Cardiac Resynchronization Therapy

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Contents 1 Introduction 2 Indications 3 Complications 4 Notes 5 More General Terms 6 Additional Terms 7 References

Introduction

• biventricular pacing device

Indications

• heart failure*, NYHA class III or IV

• used with implantable cardioverter-defibrillator [8]
• cardiac dyssynchrony [4,5]
• LVEF < 35% [4]
• QRS duration > 120 sec [4]

• not helpful for patients with narrow QRS complex [6]
• greater CRT efficacy associated with QRS duration of 150 milliseconds +/- left bundle-branch block ( LBBB) [8]

• ambulatory NYHA class IV HF despite medical therapy [4]
• may be of benefit in patients with moderate heart failure [9]

• factors associated with a favorable response to CRT [11]

• left atrial volume < 40 mL/m2
• left ventricular end- diastolic volume > 125 mL/m2
• non- ischemic cause of cardiomyopathy
• QRS duration > 150 msec
• left bundle-branch block ( LBBB)
• female
• prior hospitalization for heart failure

• * diminishes all-cause mortality & improves the quality of life

Complications

• loss of left ventricular capture can worsen heart failure [3]

• 12 lead EKG can detect this (94% sensitivity) R/S ratio of > 1 in V1 & R/S ratio of < 1 in lead 1

Notes

• may be less cost-effective than other forms of therapy
• implantable cardioverter-defibrillators ( ICDs) & cardiac resynchronization therapy ( CRT) devices often include a feature that measures intrathoracic impedance, potentially providing an early warning system for decompensation by detecting pulmonary fluid retention [10]

More General Terms

• cardiovascular implantable electronic device (CIED)

Additional Terms

• heart failure (HF)

References

1. Bristow MR, Saxon LA, Boehmer J, Krueger S, Kass DA, De Marco T, Carson P, DiCarlo L, DeMets D, White BG, DeVries DW, Feldman AM; Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) Investigators. Cardiac-resynchronization therapy with or without an implantable defibrillator in advanced chronic heart failure. N Engl J Med. 2004 May 20;350(21):2140-50. PMID: [1]
2. Journal Watch 24(20):154, 2004
   - McAlister FA, Ezekowitz JA, Wiebe N, Rowe B, Spooner C, Crumley E, Hartling L, Klassen T, Abraham W. Systematic review: cardiac resynchronization in patients with symptomatic heart failure. Ann Intern Med. 2004 Sep 7;141(5):381-90. Epub 2004 Aug 16. Review. PMID: [2]
   - Nichol G, Kaul P, Huszti E, Bridges JF. Cost-effectiveness of cardiac resynchronization therapy in patients with symptomatic heart failure. Ann Intern Med. 2004 Sep 7;141(5):343-51. Epub 2004 Aug 16. PMID: [3]
3. Journal Watch 25(16):127, 2005 Ammann P, Sticherling C, Kalusche D, Eckstein J, Bernheim A, Schaer B, Osswald S. An electrocardiogram-based algorithm to detect loss of left ventricular capture during cardiac resynchronization therapy. Ann Intern Med. 2005 Jun 21;142(12 Pt 1):968-73. Summary for patients in: Ann Intern Med. 2005 Jun 21;142(12 Pt 1):I24. PMID: [4]
4. Hunt SA et al American College of Cardiology Foundation, American Heart Association. 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults [trunc]. J Am Coll Cardiol 2009 Apr 14;53(15):e1-e90. PMID: [5]
   - Hunt SA et al Developed in Collaboration With the American College of Chest Physicians and the International Society for Heart and Lung Transplantation; Endorsed by the Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult-Summary Article A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol. 2005 Sep 20;46(6):1116-43. (No abstract) PMID: [6]
5. Bleeker GB, Holman ER, Steendijk P, Boersma E, van der Wall EE, Schalij MJ, Bax JJ. Cardiac resynchronization therapy in patients with a narrow QRS complex. J Am Coll Cardiol. 2006 Dec 5;48(11):2243-50. Epub 2006 Nov 9. PMID: [7]
   - Yu CM, Chan YS, Zhang Q, Yip GW, Chan CK, Kum LC, Wu L, Lee AP, Lam YY, Fung JW. Benefits of cardiac resynchronization therapy for heart failure patients with narrow QRS complexes and coexisting systolic asynchrony by echocardiography. J Am Coll Cardiol. 2006 Dec 5;48(11):2251-7. PMID: [8]
6. Beshai JF et al, for the RethinQ Study Investigators Cardiac-resynchronization therapy in heart failure with narrow QRS complexes. N Engl J Med 2007, Nov 4 PMID: [9]
7. Jessup M et al 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009 Apr 14;119(14):1977-2016. PMID: [10]
8. Tang ASL et al for the Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT) Investigators. Cardiac-resynchronization therapy for mild-to-moderate heart failure. N Engl J Med 2010 Nov 14; <PubMed> PMID: [11] <Internet> [12]
   - Moss AJ. Preventing heart failure and improving survival. N Engl J Med 2010 Nov 14; <PubMed> PMID: &dopt=Abstract <Internet> [13]
9. Al-Majed NS et al Meta-analysis: Cardiac Resynchronization Therapy for Patients With Less Symptomatic Heart Failure Annals of Internal Medicine Feb 14, 2011 <PubMed> PMID: [14] <Internet> [15]
   - Reynold CR and Jessup M Translating the Benefits of Cardiac Resynchronization Therapy Widely and Wisely: Challenges Remain Annals of Internal Medicine Feb 14, 2011 <PubMed> PMID: [16] <Internet> [17]
10. Journal Watch Massachussetts Medical Society Journal Watch Cardiology November 30, 2011 [18]
11. Goldenberg I et al. Predictors of response to cardiac resynchronization therapy in the Multicenter Automatic Defibrillator Implantation Trial With Cardiac Resynchronization Therapy (MADIT-CRT). Circulation 2011 Oct 4; 124:1527. PMID: [19]
12. National Guideline Clearinghouse Cardiac resynchronisation therapy for the treatment of heart failure. National Institute for Health and Clinical Excellence ngc-guideline: [20]
    - 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. ngc-guideline: [21]
    - Guidelines for cardiac pacing and cardiac resynchronization therapy. European Society of Cardiology ngc-guideline: [22]

cardiac resynchronization therapy (CRT)