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International consensus on CRT management

Recommendations for the practical management of cardiac resynchronisation therapy (CRT) patients have been set out in an international consensus statement, presented recently at the ESC Congress held in Munich, Germany.

The statement was developed by the European Heart Rhythm Association (EHRA) and the US Heart Rhythm Society (HRS), incorporating expert consensus from both sides of the Atlantic.

“We have very strong recommendations regarding clinical indications based on the clinical evidence and these are covered in multiple guidelines,” said Professor Jean-Claude Daubert, joint task force co-chair (University of Rennes 1, France). “CRT therapy improves symptoms, cardiac function, hospitalization rates and mortality in a broad range of patients with heart failure”.

He added: “On the contrary, until now we did not have a consensual document on the practical aspects of this therapy. Our goal was to establish a consensus statement on how to manage CRT patients before, during and after the implantation procedure. We do not discuss clinical indications”.

Professor Jean-Claude Daubert

Professor Jean-Claude Daubert

c“In this document we attempted to fill in the gaps in clinical evidence and provide practical recommendations for the evaluation and management of the CRT patient that could be applied to patients implanted anywhere in the world,” said Dr Leslie Saxon, US joint task force co-chair (University of Southern California, US).

The document has six sections:

  • Pre-implant evaluation: Includes recommendations on how to manage patients just before CRT implantation. This section focuses on potential temporary contraindications to the intervention, and how to manage medications, particularly anticoagulants and antibiotics, just before and during the implantation procedure.
  • CRT implantation: How to implant the CRT device. This section describes all steps of the procedure such as anaesthesia, lead implant sequence, left ventricular lead placement and defibrillation testing. “This is, to my knowledge, the first attempt to write a consensus definition of the optimal way to implant a CRT device,” said Professor Daubert. “We make recommendations on all the technical aspects of the implantation procedure”.
  • Pre-discharge evaluation and device programming: Includes how to recognise and handle acute complications, initial programming of the device just after the operation and before hospital discharge, and atrioventricular (AV) and ventriculoventricular (VV) optimisation.
  • Dr Leslie Saxon

    Dr Leslie Saxon

    CRT follow-up: This section outlines how follow-up should be organised and what assessments should be made. The complementary role of remote monitoring is discussed, with a special focus on how remote haemodynamic monitoring can be used. The need for strong cooperation between the heart failure specialist and the electrophysiologist (EP) is stressed. “We have to keep in mind that the CRT patient is primarily a heart failure patient,” said Professor Daubert. “Follow-up has to concern not only the technical follow-up of the device, but also – and primarily – the heart failure status of the patient. It is essential to optimise the heart failure management of the patient”.

  • Response to CRT management of the non-responder: Discusses how to assess the response to CRT and how to manage non-responders. The document recommends that a systematic assessment should be conducted to identify and treat reversible causes of non-response.
  • Special considerations: Includes recommendations for the management of CRT in particular situations such as patients with atrial fibrillation and patients on renal dialysis. Also discussed are how to choose between the two types of device – resynchronisation alone or resynchronisation plus defibrillation – and the relative advantages and disadvantages of each. And finally, issues related to end of life, patient education and engagement, and cost effectiveness are considered.

Professor Daubert concluded: “This is the first consensus statement on all of the practical aspects involved in managing CRT patients throughout their entire journey on CRT therapy. We hope it will be useful in the clinical practice of physicians all over the world who use this type of therapy, including heart failure specialists who refer and follow patients and EP specialists who implant the device and follow patients”.

References

1. Daubert JC, Saxon L. 2012 EHRA/HRS expert consensus statement on cardiac resynchronisation therapy in heart failure: implant and follow-up recommendations and management. ESC Congress 2012. View session details at http://spo.escardio.org/default.aspx?eevtid=54&hit=highlight-on

Published on: September 27, 2012

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