Page 135 - Simplicity is Key in CRT

Pre-assessment clinical visit
If the reviewing CRT specialist considers the referred patient suitable for CRT, a single day pre- assessment visit at the outpatient cardiology clinic should be planned, as well as the actual implantation procedure date (figure 1). The objective of the pre-procedure appointment is to check referral information and add any missing details, to further educate the patient on CRT (and ICD if relevant), to assess the patient’s ‘fitness for surgery’ and to obtain informed consent. This should be planned shortly before the implantation procedure (depending on the local waiting list). The patient invitation package to the outpatient pre-assessment cardiology clinic includes a letter detailing the pre-assessment visit, patient educational materials (booklet on implantation procedure, complications and therapy goals, follow-up and remote monitoring), the implantation procedure day details and contact information in case of questions or required change in bookings.
CRT specialist review
At pre-assessment, the CRT specialist first sees the patient. The CRT specialist evaluates HF history, complaints, current medication, comorbidities, and their influence on daily activities. The CRT specialist also explains CRT (and ICD therapy if relevant). The indication, implantation procedure, procedure related complications, benefit of CRT and the possibility of limited response, should be discussed. Also, CRT follow-up and future replacements or disabling of ICD therapies, are discussed with the patient. Any additional questions the patient may have are answered and patient consent is obtained.
The CRT specialist evaluates current antiplatelet and anticoagulation medication and determines the peri-procedural strategy [13, 19, 20]. Patient suitability for standard analgesic protocol and antibiotic strategy according to local protocols is assessed [21]. Suitability for single day case procedures is determined at this stage.
General review
A general review, focussed on CRT and ICD therapy, assessing patient’s understanding of CRT (and ICD therapy if relevant) is done. The pre-procedure, procedure and post-procedure processes are explained to the patient in simple non-medical and non-technical language. The impact of device implantation on daily life is discussed, i.e. wound care, driving restrictions, other surgical interventions, device follow-up requirements including remote monitoring, medical follow-up, HF rehabilitation and shock management. The patient is also informed about related patient- association groups.
As the aim in the CRT care pathway is a short admission for the implantation procedure, ‘fitness for surgery’ (complicating issues or contra-indications for procedure) is assessed in advance, to minimize the chance of implantation procedure cancelation at admission. Furthermore, periprocedural medication recommendations related to co-morbidities are reviewed. Discharge planning is already discussed with the patient.
Finally the pre-assessment checklist (figure 3) is completed and final approval is given for the procedure. Questionnaires may be used to assess baseline quality of life [22, 23] and psychological status [24, 25]. If necessary, the patient may be referred for further evaluation and treatment.
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