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Cardiac resynchronisation therapy: beyond the guidelines

Arrhythmias


Cardiac resynchronisation therapy (CRT) is now established as effective in heart failure management. However, despite the numerous trials and recently updated guidelines, uncertainty remains regarding the selection of patients in subgroups that have not been so extensively studied. This session dealt with a number of these issues.

Cardiac resynchronisation therapy in patients with mild heart failure

Prof. C. Linde (Stockholm, Sweden) presented the additional 24-month clinical data of the REVERSE  (Resynchronisation Reverse Remodeling in Systolic Left Ventricular Dysfunction) trial, providing a deeper understanding of how CRT improves the function of the heart, including reduction in heart size and improvements in pumping efficiency, in patients with QRS duration ≥120 msec, LVEF ≤40%, and LV end diastolic diameter (LVEDD) ≥55 mm, and mild symptoms of heart failure. This study showed a 53% risk reduction of heart failure hospitalization (p=0.003). The presenter highlighted that the result of MADIT-CRT will reinforce the importance of CRT in mild heart failure patients, reducing by 29% the risk of death or heart failure intervention. These results may add a new indication to the CRT guidelines.

Cardiac resynchronisation therapy in heart failure patients with atrial fibrillation (AF)

Prof. A. Auricchio (Lugano, Switzerland) stressed that close to one-third of advanced heart failure patients exhibit AF, however the impact of CRT in this group remains unclear. A recently published meta-analysis of prospective cohort studies comparing the impact of cardiac resynchronisation therapy (CRT) for patients in AF and sinus rhythm (SR) including 5 studies following a total of 1,164 patients shows significant improvement after CRT, with similar or improved ejection fraction as SR patients, but smaller benefits in regard to functional outcomes. Compelling data demonstrated that optimal benefit from CRT was obtained only if 100% BIV pacing was assured. In AF patients this target can only be obtained after Av nodal ablation. Further studies must be performed to evaluate the importance of PV isolation, especially in patients with paroxysmal / persistent AF.

Left-ventricular based pacing for bradycardia

Prof. E. Simantirakis (Heraklion, Greece) elucidated that right ventricular apex is the pacing site with the worst hemodynamic behavior. Several small studies have shown better acute profile with left ventricular pacing, nevertheless in normal LV function patients, standard right ventricular pacing is acceptable as indicated in current guidelines. The cost-benefit of left ventricular pacing is yet to be proven in these patients. The higher complication rate of left ventricular and biventricular pacing needs to be balanced with its potential benefits.

Upgrading conventional pacing to biventricular pacing

Prof. L. Mont (Barcelona, Spain) affirmed that the patients submitted to upgrade have the same outcomes as patients having de novo biventricular implantations. Pacemaker patients with heart failure and dominant paced heart rhythm benefit substantially from an upgrade to BVP, in terms of physical performance and symptoms. The upgrade resulted in significantly improved cardiac function. He advocates that patients need to be treated before severe left ventricular dilatation and presented results from his group showing that biventricular pacing prevents progression to heart failure in patients with ICD indication and left bundle branch block.  

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Cardiac resynchronisation therapy: beyond the guidelines

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.