Welcome to the 2021 Quality Summit. Thank you for sharing your time with us today and joining this session. I have the distinct honor to introduce our speaker, Dr. Slott Weiner, who will be presenting today regarding a case study, CRTP or CRTD. Dr. Slott Weiner is a clinical cardiac electrophysiologist who is the Chief of Cardiology at New York Presbyterian Hospital and the Assistant Professor at Weill Cornell Medical College. He has been so generous to the ACC by sharing his clinical expertise and guidance by participating in registry data set development, by serving as a member on the LAO Registry Steering Committee, and he currently is serving as a member on the EP Registry Suite Steering Committee. This committee serves both the AFib Ablation Registry and the EP Device Implant Registry. I'd like to welcome Dr. Slott Weiner. Thank you, Christina, for that kind introduction. And I'd like to thank the organizers of the ACC NCDR's 2021 Quality Summit for inviting me to present this case of cardiac resynchronization therapy with or without a defibrillator, a patient and clinician journey of shared decision-making. Of all the potential scenarios for shared decision-making, I think there may be no better example of its value than in the difficult choice that patients face when trying to understand whether or not to receive an implantable defibrillator with, rather, to receive a cardiac resynchronization therapy with or without an implantable defibrillator. These are very complicated concepts and ones that most patients have never heard of or their families. And so I want to start by presenting the beginning of a case. This is an actual patient who was referred to me from our heart failure specialist back in April of this year. He was labeled as a, quote, a difficult patient because he and his family had been advised to consider a biventricular ICD for over two and a half years, and he had refused, in quotes, and yet he seemed to be a poster child for somebody who could benefit from at least cardiac resynchronization therapy. And so let me just give you a brief overview of him. He is an 80-year-old man, and when I met him back in April, he had advanced systolic heart failure. He could walk at most a quarter of a block before stopping due to dyspnea. He was sleeping poorly due to orthopnea, and he was starting to lose weight from cardiac cachexia. His history is significant for a history of coronary disease and a remote myocardial infarction. He had previously undergone a bypass surgery and a bioprosthetic mitral valve replacement in 2018, and back in 2011, he underwent implantation of a dual-chamber pacemaker for a complete heart block, which left him pacemaker-dependent with RV apical pacing. He also had a history of a distant stroke with no residual deficit and a low burden of paroxysmal atrial fibrillation. His transthoracic echocardiogram showed severely reduced left ventricular function with an EF between 20% and 25%, mostly globally reduced, mildly reduced right ventricular function by atrial enlargement, mild to moderate aortic stenosis, and his bioprosthetic mitral valve was functioning normally, and he had severe tricuspid regurgitation. Here is his EKG showing a wide right bundle. The right bundle is because the right ventricular lead is very apically placed in what I'm sure is a large right ventricle. And so, to summarize the key points, we have here a patient with advanced heart failure, stage 3 or neurocardiassociation functional class 3, severely reduced left ventricular function, left bundle branch block pattern on his EKG due to RV pacing, and a myopathy, not clear if it's due to coronary disease or the RV apical pacing or a combination of both, most likely, but all of these fit perfectly with clinical evidence that to us as electrophysiologists or health professionals in EP seems like a pretty straight decision. The scientific evidence in terms of the implantable defibrillator is pretty clear that he has a reasonable chance of living longer if he receives an implantable defibrillator. Similarly, he has a wide QRS, he's pacemaker dependent, and he's likely to feel better with cardiac resynchronization therapy, not 100%, but, you know, most 80% response rate. So, to us who want to do things to make people live longer and feel better, it seems like a pretty clear choice. But how do we explain to him and his family, this, quote, difficult, end quote, patient, the underlying scientific evidence so that he can make a decision and his family can make a recommendation to him that aligns best with his preferences? The traditional model of explaining to patients and gaining their agreement is, of course, informed consent. This common paradigm consists of us usually in an office or at a bedside in the hospital explaining to an individual patient at a very high level verbally, just with words, potential benefits of the therapy, potential things that could happen if they don't get the therapy, and then possible risks with the therapy, and ultimately ask the patients to make a decision based on that. But there are a lot of problems with this model, particularly it assumes that the patient comes from a similar social context to ours, that they're able to interpret that information we are explaining to them the way we do, yet often they're from very different cultural, educational, familial backgrounds, so many different variables. And so the clinician really can't put themselves in the shoes of either the patient or the family. And if we try to, we're usually wrong in those assumptions, particularly for myself practicing here in the heart of Queens, New York City, one of the most diverse boroughs in the country, perhaps the world, I only meet with patients for maybe 15 to 25 minutes, often before they are asked to choose a treatment strategy. So my putting myself in their shoes is bound to create false assumptions and not help them make the decision that most aligns with their