Cardiac implantable electronic devices in heart failure: needs, challenges, and real-world implementation

Abstract Cardiac implantable electronic devices (CIEDs) are integral to heart failure (HF) management, providing therapies for bradyarrhythmias, cardiac resynchronization therapy (CRT), sudden cardiac death (SCD) prevention, and remote monitoring. This review summarizes current and potential future indications, emerging technologies, and challenges in the implementation of CIEDs in HF. Conventional right ventricular pacing in HF patients is increasingly being replaced by biventricular pacing (BVP) and left bundle branch area pacing (LBBAP), while leadless pacing pacemakers have emerged as an alternative to conventional transvenous systems, offering the potential to reduce lead- and device-related complications. As BVP remains the standard approach for CRT, recent data bestow LBBAP as a promising alternative and integration platform. Newer implantable cardioverter-defibrillator technologies, including subcutaneous and extravascular systems, may reduce lead-related complications while maintaining effective arrhythmia termination and recognition. Advances in atrial fibrillation management, implantable hemodynamic monitoring, and novel pacing indications such as atrioventricular recoupling and personalized pacing in HF with preserved ejection fraction are expanding the therapeutic potential of CIEDs. However, the adoption of these innovations is challenged by limited randomized evidence, procedural complexity, and substantial disparities in access and implementation across healthcare systems. Ongoing clinical trials will help define the role of emerging device technologies and monitoring strategies, while efforts to improve guideline adherence, value-based procurement, and equitable access remain essential to maximize the benefits of CIED therapy in patients with HF. Graphical abstract HF – heart failure; LVEF – left ventricular ejection fraction; BVP – biventricular pacing; CSP – conduction system pacing; LP – leadless pacing; LBBAP – left bundle branch area pacing; RCT – randomized clinical trial; HFrEF – heart failure with reduced ejection fraction; CRT – cardiac resynchronization therapy; LOT-CRT – left optimized resynchronization therapy; AF – atrial fibrillation; TV-ICD – transvenous implantable cardiac defibrillator; SCD – sudden cardiac death; HFpEF – heart failure with preserved ejection fraction