Heart Failure Device Therapy — Foshan Chancheng Hospital

Heart failure is not a single disease but the final common pathway of many heart conditions — coronary artery disease, high blood pressure, cardiomyopathies, valve disease and long-standing arrhythmias. Two problems dominate: the heart cannot pump enough blood forward to meet the body's needs, and blood backs up, causing congestion in the lungs (breathlessness) and the body (leg swelling, fluid retention). Typical symptoms include shortness of breath, reduced exercise tolerance, waking at night breathless, fatigue and poor appetite. Care is guided by the New York Heart Association (NYHA) functional class I–IV and by the left ventricular ejection fraction (LVEF).

Modern heart-failure care combines guideline-directed medical therapy (GDMT) — a foundation of neurohormonal and metabolic drugs — with the device therapies described below. All recommendations on this page follow the latest Chinese guidelines for the diagnosis and treatment of heart failure and major international evidence such as the COAPT and FIX-HF-5C trials.

The Heart-Failure Treatment Pathway

For patients with reduced ejection fraction (HFrEF), the first step is always optimized medical therapy: a combination of an ARNI/ACEI/ARB, a beta-blocker, a mineralocorticoid receptor antagonist and an SGLT2 inhibitor, with diuretics when fluid is present. When symptoms persist despite at least three months of the best tolerated drug therapy, device therapy is considered.

Depending on the heart's electrical pattern and how far the disease has progressed, the heart team may recommend an implantable defibrillator to prevent sudden death, a resynchronization device to re-coordinate the beat, a contractility modifier for narrow-QRS hearts, or — in end-stage disease — a mechanical pump (LVAD) or heart transplant. The right choice is always individualized.

Implantable Cardioverter-Defibrillator (ICD)

Continuous rhythm monitoring that stops life-threatening arrhythmias before they become fatal.

An ICD is a small device implanted under the skin with one or more leads placed inside the heart. It continuously watches the heart rhythm and, if it detects ventricular tachycardia or ventricular fibrillation, delivers a precisely timed shock or rapid pacing to restore a normal beat — preventing sudden cardiac death (SCD). A newer EV-ICD (extravascular ICD) places the lead outside the heart and blood vessels.

Who benefits

Secondary prevention (Class I, Level A): survivors of cardiac arrest caused by ventricular tachycardia or fibrillation, or patients with sustained ventricular tachycardia and unstable blood pressure.

Primary prevention (Class I, Level A): ischemic cardiomyopathy more than 40 days after a heart attack with an LVEF of 35% or less and NYHA class II–III symptoms; or non-ischemic cardiomyopathy with an LVEF of 35% or less after at least three months of optimized medical therapy and NYHA class II–III symptoms.

Not recommended (Class III, Level C): end-stage NYHA class IV heart failure with limited expected survival, where an ICD will not improve outcomes.

Key premise: ICDs are evaluated only after at least three months of optimized medical therapy, when expected survival exceeds one year and the LVEF remains 35% or less. A beta-blocker is the only anti-arrhythmic drug proven to reduce sudden death in HFrEF (Class I, Level A).

Cardiac Resynchronization Therapy (CRT)

Re-coordinating a poorly synchronized heartbeat with biventricular pacing.

CRT uses three leads — in the right atrium, the right ventricle and, through the coronary sinus, the left ventricle — to re-synchronize the contraction of a dilated, poorly coordinated left ventricle. This improves pumping efficiency and symptoms. A CRT-D adds defibrillation capability for patients who also need an ICD.

Indications (sinus rhythm, LVEF 35% or less, symptomatic heart failure)

QRS duration 150 ms or more with left bundle-branch block (LBBB): Class I, Level A
QRS 150 ms or more without LBBB: Class IIa, Level A
QRS 120–149 ms with LBBB in women: Class I, Level A
QRS 120–149 ms with LBBB in men: Class IIa, Level B
Atrial fibrillation with LVEF 50% or less, failed rhythm control, AV-node ablation plus CRT: Class IIa, Level B

CRT is not recommended when QRS is shorter than 130 ms (Class III, Level A). Expected survival of more than one year is assessed before implantation, and CRT-D is considered when a patient meets both CRT and ICD criteria.

Cardiac Contractility Modulation (CCM)

A newer option for patients whose hearts are too narrow-QRS for CRT.

CCM delivers high-voltage, long-duration electrical signals to the right ventricular septum during the heart's absolute refractory period. Unlike ordinary pacing, it does not increase the heart's oxygen demand; instead it strengthens contraction and reverses adverse remodeling. Implantation is similar to a standard pacemaker and has a good safety profile.

