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Guidelines for Cardiac Pacing andCardiac Resynchronisation Therapy

The Task Force for Cardiac Pacing and Cardiac Resynchronisation Therapy of the

European Society of CardiologyDeveloped in collaboration with the

European Heart Rhythm Association

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Authors/Task Force Members

Angelo Auricchio (Switzerland)Jean-Jacques Blanc (France) Jean-Claude Daubert (France)

Helmut Drexler (Germany)Hugo Ector (Belgium)

Maurizio Gasparini (Italy)Cecilia Linde (Sweden)

Francisco Bello Morgado (Portugal)Ali Oto (Turkey)

Richard Sutton (UK)Maria Trusz-Gluza (Poland)

Chairperson: Panos E. Vardas (Greece)

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Introduction

• The guidelines for the appropriate use of pacemaker devices presented in this document, a joint ESC and EHRA initiative, aim to provide for the first time in Europe an up to date specialists' view of the field.

• The guidelines cover two main areas: the first includes permanent pacing in bradyarrhythmias, syncope, and other specific conditions, while the second refers to ventricular resynchronisation as an adjunct therapy in patients with heart failure.

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Classes of Recommendations

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Levels of Evidence

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1. Pacing for Arrhythmias

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1.1. Sinus node diseaseRecommendations for cardiac pacing in sinus node disease

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Pacemaker mode selection in sinus node disease

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1.2. Atrioventricular and intraventricularconduction disturbances

Recommendations for cardiac pacing in acquired AV block

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1.2. Atrioventricular and intraventricularconduction disturbances

Recommendations for cardiac pacing in chronic bi- and tri-fascicular block

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Pacemaker mode selection in acquired atrioventricularblock, chronic bifascicular and trifascicular block

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1.3. Recent myocardial infarctionRecommendations for permanent cardiac pacing in conduction

disturbances related to acute myocardial infarction

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1.4. Reflex syncopeThe main causes of reflex syncope

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Recommendations for cardiac pacing in carotid sinus syndrome

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Recommendations for cardiac pacing in vasovagal syncope

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1.5. Paediatrics and congenital heart diseasesRecommendations for cardiac pacing in paediatrics and congenital heart disease

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1.5. Paediatrics and congenital heart diseasesRecommendations for cardiac pacing in paediatrics and congenital heart disease

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1.5. Paediatrics and congenital heart diseasesRecommendations for cardiac pacing in paediatrics and congenital heart disease

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1.6. Cardiac transplantationRecommendations for cardiac pacing

after cardiac transplantation

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2. Pacing for Specific Conditions

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2.1. Hypertrophic cardiomyopathyRecommendations for cardiac pacing

in hypertrophic cardiomyopathy

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3. Cardiac Resynchronisation Therapy (CRT) in Patients with Heart Failure

• State-of-the-art management of congestive heart failure (CHF), besides alleviating symptoms, preventing major morbidity, and lowering mortality, increasingly strives to prevent disease progression, in particularly the transition between asymptomatic LV dysfunction and overt CHF.

• The clinical effects of long-term CRT were firstly evaluated in non-controlled studies, in which a sustained benefit conferred by biventricular pacing was measured. Randomized multi-centre trials with crossover or parallel treatment assignments were subsequently conducted to ascertain the clinical value of CRT in patients with advanced CHF and in sinus rhythm, with or without indications for an implantable cardioverter-defibrillator (ICD). Meta-analyses were also published.

• The usual study enrolment criteria were: 1) CHF in New York Heart Association (NYHA) functional Class III or IV despite optimal pharmacological treatment; 2) LV ejection fraction (EF) < 35%, LV end-diastolic diameter > 55 mm, and QRS duration ≥ 120 or 150 ms.

Evidence-based clinical effects of CRT

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• Pacing for heart failure can be applied either by biventricular pacing or, in selected cases, by left ventricular pacing alone. The following recommendations consider cardiac pacing for heart failure delivered through biventricular pacing, since this mode is supported by the greatest body of evidence. This, however, does not preclude other pacing modes, such as LV pacing, to correct ventricular dyssynchrony.

• Ventricular conduction delay continues to be defined according to QRS duration (QRS ≥ 120 ms). It is recognised that ventricular conduction delay may not result in mechanical dyssynchrony. Dyssynchrony isdefined as an uncoordinated regional contraction-relaxation pattern. Although from the theoretical point of view it may be more appropriate to target mechanical dyssynchrony, rather than electrical conduction delay, no large controlled study has prospectively assessed the value of mechanical dyssynchrony in heart failure patients undergoing pacing for heart failure.

3. Cardiac Resynchronisation Therapy (CRT) in Patients with Heart Failure

Recommendations

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3. Cardiac Resynchronisation Therapy (CRT) in Patients with Heart Failure

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3. Cardiac Resynchronisation Therapy (CRT) in Patients with Heart Failure

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3. Cardiac Resynchronisation Therapy (CRT) in Patients with Heart Failure