Impact of Cardiac Resynchronization Therapy Optimization Inside a Heart Failure Programme: A Real-World Experience

Figures

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  Figure 1. Flow chart of the CRT optimization programme. CRT, cardiac resynchronization therapy; ECG, electrocardiogram; LVEF, left ventricle ejection fraction; AVd, atrioventricular delay; VVd, interventricular delay; LVOT VTI, left ventricular outflow tract velocity time integral.

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  Figure 2. Screening for potential causes of CRT non‐response. AVd, atrioventricular delay; VVd, interventricular delay; LV, left ventricular; HF, heart failure; BiV, biventricular; SVT, supraventricular tachycardia; PVC, premature ventricular contraction.

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  Figure 3. Distribution of AVd and VVd before and after optimization. (A) AS AVd before optimization. (B) AS AVd after optimization. (C) VVd before optimization. (D) VVd after optimization. AVd, atrioventricular delay; AS, atrial‐sensed; LV, left ventricular; RV, right ventricular; VVd, interventricular delay.

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  Figure 4. Examples of echo‐guided AVd and VVd optimization. (A, B) 78‐year‐old patient with non‐ishemic cardiomyopathy and complete AV block, implanted with CRT pacemaker. (A) Too long initial AS AVd (150 ms) with merged E and A waves. (B) Shortening the delay to 80 ms resulted in separation of (E) and (A). (C, D) 71‐year‐old patient with valvular cardiopathy and sinus node dysfunction, implanted with CRT defibrillator. (C) Too short initial AP AVd (120 ms) with truncated A wave. (D) After extension of AP AVd to 160 ms, mitral closure click was aligned with end of A wave. (E, F) 59‐year‐old patient with ischemic cardiomyopathy, complete LBBB and LVEF reduced to 25%, implanted with CRT defibrillator. Changing the VVd from 10 to 30 ms (LV first) resulted in an acute increase of LVOT VTI (12.3 cm to 16.8 cm, heart rate 65 b.p.m.). AVd, atrioventricular delay; AS, atrial‐sensed; AP, atrial‐paced; CRT, cardiac resynchronization therapy; LBBB, left bundle branch block; LV, left ventricular; LVEF, left ventricular ejection fraction; LVOT, left ventricular outflow tract; VTI, velocity time integral; VVd, interventricular delay.

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  Figure 5. Evolution of functional status according to the clinical composite score (CCS). CRT, cardiac resynchronization therapy.

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  Figure 6. Cumulative rate of major HF events (HF hospitalization, all‐cause death, heart transplantation, mechanical circulatory support) after optimization programme (1 year follow‐up). Kaplan–Maier curves for (A) initial CRT responders versus non‐responders; (B) initial CRT non‐responders AVd modified versus AVd non‐modified; (C) initial CRT non‐responders VVd modified versus VVd non‐modified. AVd, atrioventricular delay; CRT, cardiac resynchronization therapy; HF, heart failure; VVd, interventricular delay.