# Multipoint Left Ventricular Pacing as Alternative Approach in Cases of Biventricular Pacing Failure

## TL;DR

This paper reviews alternative pacing strategies for patients who don't respond to standard heart failure treatments.

## Contribution

The paper provides a review and strategy for optimizing cardiac resynchronization therapy in non-responders.

## Key findings

- Non-response to biventricular pacing remains a significant issue in cardiac resynchronization therapy.
- Multipoint left ventricular pacing and conduction system pacing are potential alternatives for non-responders.
- Simulation-based strategies may help determine optimal pacing approaches for individual patients.

## Abstract

Cardiac resynchronization therapy (CRT) is a cornerstone in the treatment of dyssynchronous heart failure with reduced ejection fraction. However, the phenomenon of non-response has plagued CRT since its initial application. Notwithstanding issues such as failure to capture the left ventricle, lower-than-required pacing delivery percent, and failure to optimize atrioventricular and interventricular delays, there are patients who fail to exhibit an adequate response to CRT in its classical biventricular pacing (BiVP) form. Several modalities have been proposed as a means to remedy this issue, including pacing the conduction system itself—His or left bundle branch pacing, allowing for intrinsic conduction in some myocardial segments, pacing the left ventricle from multiple points in the coronary sinus (multipoint pacing), or even combining the above (e.g., His/left bundle pacing and BiVP leading to His/left bundle-optimized CRT). In the present review, we present recent evidence for the advantages and disadvantages of each modality and attempt to formulate a pathophysiology and simulation-based strategy to determine the best way forward for delivering CRT in non-responders to BiVP.