Copyright © 2013, Canadian Cardiovascular Society 13/11/2015 1 Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167 Disclaimer The Canadian.

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Presentation transcript:

Copyright © 2013, Canadian Cardiovascular Society 13/11/ Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): Disclaimer The Canadian Cardiovascular Society (CCS) welcomes reuse of our educational slide deck for medical institution internal education or training (i.e. grand rounds, medical college/classroom education, etc.). However, if the material is being used in an industry sponsored CME program, permission must be sought through our publisher Elsevier ( If your reuse request qualifies as medical institution internal education, you may reuse the material under the following conditions: You must cite the Canadian Journal of Cardiology and the Canadian Cardiovascular Society as references. You may not use any Canadian Cardiovascular Society logos or trademarks on any slides or anywhere in your presentation or publications. Do not modify the slide content. If repeating recommendations from the published guideline, do not modify the recommendation wording.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): CANADIAN CARDIOVASCULAR SOCIETY GUIDELINES ON THE USE OF CARDIAC RESYNCHRONIZATION THERAPY: EVIDENCE AND PATIENT SELECTION R Parkash, F Philippon, D Exner, and D Birnie on behalf of the CRT Guidelines Panels.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Disclosures Guidelines are available on line Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection CCS CRT Guidelines 2012 Secondary Panel Lyall Higginson Jonathan Howlett Aaron Low Robert McKelvie John Sapp Miriam Shanks Mario Talajic Michel White Raymond Yee Primary Panel David Birnie Derek Exner (co-chair) Jeff Healey Eric LaRose Gordon Moe Ratika Parkash (co-chair) François Philippon Anthony Tang Bernard Thibault

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Session Overview Focus on evidence-based prescription of CRT, based on scientific data Review of GRADE process Case-based presentation of guidelines – Eight recommendations – Practical Tips

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Objectives At the end of this session: 1.Review the appropriate selection of patients for CRT 2.Discuss the role of CRT-pacing 3.Describe the risks and benefits related to patients with AF, RBBB and chronic RV pacing 4.Understand technical issues related to CRT including lead placement 5.Discuss the role of imaging in assessment of CRT

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection GRADE Approach Development of guidelines through: – Critical evaluation of literature – Expert consensus – Use of Grading of Recommendations Assessment, Development, and Evaluation 1.Quality of Evidence:  High, Moderate, Low or Very Low 2. Strength of Recommendations  Strong or Weak Guyatt et al J Clin Epi 64:

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 1 78 year old woman – sinus rhythm, – dilated cardiomyopathy (NYHA III), & – LVEF 25% – Co-morbidities – DM, PVD, & eGFR 33 ml/min Medications: – Carvedilol (6.125 mg BID) & ramipril (1.25 mg OD) initiated 5 weeks ago (not on spironolactone).

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 1 - ECG

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation OneStrengthQuality Adequate medical therapy be implemented prior to the initiation of CRT, that each patient’s suitability for CRT be thoroughly assessed, and the details of that assessment be recorded in their medical record. StrongLow Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Continued up-titration of medical therapy – Carvedilol (25 mg BID), ramipril (5 mg OD) & spironolactone (25mg OD) Remains class III, LVEF now 30% Case 1 - continued

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation One - Practical Tips The reasons for non-use of recommended heart failure medications or the prescription of lower than the recommended doses of these agents should be recorded. Each patient’s functional capacity should be assessed, the QRS duration measured from a standard 12 lead ECG, and the LVEF quantified using a validated assessment method.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation TwoStrengthQuality CRT is recommended for patients in sinus rhythm with NYHA class II / III / ambulatory IV heart failure symptoms, a LVEF ≤ 35%, and QRS duration ≥ 130 ms due to left bundle branch block. StrongHigh Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Clinical Trial Evidence Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Clinical Trial Evidence

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Summary of Evidence Very few NYHA I or non-ambulatory IV patients Mean QRS: ms Most had LBBB Patients with severe comorbidities excluded: – Severe pulmonary disease – Severe liver disease – Severe renal disease – Limited life expectancy

