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CLINICAL RESEARCH: CARDIAC RESYNCHRONIZATION THERAPY

Insights From a Cardiac Resynchronization Optimization Clinic as Part of a Heart Failure Disease Management Program

Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio

Manuscript received August 13, 2008; revised manuscript received November 10, 2008, accepted November 12, 2008.

^_* Reprint requests and correspondence: Dr. W. H. Wilson Tang, Section of Heart Failure and Cardiac Transplantation Medicine, Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, Ohio 44195 (Email: tangw{at}ccf.org).

Objectives: Our aim was to determine the feasibility and value of a protocol-driven approach to patients with cardiac resynchronization therapy (CRT) who did not exhibit a positive response long after implant.

Background: Up to one-third of patients with advanced heart failure do not exhibit a positive response to CRT.

Methods: A total of 75 consecutive ambulatory patients with persistent advanced heart failure symptoms and/or adverse reverse remodeling and CRT implanted >6 months underwent a comprehensive protocol-driven evaluation to determine the potential reasons for a suboptimal response. Recommendations were made to maximize the potential of CRT, and adverse events were documented.

Results: All patients (mean left ventricular [LV] ejection fraction 23 ± 9%, LV end-diastolic volume 275 ± 127 ml) underwent evaluation. Eighty-eight percent of patients had significantly better echocardiographic indexes of LV filling and LV ejection with optimal setting of their CRT compared with a temporary VVI back-up setting. Most patients had identifiable reasons for suboptimal response, including inadequate device settings (47%), suboptimal medical treatment (32%), arrhythmias (32%), inappropriate lead position (21%), or lack of baseline dyssynchrony (9%). Multidisciplinary recommendations led to changes in device settings and/or other therapy modifications in 74% of patients and were associated with fewer adverse events (13% vs. 50%, odds ratio: 0.2 [95% confidence interval: 0.07 to 0.56], p = 0.002) compared with those in which no recommendation could be made.

Conclusions: Routine protocol-driven approach to evaluate ambulatory CRT patients who did not exhibit a positive response is feasible, and changes in device settings and/or other therapies after multidisciplinary evaluation may be associated with fewer adverse events.

Key Words: heart failure • cardiac resynchronization • optimization • disease management

Abbreviations and Acronyms   AV = atrioventricular   CRT = cardiac resynchronization therapy   LV = left ventricle/ ventricular

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