Cardiac resynchronization therapy pathophysiology

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief:: Bhaskar Purushottam, M.D. [2]


Left ventricular systolic dysfunction is associated with electromechanical dyssynchrony which may be in the form of atrioventricular, interventricular, intraventricular and intramural delay. The impaired electromechanical coupling in turn diminishes the left ventricular systolic function.

Pathophysiologic Basis For CRT

Left ventricular systolic dysfunction is often accompanied by impaired electromechanical coupling, which may further diminish the left ventricular systolic function. The types of electromechanical dyssynchrony are atrioventricular, interventricular, intraventricular and intramural delay[1]. Atrioventricular dyssynchrony results in a late diastolic ventriculoatrial gradient and so called "pre-systolic" mitral regurgitation. Interventricular dyssynchrony is the time delay between the contraction of the left and right ventricles and this is calculated by measuring the difference in the time of onset of systolic flow in the aortic and pulmonic valve. A time difference greater than or equal to 40 milliseconds is indicative of interventricular dyssynchrony. There are several echocardiographic techniques to measure intraventricular dyssynchrony, which include M mode echocardiography, tissue Doppler imaging, tissue strain, strain rate analysis and speckle tracking echocardiography. Intramural dyssynchrony is the dyssynchrony within the myocardial wall and it has been measured using speckle tracking echocardiography[2]. However, the most common abnormalities are prolonged atrio-ventricular and ventricular conduction, which causes regional mechanical delay within the left ventricle.

This mechanical delay is responsible for ventricular dyssynchrony, which can result in the following hemodynamic abnormalities[3]:

  1. Reduced left ventricular systolic function, decreased dP/dT and cardiac output
  2. Delayed contraction of lateral and posterior left ventriclular wall with abnormal septal motion
  3. Increased myocardial energy expenditure
  4. Adverse remodeling with increased left ventricular dilatation left ventricular end systolic volume
  5. Functional mitral regurgitation
  6. Delayed mitral valve opening
  7. Reduced left ventricular filling time with increased left atrial pressures
  8. Distorted mitral valve annulus
  9. Delayed aortic valve opening and closure with reduced systolic ejection time


  1. Auricchio A, Abraham WT (2004). "Cardiac resynchronization therapy: current state of the art: cost versus benefit". Circulation. 109 (3): 300–7. doi:10.1161/01.CIR.0000115583.20268.E1. PMID 14744954.
  2. Bank AJ, Kaufman CL, Burns KV, Parah JS, Johnson L, Kelly AS; et al. (2010). "Intramural dyssynchrony and response to cardiac resynchronization therapy in patients with and without previous right ventricular pacing". Eur J Heart Fail. 12 (12): 1317–24. doi:10.1093/eurjhf/hfq162. PMID 20864481.
  3. Ho JK, Mahajan A (2010). "Cardiac resynchronization therapy for treatment of heart failure". Anesth Analg. 111 (6): 1353–61. doi:10.1213/ANE.0b013e3181fa3408. PMID 21059745.

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