Page 130 - Simplicity is Key in CRT

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Introduction
Cardiac resynchronization therapy (CRT) is one of the most successful HF therapies that has emerged over the last few decades. Several randomized clinical trials have shown CRT to reduce symptoms of HF, improve exercise capacity and quality of life, as well as to reduce hospitalizations and mortality [1-4]. Furthermore, economic evaluations have shown it to be a cost-effective therapy in HF [5, 6]. Clinical guidelines of the European Society of Cardiology and the American College of Cardiology Foundation/American Heart Association endorse these results and promote utilisation of CRT in selected HF patients [3, 7-9].
Despite guidelines and experts’ consensus, high variations in patient selection, implantation techniques, in-hospital management and follow-up are observed [10-12]. In part because of this, the percentage of patients experiencing limited benefit of CRT remains about 25-30%. This is, despite numerous efforts to improve the response to therapy over the last years. This emphasises the complex nature of CRT in HF and that it therefore requires thorough patient selection, deliberate device and LV lead implantation and a comprehensive follow-up [13-16]. Multiple studies have shown, that successful treatment of HF in general requires specialised (multidisciplinary) care [3, 15]. Therefore ideally, there should be a uniform, multidisciplinary approach to patient selection, therapy delivery and follow-up of patients post CRT device implantation [13].
In complex care pathways, checklists have shown to improve organisation structure, homogeneity in therapy and the ability to prevent complications. Moreover, checklists improve implementation of care pathways, especially in heart failure [17, 18]. Still, checklists are not typically used in CRT care.
Several major European hospitals, with great experience in CRT and organisation of CRT-care, have partnered in developing a structured CRT care pathway model using an integrated collaboration between the HF, electrophysiology (EP) and imaging departments. This best practice pathway model has been developed based on available clinical evidence and experts’ consensus and has become part of the routine clinical care protocol in these centres. It aims at achieving 1) high quality, integrated care for the CRT patients 2) a proactive and structured approach to the improvement of the clinical response to CRT, and 3) control of the costs of providing care.
This paper is the first to provide a detailed format and structured aid for an optimised clinical CRT care pathway. The aim is to provide centres, whether implanting or following patients post- implantation, a framework to evaluate their current CRT care, identify opportunities for improvement and to provide standardized tools for CRT care management.