Abstract
In 1993, the cardiac surgeon Bakker et al. [1] introduced biventricular pacing as a novel method to treat heart failure by synchronous stimulation of the right and left ventricle. After this first-in-man implantation, the rapid development of transvenous left ventricular (LV) leads and the implementation of biventricular pacing in implantable cardioverter/defibrillators have established cardiac resynchronisation therapy (CRT) as a standard treatment of heart failure with systolic LV dysfunction and broad QRS complexes. Although the milestone trials have proven the benefit of CRT (reduction in mortality and morbidity, reverse remodelling, improvement of LV function), the prediction of CRT response still remains a challenge [2–6]. Because of the high number of CRT non-responders, especially in patients with unspecific widening of the QRS complex, class I indication for CRT was restricted to heart failure patients with typical left bundle branch block (LBBB) in the European Heart Rhythm Association guidelines update of 2013. Two-dimensional echocardiography is the most widely used noninvasive method for the evaluation of LV function and assessment of reverse remodelling after CRT; however it has as yet failed to play an additional role in determining the indication for CRT [7]. Furthermore, even though mechanical dyssynchrony was thought to be present using echocardiographic parameters, CRT was harmful in those patients with narrow QRS complexes [8]. In more than 20 years of experience with CRT-related issues, we have deepened our knowledge about indication, implantation, evaluation, and optimisation of CRT. With the rapid development of the CRT technology new challenges arise.
Highlights
E.E. van der Wall Netherlands Society of Cardiology/Holland Heart House, Utrecht, The Netherlands ent using echocardiographic parameters, cardiac resynchronisation therapy (CRT) was harmful in those patients with narrow QRS complexes [8]
Possible answers to this question are discussed in the review article by Lahrouchi and Bezzina [10]. They found different expressions of genes encoding components of Ca2 + handling, β-adrenergic receptors, contractile proteins, and myocardial natriuretic peptide pre- and post-CRT. It remains unclear whether these changes in gene expression are truly induced by CRT itself or whether they are the result of improvement in left ventricular (LV) function
Ghani et al [14] showed in their prospective observational single-centre study of 297 CRT patients that echocardiographic assessment of mechanical dyssynchrony predicted CRT super-responders with a good longterm prognosis
Summary
E.E. van der Wall Netherlands Society of Cardiology/Holland Heart House, Utrecht, The Netherlands ent using echocardiographic parameters, CRT was harmful in those patients with narrow QRS complexes [8]. Versteeg et al [11] showed in a prospective study of 139 CRT patients that patient-reported outcome assessed prior to CRT independently identifies poor survival and hospitalisation. It seems logical to assess patient-perceived symptoms of heart failure, functional limitations, and quality of life routinely before CRT implantation and during follow-up to improve their management.
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