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation Two - Practical Tips There is insufficient evidence to recommend CRT for patients with NYHA class I or patients non-ambulatory class IV NYHA symptoms. There is also insufficient data to recommend CRT in patients with QRS duration < 130 ms. Patients with LBBB and QRS duration ≥ 150 ms appear more likely to benefit from CRT than patients with non-LBBB conduction and/or less QRS prolongation.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Review of Case 1 78 year old woman – sinus rhythm, – dilated cardiomyopathy (NYHA III), & – LVEF 30% – Co-morbidities - DM, PVD, & eGFR 33 ml/min – Carvedilol (25 mg BID), ramipril (5 mg OD) & sprionolactone (25 mg OD).

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation ThreeStrengthQuality A CRT pacemaker is recommended for patients who are suitable for resynchronization therapy, but not for an ICD. StrongModerate Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Clinical Trial Evidence Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Summary: CRT-P & CRT-D COMPANION Death or hospitalisation CRT-P: HR 0.81 p<0.01 CRT-D: HR 0.80 p<0.01 Death CRT-P: HR 0.76 p=0.059 CRT-D: HR 0.64 p=0.003 CARE HF Death or hospitalisation CRT-P: 0.73 p<0.001 Death CRT-P: 0.74 p<0.0002

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Risk Factors NYHA > II Age > 70 years BUN > 26 mg/dl QRSd > 120 ms AF MADIT II cohort 1191 pts F-UP 8 years

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection JACC 2012; 59:2075-9

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation Three - Practical Tips CRT-P has been shown to reduce morbidity and mortality in patients with NYHA class III and ambulatory class IV heart failure symptoms. Therapy should be individualized in accordance with the overall goals of care.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 2 57 year old man – Paroxysmal atrial fibrillation, – Ischemic cardiomyopathy (NYHA II), & LVEF 28% – Co-morbidities - HTN Medications: – EC ASA 81 mg OD, bisoprolol (10 mg OD), perindopril (8 mg OD), spironolactone (25 mg OD) & rosuvastatin 20 mg OD.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 2 - ECG

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation FiveStrengthQuality CRT may be considered for patients in permanent AF who are otherwise suitable for this therapy. WeakLow Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Utility of CRT in Patients with AF Systematic review and meta-analysis Death, CRT non-response, LV remodeling, quality of life, & six-min walk distance. 23 observational studies, 7,495 CRT recipients 25.5% with AF, Mean follow-up of 33 months. Wilton et al. Heart Rhythm 2011;8:

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Greater non-response (34.5% AF vs. 26.7% NSR) Wilton et al. Heart Rhythm 2011;8:

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Higher annual mortality (10.8% AF vs. 7.1% NSR) Wilton et al. Heart Rhythm 2011;8:

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection RAFT – AF Subset Healey et al. Circulation Heart Failure 2012;5: ~ 34% of CRT-treated patients had ≥95% & ~ 47% had ≥90% biventricular pacing.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection RAFT – AF Subset Healey et al. Circulation Heart Failure 2012;5:

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation Five - Practical Tips The amount of biventricular pacing needs to be evaluated. Arrhythmia device counters alone may not accurately reflect the true percent biventricular pacing. It is important to ensure a very high percentage of biventricular pacing. AV junctional ablation may be necessary to achieve sufficient biventricular pacing.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 2 – continued (amiodarone added)

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation SixStrengthQuality CRT may be considered for patients in sinus rhythm with NYHA class II / III / ambulatory IV heart failure, LVEF ≤ 35%, & QRS duration ≥ 150 msec not due to LBBB conduction. WeakLow Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection CRT in Patients with RBBB Five studies, with 259 patients randomized to CRT and 226 randomized to non-CRT. RBBB; N (%) MIRACLE28 (6.2) CONTAK CD33 (5.7) CARE-HF35 (4.3) MADIT-CRT228 (12.5) RAFT161 (9.0) Nery et al. Heart Rhythm 2011;8:

