Impact of cardiac resynchronization therapy optimization inside a heart failure programme: a real-world experience.

AIMS: This study sought to describe and evaluate the impact of a routine in-hospital cardiac resynchronization therapy (CRT) programme, including comprehensive heart failure (HF) evaluation and systematic echo-guided CRT optimization. METHODS AND RESULTS: CRT implanted patients were referred for optimization programme at 3 to 12 months from implantation. The program included clinical and biological status, standardized screening for potential cause of CRT non-response and systematic echo-guided atrioventricular and interventricular delays (AVd and VVd) optimization. Initial CRT-response and improvement at 6 months post-optimization were assessed with a clinical composite score (CCS). Major HF events were tracked during 1 year after optimization. A total of 227 patients were referred for CRT optimization and enrolled (71 ± 11 years old, 77% male, LVEF 30.6 ± 7.9%), of whom 111 (48.9%) were classified as initial non-responders. Left ventricular lead dislodgement was noted in 4 patients (1.8%), and loss or ≤90% biventricular capture in 22 (9.7%), mostly due to arrhythmias. Of the 196 patients (86%) who could undergo echo-guided CRT optimization, 71 (36.2%) required VVd modification and 50/144 (34.7%) AVd modification. At 6 months post-optimization, 34.3% of the initial non-responders were improved according to the CCS, but neither AVd nor VVd echo-guided modification was significantly associated with CCS-improvement. After one-year follow-up, initial non-responders maintained a higher rate of major HF events than initial responders, with no significant difference between AVd/VVd modified or not. CONCLUSIONS: Our study supports the necessity of a close, comprehensive and multidisciplinary follow-up of CRT patients, without arguing for routine use of echo-guided CRT optimization.

The antegrade reperfusion test avoids the risk of mitral regurgitation recurrence optimizing valve repair.

Saline injection into the left ventricle trough mitral valve (saline test) is the most commonly used intraoperative assessment method in mitral valve repair. However, potential discrepancies between the saline test findings and intraoperative transesophageal echocardiography results after the weaning of cardiopulmonary by-pass, remain significant. Here, we describe a new antegrade reperfusion test, reproducing intraoperatively, the physiologic conditions of loaded and beating heart for direct transatrial evaluation of valve tightness. The proposed test is performed by perfusing warm oxygenated blood into the aortic root under cross-clamping. From February 2016 to December 2018, 91 patients (mean age: 63 ± 11 years) underwent mitral valve repair for mitral regurgitation. In all of them, the classic saline test was completed with the newly proposed antegrade test. We report our results with this combined approach. Data were obtained from the medical records and our mitral valve repair database. In 32 (35.1%) patients, evident or undetectable minor regurgitation at the saline test were respectively unconfirmed or detected by the antegrade reperfusion test leading to their complete correction. In only three patients (3.2%) major discrepancies was present between the intraoperative evaluation and the post-pump transesophageal echocardiography. Two of them (2.1%) required a second cardiopulmonary bypass run to fix the residual regurgitation. The antegrade reperfusion test is a simple dynamic intraoperative approach mimicking the physiological conditions of ventricular systole for mitral valve repair evaluation. Combined with the classic saline test, it seems to be a valuable additional intraoperative tool, enabling a more predictable repair result.