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Outline of this thesis
Part I focuses on patient selection for CRT. Chapter 2 provides a critical appraisal of current ECG selection methods and a proposal of potentially better markers known in literature. Continuing on this critical evaluation, chapter 3 investigates the correlation between the various definitions of LBBB and clinical judgement of LBBB, as well as the inter- and intra-observer variability of applied methods. In chapter 4 and 5 we set out to compare the different LBBB definitions in CRT patients with respect to their association with reverse remodelling and clinical endpoints. Moreover, we dissect the definitions’ morphological criteria to evaluate their specific value with respect to outcomes in CRT.
Subsequently, we investigated to what extent patients that do not exhibit LBBB characteristics (non-LBBB) on their 12-lead ECG still may harbour the substrate amenable to CRT (chapter 6). To this purpose electro-anatomical mapping was used in CRT candidates. In chapter 7 we compared the predictive value of vectorcardiographic QRS area to that of established parameters QRS duration, LBBB morphology and their combination in a large cohort of CRT patients.
Part II tackles the important issue of effective patient management in CRT. In chapter 8 we elaborate on a comprehensive CRT care pathway, designed by CRT experts from 4 large implanting centres in Europe. Proposing a benchmark for clinics, naive to a patient care pathway to evaluate their current practice. The next step in optimizing local organization of CRT care is described in chapter 9. Here we show the strategy used to implement the proposed CRT care pathway into our own practice in the Maastricht University Medical Centre. With the help of expert consultants the local care process was assessed, compared and effectively reorganized in order to optimize CRT care.
This thesis ends with a general discussion (chapter 10) with special emphasis on the clinical implications of the results described in this thesis and future directions of research.
