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How to deliver optimal cardiac resynchronisation therapy
  1. Panagiota Anna Chousou,
  2. Peter J Pugh
  1. Department of Cardiology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
  1. Correspondence to Dr Peter J Pugh, Department of Cardiology, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK; peter.pugh{at}addenbrookes.nhs.uk

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Learning objectives

  • Explain the complexity of cardiac dyssynchrony.

  • Investigate the reasons for cardiac resynchronisation therapy (CRT) non-response in 30% of the patients.

  • Explore options and provide algorithms to assist in delivering optimal CRT.

  • Provide a glimpse of the future.

Introduction

Cardiac resynchronisation therapy (CRT) is a well-established treatment for heart failure (HF). The Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure1 and Cardiac Resynchronisation Heart Failure (CARE-HF)2 trials found that CRT reduces both morbidity and mortality in HF patients. Based on current guidelines, 6%–12% of patients hospitalised with HF are eligible for CRT.3

CRT helps to restore atrioventricular (AV), interventricular (VV) and intraventricular synchrony, improve left ventricular (LV) function, reduce functional mitral regurgitation and induce LV reverse remodelling, as evidenced by increases in LV filling time and left ventricular ejection fraction (LVEF), and decreases in LV end-diastolic and end-systolic volumes, mitral regurgitation and septal dyskinesis.2 4

Up to 30% of patients receiving CRT do not attain symptomatic benefit.5 Various parameters have been used to define response to CRT, including improvement in New York Heart Association (NYHA) functional class, improvement in quality of life and echocardiographic parameters. There are five different possible clinical outcomes post-CRT implantation. Responders (70%) show a measurable improvement, whereas super-responders (5%) show excellent response up to normalisation of LV function. Non-progressors (10%) do not experience the progressive decline that is observed in non-responders (10%), and negative responders (5%) experience clinical deterioration and decline in LV function.6 7

Given the inherent risks and costs of device implantation and maintenance, a reduction in the rate of lack of response to CRT is an important goal. Factors associated with a lack of response include inappropriate patient selection, suboptimal LV lead placement, presence of myocardial scar, inadequate device programming and failure to deliver continuous biventricular (BiV) pacing.5 …

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