Cardiac resynchronization therapy indications

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Bhaskar Purushottam, M.D. [2], Hardik Patel, M.D.

Overview

Cardiac resynchronization therapy (CRT) with or without an implantable cardiac defibrillator (ICD) is indicated in patients who have an LVEF less than or equal to 35%, left bundle branch block (LBBB) with a QRS duration greater than or equal to 0.15 seconds, and normal sinus rhythm, for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms in patients whose medical therapy has been optimized.

2021 ESC Guideline for management of acute heart failure

Abbreviations: AF: Atrial fibrillation; A-V: Atrio-ventricular; CRT: Cardiac resynchronization therapy ; HFrEF: Heart failure with reduced ejection fraction; ICD: Implantable cardioverter-defibrillato; LBBB:Left bundle branch block; LVEF: Left ventricular ejection fraction; NYHA:New York Heart Association; RV: = Right ventricular

Recommendations for cardiac resynchronization therapy implantation in patients with heart failure

(Class I, Level of Evidence A):

❑ CRT is recommended for symptomatic patients with HF in sinus rhythm with a QRS duration >_150 ms and LBBB QRS morphology and with LVEF <_35% despite optimal medical therapy in order to improve symptoms and reduce morbidity and mortality. ❑ CRT rather than RV pacing is recommended for patients with HFrEF regardless of NYHA class or QRS duration who have an indication for ventricular pacing for high degree AV block in order to reducemorbidity including AF

(Class IIa, Level of Evidence B):

❑ CRT should be considered for symptomatic patients with HF in sinus rhythm with a QRS duration >_150 ms and non-LBBB QRS morphology and with LVEF <_35% despite OMT in order to improve symptoms and reduce morbidity and mortality ❑ CRT should be considered for symptomatic patients with HF in sinus rhythm with a QRS duration of130-149 ms and LBBB QRS morphology and with LVEF <_35% despite optimal medical therapy in order to improve symptoms and reduce morbidity and mortality ❑ Patients with an LVEF <_35% who have received a conventional pacemaker or an ICD and subsequently develop worsening HF despite optimal medical therapy and who have a significant proportion of RV pacing should be considered for upgrade to CRT

(Class IIb, Level of Evidence B) :

❑ CRT may be considered for symptomatic patients with HF in sinus rhythm with a QRS duration of 130-149 ms and non-LBBB QRS morphology and with LVEF <_35% despite optimal medical therapy in order to improve symptoms and reduce morbidity and mortality

(Class III, Level of Evidence A) :

❑CRT is not recommended in patients with a QRS duration <130 ms who do not have an indication for pacing due to high degree AV block

The above table adopted from 2021 ESC Guideline