Recommendations for Cardiac Resynchronization Therapy in Patients With Severe Systolic Heart Failure

Class I 

(1) CRT is indicated for patients who have LVEF < 35%, sinus rhythm, LBBB with a QRS duration > 150 msec, and NYHA Class II, III, or ambulatory IV symptoms on GDMT (Guideline Directed Medical Therapy).

Class IIa

(1) CRT can be useful for patients who have LVEF < 35%, sinus rhythm, LBBB with a QRS duration 120-149 msec, and NYHA Class II, III, or ambulatory IV symptoms on GDMT (Guideline Directed Medical Therapy).

(2) CRT can be useful for patients who have LVEF < 35%, sinus rhythm, a non-LBBB pattern with a QRS > 150 msec, and NYHA Class III / ambulatory class IV symptoms on GDMT (Guideline Directed Medical Therapy).

(3) CRT can be useful in patients with atrial fibrillation and LVEF < 35% on Guideline Directed Medical Therapy if (a) the patient requires ventricular pacing or otherwise meets CRT criteria and (b) AV nodal ablation or pharmacologic rate control will allow near 100% ventricular pacing with CRT.

(4) CRT can be useful for patients on GDMT (Guideline Directed Medical Therapy) who have LVEF < 35% and are undergoing new or replacement device placement with anticipated requirement for significant (> 40%) ventricular pacing.

Class IIb

(1) CRT may be considered for patients who have LVEF < 30%, ischemic etiology of heart failure, sinus rhythm, LBBB with a QRS > 150 msec, and NYHA Class I symptoms on GDMT (Guideline Directed Medical Therapy).

(2) CRT may be considered for patients who have LVEF < 35%, sinus rhythm, a non-LBBB pattern with QRS 120-149 msec, and NYHA Class III / ambulatory class IV on GDMT (Guideline Directed Medical Therapy).

(3) CRT may be considered for patients who have LVEF < 35%, sinus rhythm, a non-LBBB pattern with QRS > 150 msec, and NYHA Class II symptoms on GDMT (Guideline Directed Medical Therapy).

Class III

(1) CRT is not recommended for patients with NYHA Class I or II symptoms and non-LBBB pattern with QRS < 150 msec.

(2) CRT is not indicated for patients whose comorbidites and/or frailty limit survival with good functional capacity to less than 1 year.

JACC Vol. 60, No 14, 2012 . October 2, 2012: 1297-1313

****CONDUCTION SYSTEM PACING****

HIS BUNDLE PACING

-In addition, it is a Class IIb indication for HBP in that "In patients with
atrioventricular block at the level of the atrioventricular node who have an
indication for permanent pacing, His bundle pacing may be considered to maintain
physiologic ventricular activation" (2018 ACC / AHA . HRS Guidelines on the
Evaluation and Management of Patients with Bradycardia and Cardiac conduction
delay: Kusumoto, Fred et al. Circulation Vol 140, Issue 8, 20 August 2019"

In patients who are ventricular pacing–dependent undergoing HBP pacemaker implantation, placement of an additional backup lead may be reasonable to mitigate the risk of high pacing capture thresholds, lead dislodgment, loss of capture, or oversensing. (Chung, Mina et al.  "2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure" Heart Rhythm, Vol 20, No 9, September 2023)

****CARDIAC PHYSIOLOGIC PACING (HBP or LBAP)****

CLASS I:

In patients with a CIED with a decline in LV function or worsening of HF symptoms attributed to substantial ventricular pacing, CRT with BiV pacing is recommended to improve LV function and improve HF symptoms.  (Chung, Mina et al.  "2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure" Heart Rhythm, Vol 20, No 9, September 2023)

CLASS IIA:

In patients with an indication for permanent pacing with an LVEF 36%–50% who are anticipated to require substantial ventricular pacing, Cardiac Physiologic Pacing (HBP / LBAP) is a Class IIA indication to reduce the risk of Pacing Induced Cardiomyopathy. (Chung, Mina et al.  "2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure" Heart Rhythm, Vol 20, No 9, September 2023)

In patients with a CIED with a decline in LV function or worsening of HF symptoms attributed to substantial ventricular pacing, revision of CIED to a Conduction System Pacing device can be beneficial to improve LV function and symptoms of HF.  (Chung, Mina et al.  "2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure" Heart Rhythm, Vol 20, No 9, September 2023)

In patients undergoing CRT with BiV pacing implantation via the CS, crossover to Conduction System Pacing with HBP or LBAP is reasonable when the CS LV lead placement is unsuccessful or suboptimal.  (Chung, Mina et al.  "2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure" Heart Rhythm, Vol 20, No 9, September 2023)

CLASS IIB:

In patients with normal LVEF who are anticipated to require substantial ventricular pacing, it may be reasonable (Class IIB) to treat patients with Cardiac Physiologic Pacing (HBP / LBAP) to reduce the risk of Pacing Induced Cardiomyopathy.  (Chung, Mina et al.  "2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure" Heart Rhythm, Vol 20, No 9, September 2023)

In patients with LVEF 36%–50%, sinus rhythm, LBBB with QRS duration > or =150 ms, and NYHA class II–IV symptoms on GDMT,  Cardiac Physiologic Pacing (HBP / LBAP) may be considered to maintain or improve LVEF.  (Chung, Mina et al.  "2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure" Heart Rhythm, Vol 20, No 9, September 2023)

In patients with LVEF £35%, sinus rhythm, LBBB with a QRS duration > or =150 ms, and NYHA class II–IV symptoms on GDMT, Cardiac Physiologic Pacing (HBP / LBAP) may be considered as an alternative to CRT with BiV pacing.  (Chung, Mina et al.  "2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure" Heart Rhythm, Vol 20, No 9, September 2023)