Electrical therapy for advanced heart failure: is it time for a multidisciplinary approach or a new subspecialty?

Treatment of cardiac resynchronization therapy non-responders: current approaches and new frontiers

INTRODUCTION

Cardiac resynchronization therapy (CRT) has developed into a very effective technology for patients with decreased systolic function and has substantially improved patients' clinical course. However, non-responsiveness to CRT, described as lack of reverse cardiac chamber remodeling, leading to lack to improve symptoms, heart failure hospitalizations or mortality, is common, rather unpredictable, and not fully understood.

AREAS COVERED

This article aims to discuss key factors that are impacting CRT response; from patient selection to LV lead position, to structured follow-up in CRT clinics. Secondly, common causes and interventions for CRT non-responsiveness are discussed. Next, insight is given into technologies representing new and feasible interventions as well as pacing strategies in this group of patients that remain challenging to treat. Finally, an outlook is given into future scientific development.

EXPERT OPINION

Despite the progress that has been made, CRT non-response remains a significant and complex problem. Patient management in interdisciplinary teams including heart failure, imaging, and cardiac arrhythmia experts appears critical as complexity is increasing and CRT non-response often is a multifactorial problem. This will allow optimization of medical therapy, the use of new integrated sensor technologies and telemedicine to ultimately optimize outcomes for all patients in need of CRT.

Emerging Implantable Device Technology for Patients at the Intersection of Electrophysiology and Heart Failure Interdisciplinary Care

Cardiac implantable electronic devices (CIEDs), including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT), are part of guideline- indicated treatment for a subset of patients with heart failure with reduced ejection fraction (HFrEF). Current technological advancements in CIEDs have allowed the detection of specific patient physiologic parameters used for forecasting clinical decompensation through algorithmic, multiparameter remote monitoring. Other recent emerging technologies, including cardiac contractility modulation (CCM) and baroreflex activation therapy (BAT), may provide symptomatic or physiologic benefit in patients without an indication for CRT. Our goal in this state-of-the-art review is to describe the commercially available new technologies, purported mechanisms of action, evidence surrounding their clinical role, limitations, and future directions. Finally, we underline the need for standardized workflow and close interdisciplinary management of this population to ensure the delivery of high-quality care.