Who it helps

Narrow QRS (less than 130 ms) and not suitable for CRT
LVEF between 25% and 45%
Persistent symptoms despite optimized medical therapy
Age 18 or older

The FIX-HF-5C study confirmed that CCM improves peak oxygen consumption, six-minute walk distance and quality of life, and reduces heart-failure-related hospitalizations. It is CE-marked and being introduced in China; it is an emerging therapy not yet in the formal 2024 Chinese guideline recommendations.

Left Ventricular Assist Device (LVAD)

A LVAD is a mechanical pump that connects the apex of the left ventricle to the aorta, partially or fully taking over the left heart's pumping work. It is used for end-stage heart failure as long-term mechanical circulatory support (Class IIa, Level B).

Indications

After optimized medical therapy, severe symptoms persisting more than two months with at least one of: LVEF below 25% and peak oxygen consumption below 12 ml·kg⁻¹·min⁻¹; three or more heart-failure admissions with no clear trigger in the past 12 months; dependence on intravenous inotropes or short-term mechanical support; or progressive kidney/liver failure, cardiac cachexia or type-2 pulmonary hypertension from poor perfusion.

Patients with severe right-heart failure or severe tricuspid regurgitation are generally excluded. Survival with third-generation fully magnetically levitated continuous-flow LVADs reaches about 84.5% at two years; domestic magnetically levitated centrifugal LVADs ("Rocket Heart") have reported 96% 90-day survival with the pump.

Transcatheter Edge-to-Edge Repair (TEER / MitraClip)

A minimally invasive way to treat secondary mitral regurgitation without open-heart surgery.

TEER uses a catheter to clip the leaflets of the mitral valve together, reducing regurgitation (leakage) in secondary (functional) mitral disease. It is performed through a vein rather than a sternotomy, making it suitable for patients at high surgical risk.

Indications for secondary mitral regurgitation (all must apply)

Moderate-to-severe or greater mitral regurgitation
NYHA class III/IV symptoms after 1–3 months of optimized medical therapy (or CRT)
LVEF between 20% and 50%
Left ventricular end-systolic diameter 70 mm or less
Pulmonary artery systolic pressure 70 mmHg or less
No significant right-heart dysfunction or severe tricuspid regurgitation
High surgical risk or contraindication, with suitable valve anatomy
Expected survival beyond one year

The COAPT trial showed that, on top of optimized medical therapy, MitraClip plus drugs — compared with drugs alone — significantly reduced two-year heart-failure hospitalizations and all-cause mortality, forming the core evidence for a Class IIa, Level B recommendation. If coronary disease is present, surgical revascularization (CABG with mitral surgery) is preferred over TEER alone.

Key premise: medical therapy and/or CRT must be optimized for 1–3 months first to confirm that regurgitation and symptoms persist, avoiding premature intervention.

TAVR and Other Adjuvant Devices

Addressing reversible causes and supporting the heart from every angle.

Transcatheter aortic valve replacement (TAVR)

For heart failure with severe aortic stenosis — a reversible cause — aortic valve intervention (TAVR or surgical replacement) is recommended to lower mortality and relieve symptoms (Class I, Level B). Aortic stenosis should always be actively evaluated and treated.

Other devices and therapies

Heart transplant — the most effective treatment for end-stage heart failure when no other option remains (Class I, Level C).
Ultrafiltration — controlled fluid removal for high-volume overload and diuretic resistance in acute heart failure (Class IIa, Level B).
CardioMEMS — a wireless pulmonary-artery pressure sensor that enables remote monitoring and lowers rehospitalization; used abroad and being adopted in China.
CPAP — continuous positive airway pressure for heart failure with obstructive sleep apnea (Class IIb, Level B).
Servo-ventilation — not recommended in HFrEF with central sleep apnea, as it increases mortality (Class III, Level B).

Choosing the Right Therapy

A structured, individualized decision after optimal medical therapy.

After at least three months of guideline-directed medical therapy, the heart team assesses the ejection fraction and the heart's electrical pattern. A left bundle-branch block with a wide QRS points toward CRT; a narrow QRS suggests CCM; an LVEF of 35% or less with a need for sudden-death protection calls for an ICD; refractory end-stage disease is evaluated for LVAD or transplant; and significant valve disease is addressed with TAVR or TEER. Reversible causes such as aortic stenosis are treated directly.

Every recommendation is made by a multidisciplinary heart team after a full individual assessment — there is no single device that fits every patient.

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