Page 140 - Simplicity is Key in CRT

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In order to identify reasons for suboptimal benefit of CRT, the checklist focusses on (1) general HF treatment, (2) device related issues, and (3) comorbidities. Additional resources (echo- cardiography, Holter monitoring, etc.) should be used accordingly.
General HF treatment includes checking clinical status, compliance to salt and fluid restriction, diet, HF medication, and cessation of substance abuse (smoking, alcohol, drugs). Underlying reasons for HF deterioration (ischemia, hypertension, right ventricular (RV) dysfunction etc.) should be excluded [3]. Furthermore HF medication should be further titrated post-implantation [50, 51].
With regard to device related issues; contribution from left ventricular (LV) pacing should be present on the 12- lead ECG [52, 53]. Also optimal atrioventricular (AV)-timing should be determined using available optimization (invasive-, echocardiographic- or ECG-) techniques [53-55] and underlying conduction disturbances re-evaluated using LV lead delay-measurements performed either intra-procedurally or at device interrogations during follow-up. As a high percentage of biventricular pacing (>95%) is required, any arrhythmias should be addressed aggressively by either rate or rhythm control strategies [7, 56, 57]. Appropriate LV lead position on the infero-lateral LV wall, outside regions of scar and at a site of delayed LV activation should be (re-) assured using pre-implantation imaging and LV lead delay-measurements [27-29, 31, 58, 59].
Co-morbidities (kidney function disturbances, anaemia, iron-deficiency, thyroid dysfunction, etc.) should be treated adequately [60, 61]. Furthermore, as stated before, special attention should be given to signs of anxiety or depression, as these are common complications of HF as well as device therapy [62].
Finally, all patients should be considered for and encouraged to join a HF rehabilitation program, regardless of previous participation in such a program. Any deconditioning that could have been caused by catabolic metabolism before implantation can perhaps now be redeemed with a more profitable metabolic situation after implantation [63].
Regular (non-intensive) follow-up
From the 6-month follow-up on, the patient will return to the regular HF outpatient clinic. CRT follow-up will consist of biannual check-ups of device function, including general device parameters, battery status, and HF diagnostics. In practice, this will come down to a once-a-year remote device transmission, checking for general device function, with special attention to percentage of biventricular pacing, presence of arrhythmias, and HF diagnostics. The 6 month remote transmission is alternated with a 6 month visit in the outpatient clinic for full device check-up, followed by HF assessment. This regular follow-up could eventually entail further optimization whenever possible, decisions about replacement of device (battery) or, in some cases, ending of therapy as demanded by the patient.
If, during regular follow-up, there is any indication of failure of CRT or complications of therapy, the patient will be evaluated on an ad hoc basis until a satisfactory situation has returned and the patient can be put back on the regular follow-up plan.
Ad hoc intensive follow-up plan
When warranted by complaints or device information at remote check-up, the patient will be evaluated in the outpatient clinic, within 1-2 weeks. The general assessment will be the same as the regular follow-up assessments, with access to CRT and HF specialist consultation, and any additional diagnostic resources needed.