Electrical manipulation of the failing heart

Chronic heart failure with reduced (≤ 40%) ejection fraction (HFrEF) poses a significant residual mortality risk despite modern optimal medical therapy. In the last decades, we have witnessed the introduction of breakthrough cardiac implantable electronic devices (CIED) aimed at addressing sudden cardiac death and HF progression in patients with HFrEF, leading to improved survival and functional capacity. Following their introduction, implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT) have undergone substantial technological improvements and have been investigated in different settings of HFrEF, some of which yielded controversial results. In this review, we provide a comprehensive, yet pragmatic, approach to the individual key points in the electrical manipulation of the failing heart with ICD and CRT including patient selection, technological advances in the implant technique, follow-up, and long-term management. The aim of the review is to provide real-life-oriented advices to maximize the desired outcomes of CIED-based therapy of HFrEF. Accordingly, a framework to inform the decision-making process in candidates to ICD and/or CRT has been developed reflective of a critical appraisal of the most recently available evidence reappraising some domains beyond the classic views.