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Anderson TJ, Gregoire J et al., Can J Cardiol 2013 Feb;29(2): 151-167
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
1
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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
3
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
CCS CRT Guidelines 2012
Primary Panel
•David Birnie
•Derek Exner (co-chair)
•Jeff Healey
•Eric LaRose
•Gordon Moe
•Ratika Parkash (co-chair)
•François Philippon
•Anthony Tang
•Bernard Thibault
Secondary Panel
•Lyall Higginson
•Jonathan Howlett
•Aaron Low
•Robert McKelvie
•John Sapp
•Miriam Shanks
•Mario Talajic
•Michel White
•Raymond Yee
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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4
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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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7
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).
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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8
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Case 1 - ECG
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
9
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Recommendation One
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.
Strength
Quality
Strong
Low
Can J Cardiol 2013; 29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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10
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Case 1 - continued
• Continued up-titration of medical therapy
– Carvedilol (25 mg BID), ramipril (5 mg OD) &
spironolactone (25mg OD)
• Remains class III, LVEF now 30%
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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11
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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
12
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Recommendation Two
Strength Quality
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.
Strong
High
Can J Cardiol 2013; 29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
13
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Clinical Trial Evidence
Favours
CRT-D
Deaths / Group Size
Favours
ICD
Relative Risk
(95% confidence Interval)
CRT-D
ICD
MIRACLE ICD II (2004)
2/85
2/101
1.19 (0.17, 8.26)
REVERSE (ICD) (2008)
9/419
3/191
1.37 (0.37, 4.99)
MADIT CRT (2009)
74/1,089
53/731
0.94 (0.67, 1.32)
RAFT Class II (2010)
11
110/708
154/730
0.74 (0.59, 0.92)
Subtotal (I-squared = 0.0%, p = 0.5)
195/2,301 212/1,753
0.80 (0.67, 0.96)
Lozano (2000)
5/109
10/113
0.52 (0.18, 1.47)
MIRACLE ICD (2003)
14/187
15/182
0.91 (0.45, 1.83)
RHYTHM ICD (2004)
6/119
2/60
1.51 (0.31, 7.27)
RAFT Class III (2010)
76/186
82/174
0.87 (0.69, 1.10)
Subtotal (I-squared = 0.0%, p = 0.7)
101/601
109/529
0.86 (0.69, 1.07)
NYHA Class I / II
NYHA Class III / IV
Overall (I-squared = 0.0%, p = 0.8)
0.83 (0.72, 0.96)
296/2,902 321/2,282
0.2
1
Relative Risk
5
Can J Cardiol 2013;
29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Clinical Trial Evidence
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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15
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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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17
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).
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
18
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Recommendation Three
A CRT pacemaker is
recommended for patients
who are suitable for
resynchronization therapy,
but not for an ICD.
Strength
Strong
Quality
Moderate
Can J Cardiol 2013; 29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
19
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Clinical Trial Evidence
Favours
CRT
Deaths / Group Size
Favours
Control
Relative Risk
(95% confidence Interval)
CRT
Control
MUSTIC SR (2001)
1/29
2/29
0.50 (0.05, 5.21)
MIRACLE (2002)
12/228
16/225
0.74 (0.36, 1.53)
COMPANION (2004)
131/617
77/308
0.85 (0.66, 1.09)
VECTOR (2005)
1/59
1/47
0.80 (0.05, 12.40)
CARE HF (2005)
101/409
154/404
0.65 (0.53, 0.80)
Subtotal (I-squared = 0.0%, p = 0.6)
246/1342
250/1,013
0.73 (0.62, 0.85)
Lozano (2000)
5/109
10/113
0.52 (0.18, 1.47)
MIRACLE ICD (2003)
14/187
15/182
0.91 (0.45, 1.83)
MIRACLE ICD II (2004)
2/85
2/101
1.19 (0.17, 8.26)
RHYTHM ICD (2004)
6/1
19
2/60
1.51 (0.31, 7.27)
REVERSE (ICD) (2008)
9/419
3/191
1.37 (0.37, 4.99)
MADIT CRT (2009)
74/1,089
53/731
0.94 (0.67, 1.32)
RAFT (2010)
186/894
236/904
0.80 (0.67, 0.94)
Subtotal (I-squared = 0.0%, p = 0.8)
296/2,902 321/2,282
Overall (I-squared = 0.0%, p = 0.8)
542/4,244 571/3,295
CRT vs. Medical
.