values. Instead, we need a patient-centered model to help patients make high-quality decisions about these complex medical considerations, like whether they want an implantable defibrillator along with cardiac resynchronization therapy. So we need to be able to present the underlying evidence in a balanced way, in a disease-specific way, and importantly, in a way that patients who often have very different educational backgrounds, a way that they can appreciate and understand. We need to show them the options for the different treatments and the trade-offs that they will be making by choosing one or another option. This way, we can help them assess the information and choose a therapy that's aligned with their values, their priorities, and their goals, and ultimately help them make a decision that aligns with their treatment strategies and their life goals. This is one of my favorite examples of why shared decision-making is needed from an article that I encourage all of you to look up. It's referenced below. The article explains how poorly patients and many physicians understand statistics that are so important to making decisions in medicine, and they have some wonderful examples of politicians giving false information by misunderstanding statistics. But this is just one example, a study where investigators in several cities in the U.S. and Europe asked 750 people on different street corners to interpret the following very simple sentence that all of us are confronted with daily, which is, there is a 30% chance of rain tomorrow. What does that mean? Seems pretty straightforward to us, but here are some of the answers that the investigators received. There is a three out of ten... One is three out of ten meteorologists believe it will rain tomorrow is one interpretation. Another is 30% means that if you look up at the sky and see 100 clouds and 30 of them are black. Another response is it's not about time. It indicates the amount of rain that will fall. Or lastly, if we had 100 lives, it would rain in 30 of these tomorrow. And I like that response, probably the closest to correct. Of course, the right answer is that it will rain on 30% of days like tomorrow. But most people on the street corner did not get that right. And so if they can't interpret a weather forecast, how do we anticipate that they'll interpret the relative risk of receiving an implantable defibrillator to prevent sudden cardiac death? This here is, of course, the now famous Kaplan-Meier survival curve from ScudHeft showing improved survival amongst patients with reduced left ventricular function who receive an implantable defibrillator versus those who receive medical therapy or medical therapy with amiodarone alone. And the finding is a 23% relative reduction in mortality. But patients will not understand this. Another way to show exactly the same information is shown on this figure right here. This is taken from a shared decision-making tool from the Colorado Program for Patient-Centered Decisions. The link is below. I'll be sharing a lot of slides with information from their site. I have no relationship with them. I just think they have some excellent tools. And so here, what we have is, as I mentioned, the same information from ScudHeft, but presented in a pictorial way that patients can understand. On the top line across, you see what a patient can expect over the next five years if they choose not to have an implantable defibrillator. They will live for a certain amount of time, but then they may die suddenly. Now, if you look at this pictograph here, it shows that over the course of those five years, these red individuals will have passed away. Now, if they choose to have an implantable defibrillator, these seven individuals who now become green could have been saved by having the implantable defibrillator. So looking over here at the graph, they would live longer potentially if they had the implantable defibrillator, but their quality of life may decline in those last years. This, I think, gives patients a very concrete way to see the underlying evidence. Without this, my experience is that most patients vastly overestimate the likelihood that an implantable defibrillator will save their lives and help them live longer. Another way to view shared decision-making versus informed consent is that shared decision-making is a meeting between two experts. We have the provider on one hand, who is an expert in the underlying scientific data and the complications and potential benefits of the therapy. And on the other side, we have the patient, who is an expert in what they value and what they want. And so the exchange is from the provider who transfers knowledge in a way that the patient can understand to the patient, who then provides their preferences back to the provider so that together they can reach a decision that the patient is most comfortable with and has the best understanding of the implications of. Now, decision aids are the bedrock of shared decision-making, and they are complicated tools that on the surface may look deceptively simple. Here again, I link to the Colorado Center Program for Patient-Centered Decisions. But these tools, which we'll talk about in the next couple of slides, are critical to helping communicate the underlying scientific information to the patients, the favorable and unfavorable features of the potential therapies and outcomes, and the likelihood that the individual patient who is reviewing these may benefit or have those complications. The tools must be available in multiple different formats because patients are individual and different learners learn in different ways. So it's important to have them in pictographs and cards, videos, printed material, really all of the above and others. Now, these tools, as I mentioned, are not just copies of graphs from scientific publications. The information has to be digested from randomized controlled trials and presented in a