Selection of candidates for cardiac resynchronization therapy and implantation management: an Italian survey promoted by the Italian Association of Arrhythmology and Cardiac Pacing

Abstract

Background Cardiac resynchronization therapy (CRT) represents an effective heart failure treatment, associated with reduction in mortality and heart failure hospitalizations. This Italian survey aimed to address relevant CRT issues. Methods An online survey was administered to AIAC members. Results One hundred and five electrophysiologists participated, with a median of 40 (23–70) CRT implantations/year (33% in high-volume centres). Forty-five percent of respondents (especially working in high-volume centres) reported an increase in CRT implantations in the last 2 years, in 16% a decrease, and in 38% CRT remained stable. Seventy-five percent of respondents implanted CRT only in patients with European Heart Rhythm Association (EHRA) class I indications. All operators collected ECG and echocardiography before implantation. Eighty-five percent of respondents selected coronary sinus target vein empirically, whereas 10% used mechanical and/or electrical delay techniques. Physicians working in high-volume centres reported a lower failure rate compared with others (16 vs. 34%; P = 0.03). If the coronary sinus lead could not be positioned in the target branch, 80% placed it in another vein, whereas 16% opted for a surgical approach or for conduction system pacing (CSP). Eighty percent accomplished CRT optimization in all patients, 17% only in nonresponders. Regarding anticoagulation, high agreement with EHRA guidelines emerged. Conclusion CRT represents a valid therapeutic option in heart failure treatment. Nowadays, CRT implantations remain stable and are mainly performed in patients with class I indications. ECG remains the preferred tool for patient selection, whereas imaging is increasingly used to determine the left pacing target area. In most patients, the left ventricular lead can be successfully positioned in the target vein, but in some cases, the result can be unsatisfactory; however, the decision to explore alternative resynchronization approaches is rarely pursued.