97/A dedicated and specialist cardiac resynchronisation therapy pre-assessment clinic carefully selects patients for implantation and avoids unnecessary interventions

Background: Cardiac resynchronisation therapy (CRT) reduces patient morbidity and mortality. However, 30–40% of patients fail to respond and a proportion of these patients may have been implanted with unfavourable characteristics such as a narrow QRS duration leading to CRT non-response. Given these concerns, we developed a CRT preassessment clinic (CRT PAC) to act as a final review for patients prior to deciding whether to proceed with CRT. All patients who were seen in a tertiary centre consultant cardiology clinic and listed for CRT were reviewed again in the CRT PAC before implantation. Patients underwent an ECG, echocardiogram, cardiac MRI and cardiopulmonary exercise test. They were reviewed by a consultant cardiologist with a specialist interest in heart failure (HF) where a final decision regarding CRT was made.
Purpose: The purpose of this analysis was to determine whether this clinic was able to carefully select appropriate patients who were likely to respond and was safe.
Methods: A prospective database of consecutive patients reviewed in CRT PAC was assessed. Patients were classified as CRT responders if they survived to follow-up and had an improvement in left ventricular end-systolic volume (LVESV) ≥15% or improvement in their clinical composite score (CCS).
Results: A total of 252 patients were reviewed between 2014–8. Patient demographics included: age 71 ± 11, 73% male; 49% ischaemic aetiology; 48% AF; 46% had ≥2 additional co-morbidities; QRS duration 156 ± 28 msec and mean left ventricular ejection fraction [LVEF] 32% ± 10%. Following CRT PAC, 192 (76.2%) patients were eligible for CRT but 60 (23.8%) patients did not fully satisfy consensus guidelines for CRT and thus were inappropriate to proceed with implantation. In these patients, after a median follow-up of 11 months, 48 (80%) had no device, 8 (13%) underwent CRT and 4 (7%) had an ICD. Additionally, 2 (3%) patients were admitted to hospital with end-stage HF and died with a further 4 deaths from non-cardiac disease. The commonest reasons for finding patients unsuitable for CRT was an improvement in LVEF (63%, n=38) and the requirement to up-titrate optimal medical therapy (OMT) (32%, n=19). Following up-titration of OMT only 5 (26%) patients required CRT, with an average improvement in LVEF of 6%. Overall, 81.6% of patients had improvement in their CCS and 56.5% had improvement in LVESV ≥15%
Conclusion: A CRT PAC is a novel approach to improve outcomes with CRT. It is able to carefully identify patients whom are not suitable for CRT, thus avoiding unnecessary interventions and resulting in patient and healthcare savings. Patients have favourable outcomes using this clinic design and given these outcomes should be considered in further centres.