State-of-the-Art Paper
Cardiac Resynchronization Therapy: Part 2—Issues During and After Device Implantation and Unresolved Questions

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Encouraged by the clinical success of cardiac resynchronization therapy (CRT), the implantation rate has increased exponentially, although several limitations and unresolved issues of CRT have been identified. This review concerns issues that are encountered during implantation of CRT devices, including the role of electroanatomical mapping, whether CRT implantation should be accompanied by simultaneous atrioventricular nodal ablation in patients with atrial fibrillation, procedural complications, and when to consider surgical left ventricular lead positioning. Furthermore, (echocardiographic) CRT optimization and assessment of CRT benefits after implantation are highlighted. Also, controversial issues such as the potential value of CRT in patients with mild heart failure or narrow QRS complex are addressed. Finally, open questions concerning when to combine CRT with implantable cardioverter-defibrillator therapy and the cost-effectiveness of CRT are discussed.

Abbreviations and Acronyms

AF
atrial fibrillation
AV
atrioventricular
COMPANION
Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure
CRT
cardiac resynchronization therapy
ICD
implantable cardioverter-defibrillator
LBBB
left bundle branch block
LV
left ventricle/ventricular
LVEF
left ventricular ejection fraction
MR
mitral regurgitation
MUSTIC
Multisite Simulation in Cardiomyopathies trial
NYHA
New York Heart Association
PET
positron emission tomography
QALY
quality adjusted life year
RV
right ventricle/ventricular
TDI
tissue Doppler imaging
VV
interventricular

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Dr. Abraham receives honoraria from GE, Guidant, Medtronic, and St. Jude and receives research support from Guidant; Dr. Barold received lecture fees from Medtronic; Dr. Breithardt has been a consultant for Medtronic and Guidant and has research affiliations with Medtronic, Guidant, and GE Vingmed; Dr. Hayes is on the advisory board of Guidant Inc. and has been a speaker for Guidant Inc., Medtronic Inc., St. Jude Medical, and ELA Medical, and has received royalties from Blackwell Futura; Dr. Gorcsan received research grant support from GE, Toshiba, Siemens, Medtronic, and St. Jude; Dr. Kass has been a consultant for Guidant Inc.; Dr. Mark has been a consultant and received grants from Medtronic, Inc. Dr. Monaghan has received support from Philips, GE, Siemens, Guidant, Medtronic, and Accusphere; Dr. Schalij is on the advisory board of Guidant and has received research grants from Medtronic, Guidant, and St. Jude; Dr. Stellbrink is a sponsored investigator for Guidant, Medtronic, St. Jude, and Biotronik and is also an advisor to Guidant and Biotronik; Dr. Nihoyannopoulos received research grants and consultant fees from Medtronic.