2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy - PowerPoint Presentation

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2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy

Jean-Claude Deharo

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2021 ESC Guidelines on cardiac pacing and

cardiac resynchronization therapy

Authors/Task Force Members:Michael Glikson (

Chairperson) (Israel), Jens Cosedis Nielsen (Chairperson) (Denmark), Mads Brix Kronborg (Task Force Coordinator) (

Denmark

), Yoav Michowitz (

Task Force Coordinator) (Israel), Angelo Auricchio (Switzerland), Israel Moshe Barbash (Israel), José A. Barrabés (Spain), Giuseppe Boriani (Italy), Frieder Braunschweig (Sweden), Michele Brignole (Italy), Haran Burri (Switzerland), Andrew JS Coats (United Kingdom), Jean-Claude Deharo (France), Victoria Delgado (Netherlands), Gerhard-Paul Diller (Germany), Carsten W. Israel (Germany), Andre Keren (Israel), Reinoud E. Knops (Netherlands), Dipak Kotecha (United Kingdom), Christophe Leclercq (France), Béla Merkely (Hungary), Christoph Starck (Germany), Ingela Thylén (Sweden), José Maria Tolosana (Spain)

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The 2021 guidelines on cardiac pacing and CRT present new and updated recommendations for these treatments in relevant patient populations

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New section

Evaluation of the patient with suspected or documented bradycardia or conduction system disease

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AV = atrioventricular; ECG = electrocardiogram; SND = Sinus node dysfunction.

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Laboratory tests

In addition to preimplant laboratory

tests,

b

specific laboratory tests are recommended in patients with clinical suspicion for potential causes of bradycardia (e.g. thyroid function tests, Lyme titre, digitalis level, potassium, calcium, and pH) to diagnose and treat these conditions.

I

C

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Electrophysiological study

In patients with syncope and

bifascicular

block, EPS should be considered when syncope remains unexplained after non-invasive evaluation or when an immediate decision about pacing is needed due to severity, unless empirical pacemaker is preferred (especially in elderly and frail patients).

IIa

B

In patients with syncope and sinus bradycardia, EPS may be considered when non-invasive tests have failed to show a correlation between syncope and bradycardia.

IIb

B

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Carotid

massage

Once carotid stenosis is ruled out

a

, carotid sinus massage is recommended in patients with syncope of unknown origin compatible with a reflex mechanism or with symptoms related to pressure/manipulation of the carotid sinus area.

I

B

Tilt test

Tilt testing should be considered in patients with suspected recurrent reflex syncope.

IIa

B

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Monitoring

In patients with infrequent (less than once a month) unexplained syncope or other symptoms suspected to be caused by bradycardia, in whom a comprehensive evaluation did not demonstrate a cause, long-term ambulatory monitoring with an ILR is recommended.

I

A

Ambulatory electrocardiographic monitoring is recommended in the evaluation of patients with suspected bradycardia to correlate rhythm disturbances with symptoms.

I

C

ILR = implantable loop recorder.

Slide16

The 2021 guidelines on cardiac pacing and CRT present new and updated recommendations for these treatments in relevant patient populations

Slide17

General indications for pacing - New

recommendations

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Recommendations

Class

Level

Cardiac pacing for bradycardia and conduction system disease

 

 

Pacing is indicated in symptomatic patients with the bradycardia-tachycardia form of SND to correct

bradyarrhythmias

and enable pharmacological treatment, unless ablation of the tachyarrhythmia is preferred.

I

B

AF ablation should be considered as a strategy to avoid pacemaker implantation in patients with AF-related bradycardia or symptomatic pre-automaticity pauses, after AF conversion, taking into account the clinical situation.

IIa

C

General indications for pacing - New

recommendations

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General indications for pacing - New

recommendations

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Spontaneous documented symptomatic

asystolic pause/s >3 s or asymptomatic pause/s >6 s due to sinus arrest or AVB

Severe, unpredictable, recurrent reflex syncope after 40 y.