way that's meaningful to patients. And these tools have to be studied and validated amongst patients who ultimately are the experts and can tell us whether the tools are functioning as we need them to. And this outlines the process of creating a shared decision-making tool taken from Dr. Matlock's paper cited below. The first step in creating a shared decision-making tool is understanding where there may be a need for a shared decision-making tool. The case we're presenting today, again, I think is a very clear one, somebody coming for cardiac resynchronization therapy, potentially with or without a defibrillator. These, as I mentioned, are complicated topics with a lot of good scientific data to guide us. So we have evidence from randomized controlled trials. This is critical in order to make a shared decision-making tool. It's not possible or much more difficult in areas where scientific evidence is less well-established. So once we have assessed the need and we know the evidence, then we have to start prototyping the tool. This takes a team of developers, not just clinicians, but individuals with expertise in showing patients information graphically in ways that they can understand and sharing this with stakeholders, patients, clinicians, family, and then putting these together in tools and testing the tools, then refining the tool based on the feedback until ultimately we get to a final product. And that final product has to be a living product that gets updated as information changes and as we get additional information from experts, from patients and families on how well the tool is working. So here's how I incorporate shared decision-making in my practice. And this is for the hospital practice. We'll talk about some of the challenges, but I wanted to first share how I do this. So for my office practice, at an initial visit, what I will do is I will introduce the shared decision-making tool, help patients understand each tool is different. And so you have to know your tool in advance. I'll show you the one I used here. I usually will give them references to the video, online booklet, and printed material I'll hand to them. And if the tool has an encounter tool specifically designed for the encounter, I'll use that. I ask them to review this information and share it with their family and write down questions, reach out to me by phone or portal, but I schedule a follow-up visit usually in about two weeks or so, so that we can then review that information and review the potential treatment and therapies, risks and benefits after the patient and family and caregivers had a chance to review the information. So I want to take us back to our case. This is our 80-year-old man with advanced dystolic heart failure, pacemaker-dependent. And so what I did with him was I used the Colorado Program for Patient-Centered Decisions. I used their tool for cardiac resynchronization therapy. Here, you can see many of the other terrific tools that they've developed. And when you go to this tool in particular, you'll see the different options that it comes in. It has an extensive booklet for patients. There's a video. There are different languages. And then there's the patient encounter tool. This is a simple two- to three-page tool that's designed specifically to be used at the encounter. And that's what I used in this case with the patient and his wife and daughter were present. And so first we talked about the potential benefits of cardiac resynchronization therapy, the potential that he would have increased physical stamina, less dysthmia, and better quality of life. And then we talked about the underlying evidence for primary prevention of sudden cardiac death, the fact that over five years follow-up, seven patients like him may have been saved by the implantable defibrillator. Now, one challenge I face, and this was a particular challenge with this patient, was explaining to the patient that one device could do either cardiac resynchronization or defibrillation or both. And I think that this tool, much as I appreciate it, could do a better job at helping that because it turned out to be a very difficult concept for this patient to understand and the family, but they did understand it, but not at this encounter. So they took this information home. That was April 12th of this year. They came back on April 30th and they had a lot of questions. This is where it became clear that they really didn't fully appreciate that I was talking about different devices that could do either cardiac resynchronization therapy, either an implantable defibrillator or both. So that's what we spent most of this time talking about. Now, he did end up choosing the CRT with the defibrillator, but between April 30th and May 19th, there were many calls. And so it was a very, very active discussion. This difficult patient wasn't difficult. He just really wanted to understand. And it was a very difficult concept for him and his patient and his family to understand. But by the time they reached their decision, they were all very, very comfortable with the decision. They had no qualms. And the procedure, I'm pleased to report, went well. And he has had significant improvement in his clinical quality of life since undergoing CRT-D. I spoke with him at the beginning of August when he came for a follow-up. He has not received any shocks. Fortunately, he has not had any ventricular arrhythmias, but he is very confident and comfortable with the decision that he reached. Now, clinical practice and shared decision-making often don't go together that easily. And it's taken me a long time to be able to incorporate some tools for shared decision-making in some areas of my practice. I think it works particularly well for the case that we're talking about here today, which is cardiac resynchronization therapy and an implantable defibrillator, that combination. Others where it's more challenging, and I know many of you are probably