Cardiac resynchronisation therapy optimisation strategies: systematic classification, detailed analysis, minimum standards and a roadmap for development and testing.
In this article an international group of CRT specialists presents a comprehensive classification system for present and future schemes for optimising CRT. This system is neutral to the measurement technology used, but focuses on little-discussed quantitative physiological requirements. We then present a rational roadmap for reliable cost-effective development and evaluation of schemes. A widely recommended approach for AV optimisation is to visually select the ideal pattern of transmitral Doppler flow. Alternatively, one could measure a variable (such as Doppler velocity time integral) and "pick the highest". More complex would be to make measurements across a range of settings and "fit a curve". In this report we provide clinicians with a critical approach to address any recommendations presented to them, as they may be many, indistinct and conflicting. We present a neutral scientific analysis of each scheme, and equip the reader with simple tools for critical evaluation. Optimisation protocols should deliver: (a) singularity, with only one region of optimality rather than several; (b) blinded test-retest reproducibility; (c) plausibility; (d) concordance between independent methods; and (e) transparency, with all steps open to scrutiny. This simple information is still not available for many optimisation schemes. Clinicians developing the habit of asking about each property in turn will find it easier to win now down the broad range of protocols currently promoted. Expectation of a sophisticated enquiry from the clinical community will encourage optimisation protocol-designers to focus on testing early (and cheaply) the basic properties that are vital for any chance of long term efficacy.
National Heart & Lung Institute, Imperial College London, UK. Electronic address: s.sohaib@imperial.ac.uk.
S M Afzal
SM
Sohaib
Zachary I
ZI
Whinnett
Kenneth A
KA
Ellenbogen
Christoph
C
Stellbrink
T Alexander
TA
Quinn
Margot D
MD
Bogaard
Pierre
P
Bordachar
Berry M
BM
van Gelder
Irene E
IE
van Geldorp
Cecilia
C
Linde
Mathias
M
Meine
Frits W
FW
Prinzen
Robert G
RG
Turcott
Henry M
HM
Spotnitz
Dan
D
Wichterle
Darrel P
DP
Francis
D058406:Cardiac Resynchronization Therapy / Q000145:classification / Q000379:methods* / Q000592:standards*; D006329:Heart Conduction System / Q000000981:diagnostic imaging / Q000502:physiology*; D006333:Heart Failure / Q000000981:diagnostic imaging / Q000503:physiopathology* / Q000628:therapy*; D006801:Humans; D008955:Models, Cardiovascular; D015203:Reproducibility of Results; D014463:Ultrasonography
AV optimisation; Cardiac resynchronization therapy; Heart failure