1. Optimization of CRT via EKG Is simple better? Winter Arrhythmia School February 11, 2012 Irving Tiong, MD FRCPC Arrhythmia Service

2. Goals Brief overview of EKG findings in cardiomyopathy Brief overview on newest studies on CRT programming Examples of CRT EKG  Disclosure None

3. Is this adequate CRT ?

4. What about this one?

5. Cardiac resynchronization therapy (CRT) Class 1 indications: LVEF ≤ 30% NYHA Class II-III QRS ≥ 120 msec (LBBB) However only 2/3 of patients will benefit. WHY? ACC/AHA/HRS 2008 Guidelines

6. Sweeny et al, Circulation 2011

7. Fantoni et al. JCE 2005

9. Singh et al. JACC 2005, 46 PP 48-67

10. Fluoroscopic view - AP

11. Optimal LV lead placement by fluoroscopic views

12. QRS Width and success of CRT Siphal et al, Ann Int Med, 2011

13. Zareba et al. Circulation 2011 MADIT - CRT

14. Zareba et al. Circulation 2011

15. SMART AV trial, Ellebogen et al, Circulation 2011 What about AV delay?

16. Sweeney et al, Circulation 2010 What to look for on the surface EKG?

17. Sweeney et al, Circulation 2010

18. Other factors for achieving successs Avoid right atrial pacing Control atrial arrthythmias Avoid pacing scar Left ventricular lead placement

19. Quantification of scar (Selvester QRS score of LBBB)

20. Prospect - EKG Hsing et al, JCE 2011

21. MADIT CRT- Singh et al, Circulation 2011 Any difference in apical vs non apical position

22. MADIT-CRT

23. Is this adequate CRT ?

24. What about this one?

25. Conclusion EKG/QRS morphology during LV lead placement Change RV-LV delay : Lead III R – QS, Lead V1 QS – R AV delay - perhaps programmed to AV delay of 120 msec, or 50% of native PR interval if QRS > 150 msec