Author + information
- Received August 13, 2008
- Revision received November 10, 2008
- Accepted November 12, 2008
- Published online March 3, 2009.
- Wilfried Mullens, MD,
- Richard A. Grimm, DO, FACC,
- Tanya Verga, RN,
- Thomas Dresing, MD,
- Randall C. Starling, MD, MPH, FACC,
- Bruce L. Wilkoff, MD, FACC and
- W.H. Wilson Tang, MD, FACC* ()
- ↵*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
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.
Dr. Mullens was supported by a fellowship training grant sponsored by Boston Scientific and St. Jude. Drs. Starling, Dresing, and Tang are consultants for Medtronic. Drs. Dresing and Tang are consultants for Boston Scientific. Dr. Dresing is a consultant for St. Jude. Dr. Grimm is a consultant/advisory board member for Medtronic, St. Jude, and GE Healthcare. Dr. Wilkoff is a consultant and receives research support from Medtronic, Boston Scientific, and St. Jude. Dr. Wilkoff is a consultant for LifeWatch. The authors had full access to the data and take responsibility for its integrity. All authors have read and agree to the paper as written.
- Received August 13, 2008.
- Revision received November 10, 2008.
- Accepted November 12, 2008.
- American College of Cardiology Foundation