CRT-D vs. ICD
0.83 (0.72, 0.96)
0.2
0.78 (0.70, 0.87)
1
Relative Risk
5
Can J Cardiol 2013;
29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
20
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Summary: CRT-P & CRT-D
COMPANION
CARE HF
Death or hospitalisation
Death or hospitalisation
• CRT-P: HR 0.81 p<0.01
• CRT-P: 0.73 p<0.001
• CRT-D: HR 0.80 p<0.01
Death
Death
• CRT-P: HR 0.76 p=0.059
• CRT-P: 0.74 p<0.0002
• CRT-D: HR 0.64 p=0.003
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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22
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
JACC 2012; 59:2075-9
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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23
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
24
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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Case 2 - ECG
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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27
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Recommendation Five
CRT may be considered for
patients in permanent AF
who are otherwise suitable
for this therapy.
Strength
Quality
Weak
Low
Can J Cardiol 2013; 29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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28
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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
RAFT – AF Subset
~ 34% of CRT-treated
patients had ≥95% &
~ 47% had ≥90%
biventricular pacing.
Healey et al. Circulation Heart Failure 2012;5:566-70.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Case 2 – continued (amiodarone added)
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Recommendation Six
Strength Quality
CRT may be considered for
Weak
Low
patients in sinus rhythm with
NYHA class II / III / ambulatory
IV heart failure, LVEF ≤ 35%, &
QRS duration ≥ 150 msec not
due to LBBB conduction.
Can J Cardiol 2013; 29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
36
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.
MIRACLE
CONTAK CD
CARE-HF
MADIT-CRT
RAFT
RBBB; N (%)
28 (6.2)
33 (5.7)
35 (4.3)
228 (12.5)
161 (9.0)
Nery et al. Heart Rhythm 2011;8:1083-87
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2017-05-25
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LBBB
RAFT
Birnie et al CCS
Conference , Vancouver
2011
HR (95% CI): 0.58 (0.46, 0.74)
Log rank p < 0.0001
CRT-D
ICD
NIVCD
RBBB
HR (95% CI): 1.24 (0.65, 2.36)
Log rank p = 0.48
HR (95% CI): 1.0 (0.60, 1.66)
Log rank p = 0.84
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
39
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Systematic review and meta-analysis
Severely
prolonged
QRS
Moderately
prolonged
QRS
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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41
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Echo Dyssynchrony Assessment
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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42
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Recommendation Eight
Strength
Routine assessment of
Strong
dyssynchrony with present
echocardiographic techniques
is not recommended to guide
the prescription of CRT.
Quality
Low
Can J Cardiol 2013; 29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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43
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Mechanical Dyssynchrony
PROSPECT STUDY (Circulation. 2008;117: 2608-2616.)
Conclusion “no echo measure
of mechanical dyssynchrony
can be used to improve
selection of patients for CRT”
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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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44
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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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45
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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
46
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Case 3
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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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47
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Case 3 - ECG
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
48
Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Recommendation Seven
Strength Quality
CRT may be considered for
Weak
Low
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%.
Can J Cardiol 2013; 29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
Copyright © 2013, Canadian Cardiovascular Society
49
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)
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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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 preexisting 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.
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Angiogram
1
2
3
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Recommendation Four
In patients treated with CRT,
pacing from a non-apical LV
epicardial region may be
considered.
Strength
Weak
Quality
Low
Can J Cardiol 2013; 29(2):182-195
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Avoid “apical”
Circulation 2011;123:1166
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
Anterior vs. lateral vs. posterior
Circulation 2011;123:1166
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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Canadian Cardiovascular Society Guidelines on the Use of Cardiac Resynchronization Therapy:
Evidence and Patient Selection
LV Lead Placement
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2017-05-25
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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
Exner DV, Birnie DH et al., Canadian Journal of Cardiology, Feb. 2013;29(2): 182-195
2017-05-25
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