Avoiding non-responders to cardiac resynchronization therapy: a practical guide
Claude Daubert1,2, Nathalie Behar3, Raphaël P Martins1,2,3
1School of medicine, Rennes 1 University, Rennes, France.
Abstract:
Over two decades after the introduction of cardiac resynchronization therapy (CRT) into clinical practice, ∼30% of candidates continue to fail to respond to this highly effective treatment of drug-refractory heart failure (HF). Since the causes of this non-response (NR) are multifactorial, it will require multidisciplinary efforts to overcome. Progress has, thus far, been slowed by several factors, ranging from a lack of consensus regarding the definition of NR and technological limitations to the delivery of therapy. We critically review the various endpoints that have been used in landmark clinical trials of CRT, and the variability in response rates that has been observed as a result of these different investigational designs, different sample populations enrolled and different means of therapy delivered, including new means of multisite and left ventricular endocardial simulation. Precise recommendations are offered regarding the optimal device programming, use of telemonitoring and optimization of management of HF. Potentially reversible causes of NR to CRT are reviewed, with emphasis on loss of biventricular stimulation due to competing arrhythmias. The prevention of NR to CRT is essential to improve the overall performance of this treatment and lower its risk-benefit ratio. These objectives require collaborative efforts by the HF team, the electrophysiologists and the cardiac imaging experts.
Insights
Cardiac resynchronization therapy (CRT) benefits only 70% of heart failure patients. Overcoming non-response requires multidisciplinary collaboration to optimize device programming and patient management.
Area of Science:
- Cardiology
- Biomedical Engineering
- Clinical Electrophysiology
Background:
- Cardiac resynchronization therapy (CRT) is a key treatment for drug-refractory heart failure (HF).
- Approximately 30% of patients do not respond to CRT, a significant clinical challenge.
- The multifactorial nature of non-response (NR) necessitates a comprehensive approach.
Purpose of the Study:
- To review endpoints used in CRT clinical trials and their impact on response rates.
- To identify factors contributing to CRT non-response.
- To provide recommendations for optimizing CRT and preventing non-response.
Main Methods:
- Critical review of landmark clinical trials for CRT endpoints and response variability.
- Analysis of different investigational designs, patient populations, and therapy delivery methods.
- Discussion of device programming, telemonitoring, and heart failure management strategies.
Main Results:
- Variability in CRT response rates is linked to diverse trial designs, patient selection, and therapy delivery.
- Potentially reversible causes of NR, such as loss of biventricular pacing due to arrhythmias, are highlighted.
- Optimizing device settings and patient management can improve CRT efficacy.
Conclusions:
- Addressing CRT non-response requires standardized definitions, technological advancements, and improved therapy delivery.
- Multidisciplinary collaboration among heart failure teams, electrophysiologists, and cardiac imaging experts is crucial.
- Preventing CRT non-response enhances treatment effectiveness and improves the risk-benefit ratio for heart failure patients.
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