What is the clinical evidence from this study?

Study design: Review. Population: Arrhythmia in cardiac resynchronisation therapy (CRT). Intervention: Arrhythmia management strategies (catheter ablation, AV node ablation, pharmacological).

August 7, 2023Open Access

Managing arrhythmia in cardiac resynchronisation therapy

FVFelicity de VereKing's College London NWNadeev WijesuriyaSt Thomas' Hospital MEMark K. ElliottKing's College London

Key Result

Effective management of arrhythmias in cardiac resynchronisation therapy, particularly through catheter or AV node ablation, is crucial to maximize biventricular pacing and improve heart failure outcomes.

Structured PICO

Does arrhythmia management improve clinical outcomes and biventricular pacing delivery in patients receiving cardiac resynchronisation therapy?

Population

A narrative review examining the impact and management of atrial and ventricular arrhythmias in patients receiving cardiac resynchronisation therapy.

Intervention

Arrhythmia management strategies (pharmacological and procedural-based approaches including atrial fibrillation ablation and atrioventricular node ablation)

Effective management of arrhythmias, particularly through AF ablation or AV node ablation, is essential in CRT patients to maximize biventricular pacing and improve heart failure outcomes.

Limitations

Relative paucity of research dedicated specifically to the management of atrial fibrillation in CRT patients.
Most current knowledge is inferred from arrhythmia trials in the general heart failure population rather than dedicated CRT trials.

Abstract

Arrhythmia is an extremely common finding in patients receiving cardiac resynchronisation therapy (CRT). Despite this, in the majority of randomised trials testing CRT efficacy, patients with a recent history of arrhythmia were excluded. Most of our knowledge into the management of arrhythmia in CRT is therefore based on arrhythmia trials in the heart failure (HF) population, rather than from trials dedicated to the CRT population. However, unique to CRT patients is the aim to reach as close to 100% biventricular pacing (BVP) as possible, with HF outcomes greatly influenced by relatively small changes in pacing percentage. Thus, in comparison to the average HF patient, there is an even greater incentive for controlling arrhythmia, to achieve minimal interference with the effective delivery of BVP. In this review, we examine both atrial and ventricular arrhythmias, addressing their impact on CRT, and discuss the available evidence regarding optimal arrhythmia management in this patient group. We review pharmacological and procedural-based approaches, and lastly explore novel ways of harnessing device data to guide treatment of arrhythmia in CRT.

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