Advanced Heart Failure Treatment in Turkey

Cardiac Resynchronisation Therapy (CRT): In HFrEF with LBBB (left bundle branch block) causing dyssynchronous LV contraction, CRT resynchronises the heart by pacing both ventricles simultaneously (biventricular pacing). This improves symptoms, EF, and survival.

Indications (current ESC guidelines):

• LVEF ≤35% + LBBB + QRS ≥150ms on optimal GDMT: Class I, Level A recommendation
• Benefits decline with narrower QRS and non-LBBB morphology

CRT-D vs. CRT-P:

• CRT-D: CRT + ICD combined — for most patients where life expectancy >1 year and VT/VF prevention indicated
• CRT-P: CRT-pacemaker only — for older/frailer patients where ICD not indicated

Implantable Cardioverter-Defibrillator (ICD) for Heart Failure:

• Indicated for all HFrEF patients with LVEF ≤35% on optimal GDMT >3 months (unless age/comorbidity limits benefit) — MADIT-II, SCD-HeFT trials
• Terminates ventricular fibrillation and ventricular tachycardia with shock or anti-tachycardia pacing
• Subcutaneous ICD (S-ICD): no transvenous leads — for patients with no pacing indication; avoids lead-related complications

Left Ventricular Assist Device (LVAD):

• For advanced HFrEF (NYHA IIIB–IV despite optimal GDMT + CRT/ICD) — bridge to transplant or destination therapy
• HeartMate 3 LVAD (Medtronic) — centrifugal flow pump significantly improved survival and reduced pump thrombosis in MOMENTUM 3 trial
• INTERMACS profiles 2–5 patients considered for LVAD implantation; INTERMACS 1 (cardiogenic shock) may have inotropic bridging first
• LVAD implantation is major open-heart surgery — available at advanced heart failure centre partners

Comprehensive heart failure workup: A thorough heart failure assessment includes:

• Echocardiography (TTE ± TOE): LV/RV function, valve disease, diastolic function, mechanical dyssynchrony (for CRT planning)
• BNP / NT-proBNP: diagnostic and prognostic biomarker; guides diuretic therapy
• 12-lead ECG: identifies LV hypertrophy, LBBB, prior MI, arrhythmia
• Blood tests: renal function, electrolytes, iron studies (iron deficiency treated with IV ferric carboxymaltose — improves symptoms and exercise capacity), TFTs, liver function, BNP
• Cardiac MRI: gold standard for characterising cardiomyopathy type (ischaemic pattern vs. myocarditis vs. storage disease), accurate EF, fibrosis/scar quantification for ICD/CRT planning
• Coronary angiography: to exclude ischaemic aetiology requiring revascularisation — important even in dilated cardiomyopathy presentation

GDMT optimisation consultation: Many patients travelling to Turkey for heart failure assessment are undertreated — doses below targets, drug combinations incomplete, SGLT2 inhibitor not started. BB Global Health heart failure specialist consultations frequently identify treatment gaps resulting in significant clinical improvement from drug optimisation alone.

Specific treatable causes:

• Valve disease → surgical or transcatheter repair/replacement
• Coronary disease → revascularisation (PCI or CABG) — can improve EF if viable myocardium present
• Cardiac sarcoidosis → immunosuppression
• Thyroid disease, haemochromatosis, alcohol-related cardiomyopathy → specific treatment

Cost of heart failure assessment Turkey: Comprehensive HF assessment (echo + BNP + cardiac MRI + cardiologist consultation) Turkey: €1,800–3,500. CRT-D implantation Turkey: €15,000–22,000 all-inclusive; UK private: £30,000–50,000.