title: Insights from a cardiac resynchronization optimization clinic as part of a heart failure disease management program.
abstract: OBJECTIVE
  Our aim was to determine the feasibility and value of a protocol-driven approach to patients with cardiac resynchronization therapy (CRT) who did not exhibit a positive response long after implant.
  
  
  BACKGROUND
  Up to one-third of patients with advanced heart failure do not exhibit a positive response to CRT.
  
  
  METHODS
  A total of 75 consecutive ambulatory patients with persistent advanced heart failure symptoms and/or adverse reverse remodeling and CRT implanted >6 months underwent a comprehensive protocol-driven evaluation to determine the potential reasons for a suboptimal response. Recommendations were made to maximize the potential of CRT, and adverse events were documented.
  
  
  RESULTS
  All patients (mean left ventricular [LV] ejection fraction 23 +/- 9%, LV end-diastolic volume 275 +/- 127 ml) underwent evaluation. Eighty-eight percent of patients had significantly better echocardiographic indexes of LV filling and LV ejection with optimal setting of their CRT compared with a temporary VVI back-up setting. Most patients had identifiable reasons for suboptimal response, including inadequate device settings (47%), suboptimal medical treatment (32%), arrhythmias (32%), inappropriate lead position (21%), or lack of baseline dyssynchrony (9%). Multidisciplinary recommendations led to changes in device settings and/or other therapy modifications in 74% of patients and were associated with fewer adverse events (13% vs. 50%, odds ratio: 0.2 [95% confidence interval: 0.07 to 0.56], p = 0.002) compared with those in which no recommendation could be made.
  
  
  CONCLUSIONS
  Routine protocol-driven approach to evaluate ambulatory CRT patients who did not exhibit a positive response is feasible, and changes in device settings and/or other therapies after multidisciplinary evaluation may be associated with fewer adverse events.
authors.affiliation: Department of Cardiovascular Medicine, Cleveland, Ohio 44195, USA.
authors.forename: Wilfried
authors.initials: W
authors.lastname: Mullens
authors.forename: Richard A
authors.initials: RA
authors.lastname: Grimm
authors.forename: Tanya
authors.initials: T
authors.lastname: Verga
authors.forename: Thomas
authors.initials: T
authors.lastname: Dresing
authors.forename: Randall C
authors.initials: RC
authors.lastname: Starling
authors.forename: Bruce L
authors.initials: BL
authors.lastname: Wilkoff
authors.forename: W H Wilson
authors.initials: WH
authors.lastname: Tang
mesh_terms: D000553:Ambulatory Care; D002304:Cardiac Pacing, Artificial; D019468:Disease Management; D018450:Disease Progression; D005240:Feasibility Studies; D005260:Female; D006333:Heart Failure / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D013318:Stroke Volume; D016896:Treatment Outcome; D018487:Ventricular Dysfunction, Left / Q000628:therapy