1. 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 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 (www.onlinecjc.com).www.onlinecjc.com 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.

2. 13/11/2015 2 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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.

3. 13/11/2015 3 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Disclosures www.ccs.ca Guidelines are available on line www.ccsguidelineprograms.ca Can J Cardiol 2013; 29(2):182-195

4. 13/11/2015 4 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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

5. 13/11/2015 5 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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

6. 13/11/2015 6 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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

7. 13/11/2015 7 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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. 2011 J Clin Epi 64: 383-94

8. 13/11/2015 8 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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).

9. 13/11/2015 9 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 1 - ECG

10. 13/11/2015 10 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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):182-195

11. 13/11/2015 11 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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

12. 13/11/2015 12 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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. 13/11/2015 13 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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):182-195

14. 13/11/2015 14 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Clinical Trial Evidence Can J Cardiol 2013; 29(2):182-195

15. 13/11/2015 15 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Clinical Trial Evidence

16. 13/11/2015 16 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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: 153-173 ms Most had LBBB Patients with severe comorbidities excluded: – Severe pulmonary disease – Severe liver disease – Severe renal disease – Limited life expectancy

17. 13/11/2015 17 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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.

18. 13/11/2015 18 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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).

19. 13/11/2015 19 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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):182-195

20. 13/11/2015 20 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Clinical Trial Evidence Can J Cardiol 2013; 29(2):182-195

21. 13/11/2015 21 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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

22. 13/11/2015 22 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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

23. 13/11/2015 23 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection JACC 2012; 59:2075-9

24. 13/11/2015 24 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection

25. 13/11/2015 25 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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.

26. 13/11/2015 26 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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.

27. 13/11/2015 27 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 2 - ECG

28. 13/11/2015 28 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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):182-195

29. 13/11/2015 29 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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;8:1088-94

30. 13/11/2015 30 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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;8:1088-94

31. 13/11/2015 31 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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;8:1088-94

32. 13/11/2015 32 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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;5:566-70. ~ 34% of CRT-treated patients had ≥95% & ~ 47% had ≥90% biventricular pacing.

33. 13/11/2015 33 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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;5:566-70.

34. 13/11/2015 34 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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.

35. 13/11/2015 35 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 2 – continued (amiodarone added)

36. 13/11/2015 36 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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):182-195

37. 13/11/2015 37 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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;8:1083-87

38. 13/11/2015 38 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 CRT-D ICD LBBB HR (95% CI): 0.58 (0.46, 0.74) Log rank p < 0.0001 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

39. 13/11/2015 39 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection

40. 13/11/2015 40 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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

41. 13/11/2015 41 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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.

42. 13/11/2015 42 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Echo Dyssynchrony Assessment

43. 13/11/2015 43 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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):182-195

44. 13/11/2015 44 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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: 2608-2616.) Conclusion “no echo measure of mechanical dyssynchrony can be used to improve selection of patients for CRT”

45. 13/11/2015 45 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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.

46. 13/11/2015 46 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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.

47. 13/11/2015 47 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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

48. 13/11/2015 48 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Case 3 - ECG

49. 13/11/2015 49 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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):182-195

50. 13/11/2015 50 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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)

51. 13/11/2015 51 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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.

52. 13/11/2015 52 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Angiogram 1 2 3

53. 13/11/2015 53 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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):182-195

54. 13/11/2015 54 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Avoid “apical” Circulation 2011;123:1166

55. 13/11/2015 55 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection Anterior vs. lateral vs. posterior Circulation 2011;123:1166

56. 13/11/2015 56 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy: Evidence and Patient Selection LV Lead Placement

57. 13/11/2015 57 Copyright © 2013, Canadian Cardiovascular Society Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195 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