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): CRT-D ICD LBBB HR (95% CI): 0.58 (0.46, 0.74) Log rank p < RBBB HR (95% CI): 1.24 (0.65, 2.36) Log rank p = 0.48 NIVCD HR (95% CI): 1.0 (0.60, 1.66) Log rank p = 0.84 RAFT Birnie et al CCS Conference, Vancouver 2011

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Severely prolonged QRS Moderately prolonged QRS Systematic review and meta-analysis

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation Six - Practical Tip There is no clear evidence of benefit with CRT among patients with QRS durations < 150 ms due to non-LBBB conduction.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Echo Dyssynchrony Assessment

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation EightStrengthQuality Routine assessment of dyssynchrony with present echocardiographic techniques is not recommended to guide the prescription of CRT. StrongLow Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Mechanical Dyssynchrony Mostly echo; some nuclear & MRI Single center studies: echo mechanical dyssynchrony accurately predicts response to CRT Large multi-centre study (PROSPECT): failed to confirm this. PROSPECT STUDY (Circulation. 2008;117: ) Conclusion “no echo measure of mechanical dyssynchrony can be used to improve selection of patients for CRT”

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection LV scar and response to CRT The extent of LV scaring seems important in determining response to CRT Some studies have found that it is the global extent of LV scar that is important Others found the size of the lateral to be key.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation Eight - Practical Tips Issues of reproducibility and inter- and intra-rater assessment limit the routine role of echo to guide the prescription of CRT. The utility of imaging methods is under investigation.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection 72 year old female Dual chamber pacemaker (AVB in 2006) Before PM - underlying atrial rhythm with 1° AV block, QRS 80 ms, & LVEF 45% Now - 100% RV paced (underlying CHB) LVEF now 32%, BNP is 1200 Progressive DOE (now NYHA III) Carvedilol 25 mg BID, Ramipril 10 mg BID, & Spironolactone 25 mg OD Case 3

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 3 - ECG

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation SevenStrengthQuality CRT may be considered for patients who are chronically RV-paced or are likely to be chronically paced, have signs and/or symptoms of heart failure, and a LVEF ≤ 35%. WeakLow Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Biventricular vs. LV Pacing in Patients with LV Dysfunction and AV Block (BLOCK HF) N = 691; LV dysfunction & heart block CRT versus RV pacing (pacemaker or ICD). Mean LVEF 40%, 84% NYHA class II or III, Average follow-up 37 months Results for CRT vs. RV pacing -25% reduction in risk of death, need for IV HF therapy, or > 15%  LV ESV index (1° outcome) -30% reduction in HF hospitalization (2° outcome) -No significant Δ in mortality (2° outcome)

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation Seven - Practical Tips RV pacing may be harmful and strategies to minimize RV pacing should be implemented prior to CRT upgrade. The utility of CRT in patients who do not have a pre- existing LBBB and are chronically RV paced is uncertain. Patients undergoing AV junctional ablation with moderate LV dysfunction may benefit from CRT. It is often difficult to reliably predict which patients will be chronically RV paced at the time initiating pacing. The risks of CRT upgrade need to be considered and balanced with the potential benefits of CRT upgrade.

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Angiogram 1 2 3

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Recommendation FourStrengthQuality In patients treated with CRT, pacing from a non-apical LV epicardial region may be considered. WeakLow Can J Cardiol 2013; 29(2):

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Avoid “apical” Circulation 2011;123:1166

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Anterior vs. lateral vs. posterior Circulation 2011;123:1166

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection LV Lead Placement

13/11/ Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Questions & Review of Objectives 1.Review the appropriate selection of patients for CRT 2.Discuss the role of CRT-pacing 3.Describe the risks and benefits related to patients with AF, RBBB and chronic RV pacing 4.Understand technical issues related to CRT including lead placement 5.Discuss the role of imaging in assessment of CRT