Cardiac Resynchronization Therapy In Heart Failure: Implant And Follow-Up Recommendations And Management

Publication Date: September 1, 2012

Consensus Recommendations

Pre-implant recommendations

A careful evaluation of comorbidities and an estimate of life expectancy is recommended.
A thorough pre-implant history and physical examination including review of vital signs and laboratory tests is recommended.
CRT candidates should have stable heart failure status on guideline-directed medical therapy prior to implant.
A pre-implant comprehensive echocardiogram for quantification of LVEF and assessment of cardiac size and function is recommended.
A pre-implant 12-lead ECG including QRS duration measure (>120–130 ms) and characterization of QRS morphology is recommended.
In patients at high thromboembolic risk on oral anticoagulant therapy with warfarin, continuing therapy at reduced dosage with close monitoring of INR (INR 2–3) is recommended perioperatively. Post-operative use of heparin is discouraged.
Preoperative treatment with an antibiotic that has in vitro activity against staphylococci is recommended for infection prophylaxis.

CRT implant recommendations 

Intra-operative haemodynamic monitoring including careful attention of volume status is recommended.
The RV lead is recommended as the first intracardiac lead implanted.
CS venography is recommended to create a roadmap that guides lead selection and assists with navigation.
LV lead testing is recommended to assure an adequate safety margin for capture and avoidance of PNS.
Careful discussion with patients regarding the risk and benefits of CRT-D vs. CRT-P device implant is recommended prior to the decision as to the type of CRT device implanted.

Pre-discharge evaluation recommendations

A physical examination, device interrogation, chest X-ray, and surface ECG is recommended prior to discharge.
Careful attention to volume status is recommended after the implantation procedure as an acute response to CRT may include significant diuresis.
A standard echocardiographic assessment is recommended prior to discharge if a procedural complication is suspected on the basis of patient symptoms or clinical findings.
An assessment to assure 100% biventricular capture is recommended prior to discharge.
The majority of patients implanted with CRT should remain in the hospital overnight after implant to observe clinical status.

CRT follow-up recommendations

A close degree of cooperation is recommended in the follow-up of the CRT recipient between the heart failure and electrophysiology follow-up physician.
A minimum in-clinic follow-up interval of 6 months is strongly recommended for CRT recipients.
Remote monitoring and follow-up in addition to in-clinic follow-up is recommended. Patients should be encouraged to initiate a remote transmission if new symptoms or concerns arise.
Follow-up visits that include a patient history, physical examination, device interrogation and testing, and systematic analysis of device data is recommended.
Optimization including upward titration of heart failure drug therapies, if appropriate, is recommended to maximize response to CRT.
Evaluation of LV function or other adjuncts to assess heart failure progression or regression is recommended during follow-up.

CRT management recommendations 

Assessment of patient response to CRT, including an evaluation of symptoms and functional response and echocardiographic measures of cardiac function, is recommended.
An assessment of potentially reversible causes for non-response is recommended in patients without demonstrable improvement in heart failure status after CRT implant.
A device interrogation is recommended to assess for atrial and ventricular arrhythmias, quality of CRT delivery (% effective biventricular capture) and rate response.
Optimization of medical therapy, assurance of appropriate and consistent biventricular pacing and treatment of arrhythmias is recommended .

Special considerations

Pre-implant patient education including information about the need and function of the CRT device and follow-up plan is recommended. There are a variety of digital patient educational tools that can be utilized to fully inform the patient as to the risks and benefits of CRT or CRT-D therapy.

Recommendation Grading




Cardiac Resynchronization Therapy in Heart Failure: Implant and Follow-up Recommendations and Management

Authoring Organizations

Endorsing Organizations

Publication Month/Year

September 1, 2012

Document Type


External Publication Status


Country of Publication


Document Objectives

To advise the implanting physician on issues regarding CRT patient care, and are intended to help maximize response to therapy acutely and chronically.

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D054143 - Heart Failure, Systolic, D058406 - Cardiac Resynchronization Therapy, D058409 - Cardiac Resynchronization Therapy Devices


heart failure, cardiac resynchronization therapy, heart failure with reduced ejection fraction (HFrEF), CRT

Source Citation

Task Force Chairs, Jean-Claude Daubert, Leslie Saxon, Philip B. Adamson, Angelo Auricchio, Ronald D. Berger, John F. Beshai, Ole Breithard, Michele Brignole, John Cleland, David B. DeLurgio, Kenneth Dickstein, Derek V. Exner, Michael Gold, Richard A. Grimm, David L. Hayes, Carsten Israel, Christophe Leclercq, Cecilia Linde, JoAnn Lindenfeld, Bela Merkely, Lluis Mont, Francis Murgatroyd, Frits Prinzen, Samir F. Saba, Jerold S. Shinbane, Jagmeet Singh, Anthony S. Tang, Panos E. Vardas, Bruce L. Wilkoff, Jose Luis Zamorano, Peer Reviewers, Inder Anand, Carina Blomström-Lundqvist, John P. Boehmer, Hugh Calkins, Serge Cazeau, Victoria Delgado, N.A. Mark Estes, David Haines, Fred Kusumoto, Paco Leyva, Frank Ruschitzka, Lynne Warner Stevenson, Christian Tobias Torp-Pedersen, 2012 EHRA/HRS expert consensus statement on cardiac resynchronization therapy in heart failure: implant and follow-up recommendations and management: A registered branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society; and in collaboration with the Heart Failure Society of America (HFSA), the American Society of Echocardiography (ASE), the American Heart Association (AHA), the European Association of Echocardiography (EAE) of the ESC and the Heart Failure Association of the ESC (HFA)., EP Europace, Volume 14, Issue 9, September 2012, Pages 1236–1286,