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cardiac resynchronization therapy

biventricular pacing device with ICD Indications: - heart failure*, NYHA class III or IV a) used with implantable cardioverter-defibrillator [8] b) cardiac dyssynchrony [4,5,17] c) LVEF <= 35% [4] d) QRS duration > 120 msec [4,17]; >= 150 msec [13] - greater CRT efficacy associated with QRS duration of 150 milliseconds +/- left bundle-branch block (LBBB) [8] - women may benefit from CRT if QRS duration is 130-149 msec [18] - men may not benefit if QRS duration is < 150 msec [18] e) sinus rhythm f) ambulatory NYHA class IV HF despite optimal medical therapy [4,13] g) may be of benefit in patients with moderate heart failure [9] - factors associated with a favorable response to CRT [11,12] a) left atrial volume < 40 mL/m2 b) left ventricular end-diastolic volume > 125 mL/m2 c) non-ischemic cause of cardiomyopathy d) QRS duration > 150 msec [14] e) left bundle-branch block (LBBB)* [14] or intraventricular conduction delay [23] f) female g) prior hospitalization for heart failure * diminishes all-cause mortality & improves the quality of life * diminished mortality benefit of CRT limited to patients with LBBB or intraventricular conduction delay [18,23] * His bundle pacing may be non-inferior to CRT [22] Contraindications: - not helpful for patients with narrow QRS complex [6,15] - not useful for right bundle branch block [23] Procedure: - an ICD with placement of an additional lead in the coronary sinus [17] 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 - device-related infection: 1.9 vs 1.0% for ICD alone (RR=1.90) [17] - device related complications 2% (same as ICD alone) [17] Notes: 1) may be less cost-effective than other forms of therapy 2) 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] 3) mortality: 25.7 vs 29.8% for ICD alone (RR=0.82) [17] 4) hospital readmissions: 68.6 vs 72.8% for ICD alone (RR=0.86) 5) use labeled inappropriate in 27% of cases [21]

Related

heart failure (HF)

General

cardiac pacemaker

References

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