Selection of the right patients for CRT is critical for good prognoses. Before CRT implantation, the patients with the following conditions should be excluded: untreated myocardial ischemia, valvular heart disease, mechanical obstruction, and untreated arrhythmia–induced cardiomyopathy. Electrocardiogram (ECG) is the most important investigation in the selection of patients in order to identify those with ventricular dyssynchrony. The latest European guideline identify complete left bundle branch block (LBBB) with QRS duration ≥ 150 ms as class IA evidence, while QRS duration between 130 and 150 ms is identified as class IB evidence. Patients with QRS duration < 130 ms should not be treated with CRT. Patients with non-left bundle branch block belong to the class II evidence group [
7]. In patients with non-left bundle branch conduction block, left ventricular dyssynchrony is often not significant. After the implantation of CRT, the rate of nonresponse is higher in these patients than those with left bundle branch block, with worsening of the clinical condition in some patients [
8]. Despite current concerns about the effects of CRT implantation in patients with non-left bundle branch block, recent studies have indicated that the QRS duration in patients with right bundle branch block is significantly shorter and left ventricular function can be improved by permanent His bundle pacing, which may be a promising option for cardiac resynchronization in this subgroup of patients with reduced left ventricular ejection fraction [
9]. Better outcomes are usually observed in patients with left bundle branch block with the following features that often suggest left intraventricular conduction delay: lead V1 with QS or rS wave; lead V6 with R wave; leads I, aVL, V5, and V6 with notches on the R wave [
10,
11]. The latest studies have reported a strong positive correlation between QRS area and CRT response and that this correlation is as valuable as the other current ECG criteria. QRS area may be predictive of CRT response in patients with non-wide left bundle branch block [
12]. In addition to ECG, magnetic resonance and other tests were used in recent studies to determine left ventricular dyssynchrony. A new study indicates that assessment of mechanical dyssynchrony using apical rocking or septal flash technique can improve the prognostic value of guideline-based patient selection for cardiac resynchronization therapy [
13]. However, the results from echocardiogram and magnet resonance were inconsistent and not unanimously recognized. Therefore, such methods should not be currently used as standard practices in selecting patients. However, such methods can be evaluated as references for predictions. Newer technologies such as three-dimensional spot tracking technology and stress ultrasound can be used to screen for some characteristics that are related to non-response.
Patients with different clinical features have different outcomes. A previous study reported that ischemic heart disease, male sex, NYHA class IV, severe mitral regurgitation (MR) and left atrial expansion, and shorter ventricular mechanical delay were associated positively with non-response in CRT. However, these features are limited to the process of patient selection and cannot be used as independent predictors of nonresponse [
14].
In patients with atrial fibrillation, the efficacy of CRT implantation remains controversial [
15]. For heart failure patients with atrial fibrillation, the current recommendation is that radiofrequency catheter ablation plus CRT is more effective than pharmacological therapy [
16].