Comprehensive cardiac resynchronization therapy optimization in the real world

Abstract

Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients suffering from chronic heart failure (CHF (17.5% and 28.4% for sAV and pAV, respectively). In contrast, interventricular delay (VV delay) was rarely changed (11.9%). Conclusions: In our "real world" cohort, a substantial proportion of patients presented to their first post-operative consultation with suboptimal device settings. Our data indicate that the opportunity to optimize device settings is frequently wasted in the "real world", underlining the necessity for expert device follow-up to deliver optimal care to this challenging group of heart failure patients. (Cardiol J 2014; 21, 3: 316-324)

Atrioventricular dyssynchrony from empiric device settings is common in cardiac resynchronization therapy and adversely impacts left ventricular morphology and function

“…Empiric device settings are not routinely adjusted post implantation at our institution unless patients report subjective worsening of symptoms. However, many patients present to their first follow‐up appointment with suboptimal AV delay settings regardless of subjective response to CRT . Suboptimal settings can equate to a 10%‐15% decline in cardiac output over time, and 47% of patients who experience poor clinical response at 6‐month follow‐up lack optimal AV delay settings .…”

“…All echocardiographic studies were obtained in an ICAEL‐accredited laboratory using a state‐of‐the‐art ultrasound system (Philips Ultrasound Platform Sonos 5500 or iE33; Philips Medical Systems, Andover, MA, USA). All volumetric measurements were made in accordance with the 2015 American Society of Echocardiography guidelines . Left atrial volume index (LAVI), LV end‐diastolic volume (LVEDV), and LV end‐systolic volume (LVESV) were calculated using Simpson's biplane method in the apical two‐ and four‐chamber views.…”

“…All volumetric measurements were made in accordance with the 2015 American Society of Echocardiography guidelines. 17 Left atrial volume index (LAVI), LV end-diastolic volume (LVEDV), and LV end-systolic volume (LVESV) were calculated using Simpson's biplane method in the apical twoand four-chamber views. Left ventricular ejection fraction (LVEF) and stroke volume (SV) were calculated.…”

“…However, many patients present to their first follow-up appointment with suboptimal AV delay settings regardless of subjective response to CRT. 17 Suboptimal settings can equate to a 10%-15% decline in cardiac output over time, 23 and 47% of patients who experience poor clinical response at 6-month follow-up lack optimal AV delay settings. 15 The consequences of an inappropriately prolonged AV delay may include suboptimal LV preload, diastolic mitral regurgitation, and permissive native LV conduction, which would render CRT ineffective.…”

Superresponse to Cardiac Resynchronization Therapy

“…13 Appropriately adjusting these settings, however, requires extensive experience in the programming of these devices.…”