Page 15 - Simplicity is Key in CRT

Patient Management in CRT
CRT starts after implantation of the biventricular pacing device. However, in many patients this does not mean that this therapy leads to optimal benefit. Not only does the device need individualization, as every patient’s heart shows different electrical, structural and mechanical properties, but also treatment of the underlying cause of HF, general HF treatment and consideration of relevant comorbidities is needed to achieve optimal clinical benefit.
As CRT has proven to be of great benefit in many patients, research has focussed on finding factors reducing the odds of response to therapy. Over time, many aspects of both device and HF management have been identified as important conditions that need to be met in order to ensure that the patient optimally benefits from therapy [30]. Achieving effective resynchronization needs reassurance of the presence of significant intrinsic dyssynchrony (patient selection); optimization of timing (AV and VV delays) and location of the pacing-electrode on the LV lateral wall outside of scar, and optimization of the ‘dosage’ of resynchronization (over 98% biventricular pacing). Moreover, in order to be able to establish beneficial effect, the heart needs a reduction of elevated filling pressures, optimization of general HF treatment (which often allows for rigorous up-titration of HF drugs after implementation of CRT), treatment of underlying cause(s) and triggers of HF, and diagnosis and treatment of relevant comorbidities like supraventricular and ventricular tachyarrhythmias, hypertension, kidney dysfunction, anaemia and iron- deficiency, thyroid dysfunction, and obstructive sleep-apnoea. Finally, in order to maintain long term beneficial effects, patients need education and support of lifestyle changes and individualized rehabilitation [30-32].
In general HF management, it is well established that multidisciplinary care management leads to a reduction in HF hospitalizations and mortality [33]. However, as CRT is an electrical therapy, it is often left to the electrophysiologists to manage it. Therefore, in current practice CRT patients often get separate appointments with several specialized cardiologists, device technicians and specialized HF nurses. On top of the additional investigations, this creates a large burden for these mostly fragile patients, their family as well as for the health care system. Moreover, as elucidated above, the complex natures of both HF disease management and CRT management necessitate elaborate and structured evaluation of this patient group. Although CRT has been shown be the most effective therapy for HF patients in the last decades, a single missing link in the chain of disease management may be the difference between ‘response’ and ‘non-response’. Therefore, patient management in CRT profits from a multidisciplinary approach [34], moreover efficient organization of care for these patients could lead to great improvements in patient and health care burden, as well as improved clinical outcome.
Aim of this thesis
The overarching theme of this thesis is to maximize the benefit of CRT for HF patients. The specific topics this thesis will target are;
(1) Improving patient selection; evaluating current ECG selection criteria and investigate possibly better ones. (2) Improving patient management; introducing a comprehensive re-organization of patient management in
CRT; making patient management governable, effective and efficient.
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