Management of Patients Requiring a Biventricular Pacemaker Defibrillator (BPD)
Patients with heart failure, reduced ejection fraction, and wide QRS should receive a biventricular pacemaker defibrillator (CRT-D) to reduce mortality, hospitalization, and improve quality of life. 1
Patient Selection Criteria
Primary Indications for CRT-D:
- NYHA class III-IV heart failure symptoms
- Left ventricular ejection fraction (LVEF) ≤35%
- QRS duration ≥120 ms
- Optimal medical therapy for heart failure 2, 1
Additional Considerations:
- Patients with LVEF ≤30% and QRS ≥130 ms may benefit even with milder symptoms (NYHA I-II) 3
- Patients requiring permanent pacing with LVEF ≤35% should receive CRT-D rather than standard ICD, especially if ventricular pacing is expected to exceed 40% 2
- Patients with an existing ICD who develop heart failure criteria may require upgrade to CRT-D 3
Pre-Implantation Assessment
Cardiac Function Evaluation:
- Echocardiography to assess LVEF and ventricular dyssynchrony
- ECG to confirm QRS duration and morphology
- Coronary anatomy assessment (especially for ischemic cardiomyopathy)
Heart Failure Status:
- NYHA functional class determination
- Optimization of heart failure medications
- Assessment of comorbidities
Arrhythmia Assessment:
- History of ventricular arrhythmias
- Need for bradycardia support
- Presence of atrial fibrillation
Device Selection Considerations
- Transvenous CRT-D is indicated for most patients requiring both resynchronization therapy and defibrillation 4
- Subcutaneous ICD should NOT be used in patients requiring bradycardia pacing or cardiac resynchronization therapy 2, 4
- Wearable cardioverter-defibrillator may be reasonable as a bridge to permanent CRT-D implantation in high-risk patients 2
Implantation Procedure Requirements
The implanting physician should have:
- Thorough knowledge of coronary sinus anatomy
- Understanding of heart failure device management principles
- Ability to interpret LV and biventricular pacing ECGs
- Ability to interpret chest X-rays with coronary sinus leads 2
Adequate proficiency typically requires:
- Participation as primary operator in at least 20 supervised CRT implants
- Observation of at least 15 cases under experienced supervision
- Performing at least 20 implants with an experienced proctor 2
Post-Implantation Management
Immediate Post-Procedure (Pre-Discharge):
- Clinical evaluation
- Device programming with optimization of AV and VV intervals
- Assessment for complications (tamponade, lead dislodgement, infection) 2
Follow-Up Schedule:
- First visit at 1 month post-discharge
- Regular visits every 3-6 months thereafter 2
Each Follow-Up Visit Should Include:
- Heart failure status assessment
- Device interrogation to ensure:
- 100% biventricular pacing
- Proper sensing and capture thresholds
- Optimal AV and VV intervals
- Appropriate detection and therapy for ventricular arrhythmias
- Battery status 2
Long-Term Management
- Coordination between heart failure and electrophysiology teams is essential
- Continued optimization of heart failure medications
- Regular assessment of response to CRT using:
- Clinical evaluation (symptoms, NYHA class)
- Echocardiography to assess ventricular function
- Cardiopulmonary exercise testing when appropriate 2
Potential Complications and Management
- Loss of biventricular capture: Requires prompt lead repositioning
- Phrenic nerve stimulation: May need LV lead output adjustment or repositioning
- Device pocket infection: May require complete system removal
- Lead dislodgement: Requires lead repositioning
- Inappropriate ICD shocks: Requires programming optimization 2
Special Considerations
- Atrial fibrillation: May reduce effective biventricular pacing; consider AV node ablation if rate control is inadequate
- Upgrades from existing devices: Associated with higher complication rates (15.3% vs. 4.0% for new implants) 2
- Non-responders: Approximately 30% of patients show minimal benefit; requires careful evaluation of lead position, programming, and underlying cardiac condition 2
By following these guidelines, CRT-D therapy can significantly reduce mortality by 36% and hospitalization for heart failure by 40% compared to optimal medical therapy alone 1.