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Ms Cecilia Linde,
By the discussant- Cecilia Linde, MD,PhD, FESC, Dpt of Cardioogy, Karolinska University Hospital, Stockholm, Sweden. With the present eligibility criteria using wide QRS to establish ventricular dyssynchrony, only 60-70% of patients respond to CRT. Previous trials have demonstrated a good agreement between a single or a set of measures of MD and response to cardiac resynchronisation therapy. The PROSPECT (Predictors of response to CRT) study evaluated if a set of single MD criteria on top of wide QRS width increased the clinical and echocardiographic response to CRT in a multicentre non-randomised study of 426 heart failure patients with a classical indication for CRT including a QRS > 130 ms. MD and response to CRT was assessed at baseline and after 6 months of CRT. Each enrolling centre was trained on image acquisition and the echo-protocol and all echo assessments were performed in core labs. The patient characteristics in PROSPECT were similar to classical CRT recipients and clinical and echocardiographic response to CRT were in agreement with previous CRT trials. The yield for echo measures varied between 50 – 92 %, the inter core lab variability was relatively great (6.5-72.1%) in view of the expertise of the included centres, indicating the need for further simplification of methodology. Presence of MD was linked to a 11-13% additional clinical response rate to CRT and 13-23 % additional response for reverse remodelling compared compared absence of MD.
In this first attempt in a multi-centre study to establish the value of adding MD criteria to QRS no single MD measurement was reliable and ready for widespread use in the selection of candidates for CRT. Further elaboration of MD criteria is needed. Determination of MD should remain a part of the assessment of a patient considered for CRT. At present, QRS width remains as the ventricular dyssynchrony criterium to identify heart failure patients suitable for CRT.
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