McNitt S, Goldenberg I, Klein H, et al. Predictors of super-response to cardiac resynchronization therapy and associated improvement in clinical outcome: the MADIT-CRT (Multicenter Automatic Defibrillator Implantation Trial with Cardiac Resynchronization Therapy) study. J Am Coll Cardiol. 2012;59:2366–73.

    PubMed  Article  Google Scholar 

  57. Manne M, Rickard J, Varma N, Chung MK, Tchou P. Normalization of left ventricular ejection fraction after cardiac resynchronization therapy also normalizes survival. Pacing Clin Electrophysiol. 2013;8:970–7.

    Article  Google Scholar 

  58. Ruschitzka F. The challenge of non-responders to cardiac resynchronization therapy: lessons learned from oncology. Heart Rhythm. 2012;9(8 Suppl):S14–7.

    PubMed  Article  Google Scholar 

  59. Rickard J, Cheng A, Spragg D, Bansal S, Niebauer M, Baranowski B, Cantillon DJ, Tchou PJ, Grimm RA, Wilson Tang WH, Wilkoff BL, Varma N.Durability of the survival effect of cardiac resynchronization therapy by level of left ventricular functional improvement: Fate of nonresponders. Heart Rhythm. 2013. doi:10.1016/j.hrthm.2013.11.025.

  60. Mullens W, Tang WH. Optimizing cardiac resynchronization therapy in advanced heart failure. Congest Heart Fail. 2011;17:147–51.

    PubMed  Article  Google Scholar 

  61. Altman RK, Parks KA, Schlett CL, Orencole M, Park MY, Truong QA, et al. Multidisciplinary care of patients receiving cardiac resynchronization therapy is associated with improved clinical outcomes. Eur Heart J. 2012;17:2181–8.

    Article  Google Scholar 

  62. Varma N, Epstein AE, Irimpen A, Schweikert R, Love C. Efficacy and safety of automatic remote monitoring for Implantable Cardioverter-Defibrillator follow-up: the LUMOS-T safely reduces routine office device follow-up (TRUST) trial. Circulation. 2010;122:325–32. Landmark trial showing how automatic remote monitoring performs continuous monitoring of a large volume of heart failure patients yet reduces clinic workload while enabling early detection of salient problems.

    PubMed  Article  Google Scholar 

  63. Crossley GH, Boyle A, Vitense H, Chang Y, Mead RH. The CONNECT (clinical evaluation of remote notification to reduce time to clinical decision) trial: the value of wireless remote monitoring with automatic clinician alerts. J Am Coll Cardiol. 2011;57:1181–9.

    PubMed  Article  Google Scholar 

  64. Varma N, Wilkoff B. Device features for managing patients with heart failure. Heart Fail Clin. 2011;7:215–25. viii.

    Google Scholar 

  65. Saxon LA, Hayes DL, Gilliam FR, Heidenreich PA, Day J, Seth M, et al. Long-term outcome after ICD and CRT implantation and influence of remote device follow-up: the ALTITUDE survival study. Circulation. 2010;122:2359–67. Patients assigned to automatic remote monitoring during follow-up derived survival benefit.

    PubMed  Article  Google Scholar 

  66. Brignole M, Auricchio A, Baron-Esquivias G, Bordachar P, Boriani G, Breithardt OA, et al. ESC guidelines on cardiac pacing and cardiac resynchronization therapy: the task force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). developed in collaboration with the European Heart Rhythm Association (EHRA). Europace. 2013;15:1070–118.

    PubMed  Article  Google Scholar 

  67. Hindricks G, et al. In TIME Trial, Late Breaking Clinical Trial European Society of Cardiology Meeting Amsterdam, The Netherlands 2013.

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Dr. John Rickard received honoraria from St. Jude Medical and travel/accommodations expenses covered or reimbursed by Medtronic Inc.

Dr. Niraj Varma received honoraria from Medtronic, St. Jude Medical, Boston Scientific, Sorin and Biotronik. Dr. Varma received payment for the development of educational presentations including service on speakers’ bureaus from Medtronic, Boston Scientific, St. Jude Medical and Biotronik. Dr. Varma received travel/accommodations expenses covered or reimbursed by St. Jude Medical, Biotronik, Medtronic, Sorin, and Boston Scientific.

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.

Author information

Affiliations

  1. Division of Cardiology, The Johns Hopkins Hospital, Baltimore, USA

    John Rickard MD, MPH

  2. Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA

    Niraj Varma MD

Authors
  1. John Rickard MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Niraj Varma MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Niraj Varma MD.

Additional information

This article is part of the Topical Collection on Heart Failure

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Rickard, J., Varma, N. Periprocedural Management of Cardiac Resynchronization Therapy. Curr Treat Options Cardio Med 16, 298 (2014). https://doi.org/10.1007/s11936-014-0298-1

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11936-014-0298-1

Keywords

  • Heart failure
  • Cardiac Resynchronization Therapy
  • QRS morphology
  • Echocardiography
  • Left ventricular dyssynchrony