Cardiac resynchronization therapy in cancer patients with chemotherapy-induced cardiomyopathy: a mini review

Abstract

Chemotherapy-induced cardiomyopathy (CHIC) represents a growing clinical challenge due to the increasing use of cardiotoxic treatments. These therapies can lead to progressive myocardial dysfunction, ultimately resulting in heart failure. Cardiac resynchronization therapy (CRT) has been widely investigated in selected patients with chronic heart failure; however, those with CHIC remain underrepresented in CRT trials. Current evidence is largely based on retrospective and observational studies, with MADIT-CHIC being the only prospective trial to date. No randomized controlled trials are currently available. Despite encouraging findings, existing data remain limited by small sample sizes and short follow-up durations. In particular, the impact of CRT on left ventricular dyssynchrony, arrhythmic burden, and long-term survival in this population has not been fully elucidated. A multidisciplinary cardio-oncology approach is essential not only for the comprehensive management of these complex patients, but also to guide appropriate timing of CRT implantation. Further research is warranted to refine patient selection criteria and to fully assess the long-term benefits and risks of CRT in patients with CHIC.

Keywords: Cancer; Cardiac resynchronization therapy; Cardiomyopathy; Chemotherapy; Heart failure.

Fig. 1

A 70-year-old woman previously treated with high-dose anthracycline chemotherapy for breast cancer developed chemotherapy-induced cardiomyopathy, progressing to symptomatic heart failure with reduced ejection fraction despite maximally tolerated doses of bisoprolol, valsartan, spironolactone, empagliflozin, and furosemide. After developing left bundle branch block, she underwent CRT implantation. LV global longitudinal strain, assessed at discharge (a) and three months post-CRT (b), showed an average improvement by 41% (from −8.2% to −11.6%), with an evident correction of septal to lateral wall activation delays as shown in the bull’s eye time to peak strain (white arrows)

Fig. 2

A simplified clinical pathway for the evaluation and timing of CRT in patients with chemotherapy-induced cardiomyopathy is proposed, based on current evidence and expert consensus. This pathway integrates cardiac function, oncological status, and predictors of recovery to support individualized decision-making regarding the timing of CRT CHIC chemotherapy-induced cardiomyopathy, CMR cardiac magnetic resonance, CRT cardiac resynchronization therapy, GDMT guideline-directed medical therapy, GLS global longitudinal strain, LVEF left ventricular ejection fraction, LBBB left bundle branch block, NYHA New York Heart Failure functional class, ST2 soluble suppression of tumorigenicity 2