Page 137 - Simplicity is Key in CRT

As LV lead positioning plays an important role in CRT optimization, careful consideration of positioning is critical [27-29]. Once access to the coronary sinus (CS) has been obtained, we recommend performing a retrograde angiography of the coronary venous anatomy, preferably in two orthogonal views for optimal visualization of the target vein.
LV lead implantation should target the basal infero-lateral wall outside regions of scar. [28, 30, 31] There is increasing evidence that LV lead placement in a location on the free wall with delayed LV activation (determined either by echocardiography [27, 32] or specific electrical measurements [33-36]) improves benefit from CRT. A specific way to measure the extent of electrical delay during procedure, is to measure the Q-LV sense delay; defined by the time interval from the first deflection on the surface ECG to the local intrinsic activation at the LV stimulation site [35, 37]. To provide pacing vector options (in case of phrenic nerve stimulation or an apical position of the lead tip), and to ensure lead stability (by distal positioning) and still being able to pace at a mid or basal electrode, a multi-electrode LV lead is preferred [38-42]. The final position of all leads should be registered fluoroscopically in two orthogonal views to provide a reference for re-assessing lead-position in the future.
We believe optimization should begin at implantation. The implanting specialist should explicitly recommend protocols for medication cessation, continuation or up-titration of HF medication in the procedure report. This is also the case with respect to advice about treatment of existing atrial fibrillation and optimizing rate or rhythm control.
Post-procedure
The post-procedure check-up should take place at least 2 hours after the implantation and includes a chest X-ray, wound check, 12-lead ECG and a device check-up. These checks are performed to ensure successful CRT system implantation, appropriate CRT device function and absence of complications before discharge.
As there currently is no convincing evidence for device optimization, we suggest a pragmatic approach. Optimization can be performed at the discretion of the CRT specialist by either echocardiographic or ECG methods [43-46]. Whether or not optimization is performed, appropriate CRT with contribution from LV pacing should be confirmed on the ECG before discharge [47, 48].
A discharge checklist (figure 4) is used to ensure patient education (reminders, dos and don’ts), remote monitoring enrolment, and verification of medication (and device optimization plan, if applicable) at discharge. Also standardized follow-up appointments are planned.
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