The value of the 12-lead ECG for evaluation and optimization of cardiac resynchronization therapy in daily clinical practice

Based on existing literature and some new data we propose a simple three-step strategy using the standard 12-lead ECG for patient selection and optimal delivery of cardiac resynchronization therapy (CRT). (1) Complete LBBB with regard to the indication for CRT can probably best be identified by a QRS duration of a >= 130 ms for women and >= 120 ms for men with the presence of mid-QRS notch-/slurring in >= 2 contiguous leads of V-1, V-2, V-5, V-6, I and aVL. (2) Left ventricular (LV) free wall pacing should result in a positive QRS complex in lead V-1, with estimation of the exact LV lead position in the circumferential and apico-basal direction using lead aVF and the precordial leads, respectively. Wide and fractionated LV-paced QRS complexes may indicate pacing in scar tissue. (3) Atrioventricular and interventricular stimulation intervals may be optimized by adjusting them until precordial leads show fusion patterns between left and right ventricular activation wavefronts in the QRS complex.