facing that, is with percutaneous left atrial appendage closure and Watchman. We're not going to talk about that today, but that's, I think, a challenge where we don't have a good model yet, although there are great tools to help patients decide whether they might want to take anticoagulation for atrial fibrillation. But I find, and I found in the beginning in particular, that many patients did not want to engage in shared decision-making. They just said, Doc, just tell me what to do. What would you do if it was your family? What would you do if I was you? And that's a challenge, and I don't have a simple answer for that. Some patients just don't want to engage in shared decision-making, and sometimes it can be very hard to figure out how to find time to do it. It can be disruptive to the workflow, especially in inpatient settings, and so there's no simple answer for those, and I think those are problems that we need to acknowledge. But in terms of implementation, who implements it? There's no single right or wrong answer. Here, in my practice, I've implemented it, but I have colleagues across the country, particularly in the Midwest, where distances to travel are much greater, where allied professionals often interact with patients multiple times before the initial consult or after, where they're the individuals who will present the shared decision-making tool and references. In terms of how to, which medium, electronically or in person or print or DVD, I think all of these have to be available, and some will work for some patients in some situations. In terms of where to do it, I do it at the initial encounter in the office, but others that I know do it prior to the visit by sending information to patients in advance. Others do it after the visit, at follow-up visits. Again, I don't think there's a right or wrong answer, and when. I think we've covered this topic already. You have to do what works for you, and sometimes none of them will work. I find the encounter-based tool to be a critical way to start because the booklets or videos are too long often, and patients need to go through those at their own time. So, if there's an encounter-based tool, that's usually a great way to get started. Now, do these make any difference? What's the evidence supporting shared decision-making tools? Well, here I reference a systematic review published several years ago, which looked at 105 studies of shared decision-making tools. These were randomized controlled trials looking at shared decision-making versus the standard informed consent, and they looked at first the attributes of the choice made by the individuals following a shared decision-making process, and then secondary outcomes was behavioral health and health system effects by using a shared decision-making tool. What they found was that the attributes of the choice made by patients who used shared decision-making, patients felt that they had much better knowledge of the underlying science and issues behind the decision that they were making, and they also had a much more accurate perception of the risk of the therapies, and they had a better understanding of whether the therapy was congruent with their health care values. They also had less decisional conflict. They were more comfortable with the final decision they made, and it was more aligned with their value, and they felt more involved in the decision. They felt patients who previously had been more passive, who said, you know, doc, just let me… you decide. Let me do whatever you recommend. Fewer patients did that. More were engaged, and so I think we have good evidence to show that these do improve the quality of the decision patients make. Now, they don't shorten the time to decision, and in my experience, I think they do reduce the number of patients who tend to choose invasive therapies, but they do lead to better decisions on patients' behalf. I want to just close with examples of other shared decision-making tools. The primary prevention ICD has multiple good tools. I'm not going to go through all of these. I'm referencing some sites here at ACC, the Colorado Program for Patient-Centered Decision. The Mayo Clinic has a superb shared decision-making tool to help patients with atrial fibrillation decide whether they want to take pericardial intercoagulation, but I encourage you to check these out. See which ones work for you in your practice and for your patients, and have several available since individual patients may respond more to one versus another. I just want to close with this quote from Malcolm Gladwell, which I think summarizes the importance of shared decision-making and what it does very well. The key to good decision-making is not knowledge. It's understanding. We're swimming in the former, and we're desperately lacking in the latter, and I think shared decision-making helps patients understand and therefore make higher quality decisions. Thank you. Thank you very much, Dr. Slotweiner, for sharing that information with us. It's very helpful. We do have a few questions that have come in, and we have some time to to tackle a few of these, so we'll jump right in if you don't mind. Terrific. The first question I have, and at my facility I've seen a case when the RA lead is not always implanted with a CRT device. Can you please explain that rationale? Absolutely. So some patients have persistent atrial fibrillation, and so because the atrial rhythm is always atrial fibrillation, the atrial lead would not serve any purpose potentially. So usually the point of the atrial lead is to allow the device to synchronize the atrial and ventricular contractions, but if the atria are not contracting, then there's no need to synchronize that. Now some patients go in and out of atrial fibrillation, and so when they're in sinus rhythm, having an atrial lead will allow you to synchronize the AV relationship. That's why I will typically place an atrial lead in most patients, even