How to build a baroreceptor activation therapy (BAT) program: from development to implementation

Baroreflex activation therapy (BAT) is a Food and Drug Administration-approved neuromodulation therapy for patients with heart failure with reduced ejection fraction (HFrEF) who remain symptomatic despite optimal medical therapy. Prior randomized clinical trials have demonstrated improvements in quality of life, functional capacity, and N-terminal pro-B-type natriuretic peptide, while emerging observational evidence suggests reductions in mortality, heart failure (HF) hospitalizations, and emergency-department utilization. Despite this evidence and expanding real-world use, practical guidance on how to design, launch, and sustain a BAT program is limited. This manuscript provides a comprehensive, pragmatic framework for developing an integrated BAT clinical program adaptable to community, academic, rural, and urban settings. Key components include defining institutional need, identifying eligible patients, establishing referral pathways, and creating a multidisciplinary workflow involving HF clinicians, advanced practice providers, vascular or cardiothoracic surgeons, anesthesiologists, and administrative support. We address common referring-clinician and institutional reservations (such as knowledge gaps and misconceptions about patient candidacy and/or procedural risk and reimbursement concerns) and propose actionable strategies to overcome these barriers. We additionally comment on where selection of BAT falls in the array of device options available for heart failure management. We outline perioperative and post-implant processes, including pre-implant evaluation, surgical best practices, structured titration protocols, and optimization of guideline-directed medical therapy post implantation. A process for longitudinal outcome tracking is presented to support program quality, refine workflows, and contribute to broader evidence generation. By integrating clinical evidence with operational guidance, this framework aims to help centers implement safe, scalable BAT programs that expand therapeutic options and improve care for patients with symptomatic HFrEF.