General indications for pacing - New

recommendations

Test

inducedpause

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Recommendations

Class

Level

LBBB QRS

morphology

CRT is recommended for symptomatic patients with HF in SR with LVEF ≤35%, QRS duration ≥150

ms

, and LBBB QRS morphology despite OMT, in order to improve symptoms and reduce morbidity and mortality.

I

A

CRT should be considered for symptomatic patients with HF in SR with LVEF ≤35%, QRS duration 130–149

ms

, and LBBB QRS morphology despite OMT, in order to improve symptoms and reduce morbidity and mortality.

IIa

B

CRT = cardiac resynchronization therapy; HF = heart failure; LBBB = left bundle branch block; LVEF = left ventricular ejection fraction; OMT = optimal medical therapy; SR = sinus rhythm.

CRT (1) – LBBB

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Recommendations

Class

Level

Non-LBBB QRS

morphology

CRT should be considered for symptomatic patients with HF in SR with LVEF ≤35%, QRS duration ≥150

ms

, and non-LBBB QRS morphology despite OMT, in order to improve symptoms and reduce morbidity.

IIa

B

CRT may be considered for symptomatic patients with HF in SR with LVEF ≤35%, QRS duration 130–149

ms

, and non-LBBB QRS morphology despite OMT, in order to improve symptoms and reduce morbidity.

IIb

B

QRS duration

CRT is not indicated in patients with HF and QRS duration <130 

ms

without an indication for RV pacing.

III

A

CRT = cardiac resynchronization therapy; HF = heart failure; LBBB = left bundle branch block; LVEF = left ventricular ejection fraction; OMT = optimal medical therapy; SR = sinus rhythm.

CRT (2) – Non-LBBB

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CRT rather than RV pacing is recommended for patients with

HFrEF (<40%) regardless of NYHA class who have an indication for ventricular pacing and high degree‑ AVB in order to reduce morbidity. This includes patients with AF.

I

A

CRT (3) –

Frequent

ventricular

pacing

Patients who have received a conventional pacemaker or an ICD and who subsequently develop symptomatic HF with LVEF ≤35% despite OMT, and who have a

significant

a

proportion of RV pacing, should be considered for upgrade to CRT.

IIa

B

> 20% stimulation VD

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Recommendations

Class

Level

Cardiac resynchronization therapy

 

 

In patients with symptomatic AF and an uncontrolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), CRT rather than standard RV pacing should be considered in patients with

HFmrEF

.

IIa

C

In patients with symptomatic AF and an uncontrolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), RV pacing should be considered in patients with

HFpEF

.

IIa

B

In patients with symptomatic AF and an uncontrolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), CRT may be considered in patients with

HFpEF

.

IIb

B

CRT (4) – AVJ Ablation

Ablation NAV

CRT

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Recommendations

Class

Level

Cardiac resynchronization therapy

 

 

In patients with symptomatic AF and an uncontrolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), CRT rather than standard RV pacing should be considered in patients with

HFmrEF

.

IIa

C

In patients with symptomatic AF and an uncontrolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), RV pacing should be considered in patients with

HFpEF

.

IIa

B

In patients with symptomatic AF and an uncontrolled heart rate who are candidates for AVJ ablation (irrespective of QRS duration), CRT may be considered in patients with

HFpEF

.

IIb

B

CRT (4) – AVJ Ablation

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His Bundle Pacing - New

recommendations

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His Bundle Pacing - New

recommendations

In CRT candidates in whom coronary sinus lead implantation is unsuccessful, HBP should be considered as a treatment option along with other techniques such as surgical epicardial lead.

IIa

B

HBP may be considered as an alternative to right ventricular pacing in patients with AVB and LVEF >40%, who are anticipated to have >20% ventricular pacing.

IIb

C

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Leadless

Pacing - New recommendations

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Leadless

Pacing - New recommendations

Recommendations

Class

Level

Alternate

site pacing

–

Leadless

pacing

IIa

C

Leadless pacemakers should be considered as an alternative to transvenous pacemakers when no upper extremity venous access exists or when risk of device pocket infection is particularly high, such as previous infection and patients on haemodialysis.