if they have atrial fibrillation, but for somebody who's been in atrial fibrillation for years and years with little expectation of restoring normal rhythm, that atrial lead may really serve no purpose, and so in those cases that's where you may see the absence or you may not see an atrial lead implanted. I see. Thank you. In your case study, you speak about the causes of this patient's cardiomyopathy issues could have been acing induced or a combination of factors leading to that. Are there patient characteristics that you can evaluate up front which make a patient you think possibly more prone to develop RV pacing-induced cardiomyopathy, so that when you're evaluating or making those decisions, you might go straight to a CRT? That's a great question, and a question where we don't yet know the exact answer, but we do believe…we know that the more RV pacing there is, the greater chance there is of causing myopathy, whether that is 60 percent, 70, 80 percent pacing. We don't know because it's very difficult to do those types of studies, but in general, if a patient's going to be paced more than 40 or 50 percent of the time RV apically, at this point, we will often consider cardiac resynchronization therapy from the start to avoid a cardiomyopathy. Now, if we're starting out with a patient who has heart block and normal left ventricular function, that's different, but if we're there, there we would generally use a dual-chamber device because we know most patients will do fine with even a slight reduction in their left ventricular function, and this is well addressed in the most recent pacing guidelines from ACC, HRS, and AHA in detail. It's a great complicated topic and one that will also be addressed in the upcoming physiologic pacing guidelines, but to make it not too complicated, I think if somebody's got mildly reduced left ventricular function or moderate, they're going to be paced more than 40, 50 percent of the time, that's when we start thinking about cardiac resynchronization therapy. And is that typically one of those decisions that you would have a conversation with the patient about between dual or CRT? Is that a type of in-depth clinical discussion you get into, or you typically would make that judgment call based on what you think? And that's one where we don't have a good shared decision-making tool because we don't have evidence. I think that is an area that's challenging, and I would probably, personally, I would individualize that based on the patient, but probably it would be one that mostly would be made by the clinician. I may or may not involve the patient more or less, depending on what I think they would want, and that may be wrong, that may be inserting my values there, but it's hard when there are gray areas, that's where it's very challenging to do shared decision-making or informed consent. So great question, not a simple answer. Yeah, I can imagine. Another question that's come in, do you frequently encounter patient preference to land on opting for a CRTP, basically due to fear of defibrillator? They may meet guidelines for the CRTD, but they're fearful of that. Do you experience that frequently? You know, I don't. Actually, I encounter a little bit of the opposite. I encounter the fact that most patients presented with the word sudden cardiac death, and any therapy that might protect them or help them survive sudden cardiac death, they have a difficult time removing the defibrillator part from their thought process. And so I see in my patient population, I think it leans a little bit more towards the opposite of having difficulty imagining not getting the defibrillator. Now, there are many questions about the shock, but that doesn't tend to prevent them from wanting it. It scares them to hear sudden cardiac death. It scares them to hear a possible shock, but it scares them more to hear there's something that could help me survive sudden cardiac death, and I might choose not to have it. And I think that's unfortunate because most patients, as I mentioned earlier, I think overestimate the likelihood that their survival will be prolonged by the defibrillator. And often I think CRT-P alone might be aligned better with their values, but my experience is that they choose the CRT with the defibrillator more out of fear of not having a defibrillator. That's good. Do you know, are there currently any ongoing trials evaluating any new pacing or defibrillator technology that you would anticipate coming on the market soon? There are always new trials, and I am sure that I don't know most of them. I know that there are trials looking at new therapies for heart failure that could be delivered in combination with the defibrillator. Right now there is a therapy that can be delivered by a device, but it's an implant that doesn't go along with a defibrillator. So there's a trial looking at that with the defibrillator. There are always new defibrillators coming down the road with new sensors for heart failure in particular to try to help anticipate heart failure exacerbations before patients become symptomatic. And so you can be sure that there are many trials, but I wouldn't, if you're dealing with an individual patient, I would of course encourage them not to wait. The best defibrillator for them is one that's available now, and if any critical features come out that theirs doesn't have, of course, there's always a possibility to upgrade in the future. Absolutely. Do you happen to encounter situations where a patient chooses CRT-P, but the family or the physician wants the patient to receive a CRT-D? That's a little bit opposite of the previous question, but this is involving opposite choices here. Yes, yes, I do encounter that. I think one thing we have particularly encountered is situations where patients choose CRT-P, but other physicians involved in the patient's care are not as familiar with the possibility of CRT-P and feel for medical legal reasons that it's not right to not have them get a defibrillator. And so helping physicians who are used to having every patient with an ejection fraction of less than 30 or 35 percent get a defibrillator, helping them appreciate that that may not be aligned with patient's values, that's pretty different thinking from just 10 to 15 years ago. And so a lot of our cardiologists who've been practicing for a while, that's a new way to think. And sometimes even within families, we'll see patients, and patients I think tend to understand their desires and their goals of care as they age better than, say, their younger children or grandchildren, and they have more realistic expectations of what they want, but it can be hard for other members of their family to appreciate that. And so it can get into some pretty uncomfortable situations, some heated family dynamics, and I think that's where shared decision-making tools like the one I showed you are critical. You know, being able to show the family members and the patients that evidence in ways that basically anybody can appreciate makes it black and white, and the patient, of course, as long as they have capacity, is the final decider. And being able to do that and document that in the chart for medical legal reasons and making sure that, and then for moral reasons, just making sure that everyone understands and that the patient is reaching the right decision for them is very gratifying for these complicated social interactions. Thank you for that. What do you do when you're concerned that a patient does not comprehend the implications of a decision when choosing between CRT-P versus CRT-D? Yeah, that definitely is a problem, and one that we tend to see more among patients who are hospitalized when we are called to evaluate them. And the number one thing I do is explain to the team taking care of the patient that, except for rare circumstances, this decision is not emergent unless patients have complete heart block and need an emergent device. You know, it's important to take time to make sure that we get other family members involved in the discussion. Other caregivers. Now, if cognitive abilities are an issue for the patient, you know, that really calls into question whether the defibrillator is appropriate. But the first thing we do is we take a deep breath and we, you know, don't rush it. We take time to gather other care members of the family and the care team into the discussion to try to understand the patient's goals, their to try to understand the patient's goals, their cognitive abilities, and then make a recommendation or help them decide preferably. We like them to decide rather than us make a recommendation with that whole broader team involved. Thank you. I think we do have time for one more question. How do you incorporate into your discussion with patients the fact that there is conflicting evidence if patients with ischemic versus non-ischemic cardiomyopathy receive additional benefit from the CRTD over the CRTP? Yeah, that's a good question. It's similar to that question you asked earlier about when do we consider CRT versus just dual chamber pacing, you know, what percentage pacing. So this becomes a gray area. There is conflicting evidence whether patients who get CRTP get additional benefit from the defibrillator if they have ischemic or non-ischemic myopathies as you referenced. And I don't think that issue has been fully decided. I've seen studies on both ends, most recently a study from Companion showing that the non-ischemics may get additional benefit from the defibrillator while the ischemics may not. But I think that this is difficult to incorporate into the shared decision-making process for the reasons, you know, stated earlier in that the science is not well understood. And so I tend to not focus on this. I tend to take the two data points separately, the evidence for CRTP on one hand and the evidence for ICD for sudden cardiac death on the other, and then combine those as the shared decision-making tool did that I showed in my presentation. Now I'm not saying this is right, but that's the way I do it because I don't have a better alternative at the moment. I think if we were to start getting into the nuances of the present literature and explaining to patients, well, a study that just was published a few months ago shows that since you have an ischemic myopathy, you may not really get additional benefit from the defibrillator, so why don't we just go with CRTP, then I'm really interjecting my values to some degree and my interpretation of the literature, but it's not been incorporated into guidelines, it's not fully vetted, and there are not multiple sources for it. So I tend to avoid those nuances for these discussions and present them separately. I'm not saying that's right, but I think often as clinicians we're faced with this because it's rare that patients are black and white and it's rare that we have all the answers for everything, so we just have to always be on our toes and try to make the best accommodations around the evidence that we can to help patients make the best decisions possible. Thank you very much, that's very helpful. Well, that's all we have time for during this session, sad to say, but I want to thank you very, very much for your time, for being with us today and sharing this helpful information, understanding a little bit more that goes into the CRTP versus CRTD procedural decisions that have to get made. So thank you again for sharing this with us, and I also want to thank our audience for being with us today, for taking your time out of your busy day to attend, and thank you also for all you do to support optimizing patient care. So I hope you have a great rest of your day. Thank you. Thank you. I enjoyed it, Christina. Thank you very much.

shared decision-making

cardiac resynchronization therapy

CRT

defibrillator

patient-centered care

decision aids

treatment options

patient values