IIa

B

Leadless pacemakers may be considered as an alternative to standard single lead ventricular pacing, taking into consideration life expectancy and using shared decision-making.

IIb

C

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For long‑term temporary transvenous pacing, an active fixation lead inserted through the skin and connected to an external pacemaker should be considered.

IIa

C

Temporary

Pacing - New

recommendation

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Recommendations

Class

Level

Implantation of a permanent pacemaker is indicated with the same recommendations as in a general population (

section 5.2

) when AVB does not resolve within a waiting period of at least 5 days after MI.

I

C

Myocardial

infarction

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Characteristics

ECG

Right BBB

PR-interval prolongation

Left anterior hemiblock

Patient

Older age (per 1-year increase)

Male sex

Larger body mass index (per 1-unit increase)

Predictors for permanent pacing after transcatheter aortic valve implantation (1)

AVB = atrioventricular block; BBB = bundle branch block; ECG = electrocardiogram; LV = left ventricular; TAVI = transcatheter aortic valve implantation.

For more detailed data see

Supplementary Tables 14

and

15

.

TAVI

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Characteristics

Anatomical

Severe mitral annular calcification

LV outflow tract calcifications

Membranous septum length

Porcelain aorta

Higher mean aortic valve gradient

Predictors for permanent pacing after transcatheter aortic valve implantation (2)

AVB = atrioventricular block; BBB = bundle branch block; ECG = electrocardiogram; LV = left ventricular; TAVI = transcatheter aortic valve implantation.

For more detailed data see

Supplementary Tables 14

and

15

.

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Characteristics

Procedural

Self-expandable valve

Deeper valve implantation

Larger ratio between prosthesis diameter versus annulus or LV outflow tract diameter

Balloon post-dilatation

TAVI in valve-in-valve vs. native valve procedure

Predictors for permanent pacing after transcatheter aortic valve implantation (3)

AVB = atrioventricular block; BBB = bundle branch block; ECG = electrocardiogram; LV = left ventricular; TAVI = transcatheter aortic valve implantation.

For more detailed data see

Supplementary Tables 14

and

15

.

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a

24-48 h post procedure.

bTransient high-degree AVB, PR prolongation, or axis change.

cHigh-risk parameters for high-degree AV block in patients with new-onset LBBB include: AF, prolonged PR interval, and LVEF <40%.d

Ambulatory

continuous ECG monitoring for 7−30 days.

eEPS with HV interval ≥70 ms may be considered positive for permanent pacing.fWith no further prolongation of QRS or PR during 48-h observation.AF = atrial fibrillation; AV = atrioventricular AVB = atrioventricular block; BBB = bundle branch block; ECG = electrocardiogram; EPS = electrophysiology study; HV = His-ventricular interval; LBBB = left bundle branch block; LVEF = left ventricular ejection fraction; PM = pacemaker; QRS = Q, R, and S waves; RBBB = right bundle branch block; TAVI = transcatheter aortic valve implantation.

TAVI

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MRI = magnetic resonance imaging; SAR = specific absorption rate.

a Consider only if there is no imaging alternatives and the result of the test is crucial for applying life-saving therapies for the patient.

IRM

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ECG = electrocardiographic; PM = pacemaker.

aRelocation of the device, continuous ECG monitoring, reprogramming, or magnet application are very rarely indicated.

Radiothérapie

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In-office only

In-office + remote

All devices

Within 72 h and 2–12 weeks after implantation

In-office within 72 h and

2–12 weeks after implantation

CRT-P or HBP

Every 6 months

Remote every 6 months and in-office every 12

months

a

Single/dual-chamber

Every 12 months then every 3−6 months at signs of battery depletion

Remote every 6 months and in-office every 18−24

months

a

CRT-P = cardiac resynchronization therapy-pacemaker; HBP = His bundle pacing.

a

Remote

follow-up can only replace in-office visits if automatic capture threshold algorithms perform accurately (and are previously verified in-office).

Note: Additional in-office follow-up may be required (e.g. to verify the clinical effect of modification of programming, or for follow-up a technical issue).

Follow-up:

Remote

/In-office