Cardiac Physiologic Pacing for the Avoidance and Mitigation of Heart Failure
Introduction
Introduction
Top 10 Take-Home Messages
- Cardiac physiologic pacing (CPP) is defined here as any form of cardiac pacing intended to restore or preserve synchrony of ventricular contraction. CPP can be achieved by engaging the intrinsic conduction system via conduction system pacing (CSP; which includes His bundle pacing [HBP] or left bundle branch area pacing [LBBAP]), or cardiac resynchronization therapy (CRT), the latter most commonly achieved by biventricular (BiV) pacing using a coronary sinus (CS) branch or epicardial left ventricular (LV) pacing lead.
- The strength of evidence for CRT in heart failure (HF) is substantially greater than what is available to support CSP. Multiple randomized controlled trials (RCTs) have shown a beneficial effect of CRT in reducing HF symptoms and hospitalization, improving LV function, and increasing survival. The majority of data on CSP are observational, and long-term data on lead survival are lacking. Ongoing and planned studies are likely to provide future guidance on the use of CSP compared to CRT.
- Response to CRT has a variable definition and includes improvements in mortality and HF hospitalization but may also include improvement in clinical parameters of HF, stabilization of ventricular function, or prevention of progression of HF.
- Periodic assessment of ventricular function is recommended for patients who require substantial right ventricular (RV) pacing (≥20%–40%) or have chronic left bundle branch block (LBBB) to detect pacing- or dyssynchrony-induced cardiomyopathy.
- Patients undergoing pacemaker implant who are expected to require substantial ventricular pacing (≥20%–40%) may be considered for CPP to reduce the risk of pacing-induced cardiomyopathy (PICM).
- Patients with left ventricular ejection fraction (LVEF) of 35%–50% who are expected to require less than substantial (<20%–40%) ventricular pacing may not have a sizable benefit from CPP; therefore, traditional RV lead placement with minimization of ventricular pacing, CSP, or CRT in the setting of LBBB are all acceptable options.
- New recommendations for left bundle branch area pacing are made for patients with normal LVEF (class of recommendation [COR] 2b) needing a pacing device.
- CRT remains recommended for patients with HF, LVEF ≤35%, LBBB, QRS duration ≥150 ms, and New York Heart Association (NYHA) class II–IV symptoms on guideline-directed medical therapy (COR 1). New recommendations are made for CSP when effective CRT cannot be achieved (COR 2a); and for CRT in patients with select characteristics (eg, female sex), as they may derive benefit from CRT at QRS durations of 120–149 ms (COR 1). New recommendations are also made for patients with HF, LVEF 36%–50%, LBBB, and QRS duration ≥150 ms for CRT or CSP to maintain or improve LVEF (COR 2b).
- New CPP recommendations are provided for patients with HF, LVEF ≤35%, and non-LBBB pattern for QRS duration both <150 and ≥150 ms (COR 2b).
- During implantation and follow-up of patients with CPP devices, electrocardiographic demonstration of BiV (for CRT) or conduction system (for CSP) capture is essential.
Other Important Considerations
- Shared decision-making is recommended when contemplating implantation of a CPP device and should include considerations of the patient's values, preferences, goals of care, and prognosis, along with the potential benefits, short- and long-term risks (in particular, device-associated infection), effects of these pacing modalities on battery longevity, future lead management issues, evidence base for different types of CPP, and considerations at end of life.
- Substantial RV pacing of ≥20%–40% may induce cardiomyopathy in a subset of patients.
- Remote monitoring and in-person echocardiographic and electrocardiographic evaluations are essential during follow-up after implantation of a CPP device to ensure appropriate capture and optimization of therapy.
- In patients with HF with improved LVEF or benefit from CRT (including improvement, stabilization, or partial reversal of natural decline), continuation of CRT with BiV pacing is recommended at device replacement.
- In patients with an unfavorable response to CRT with BiV pacing, optimization of both medical and device therapies is recommended.
- In selected patients with congenital heart disease (CHD) or congenital atrioventricular block (AVB), CRT or conduction system area pacing may be considered.
- Long-term data on CSP are emerging, with current data derived from observational studies or small randomized clinical trials without long-term follow-up. Robust data from ongoing, larger randomized trials are expected.
Definitions
...initions...
...efinitionsHaving trouble viewing table? Expand L...
...2. CRT Response CriteriaHaving trouble view...
Epidemiology, Pathophysiology, and Detection of Electrical Dyssynchrony-induced Cardiomyopathy
...miology, Pathophysiology, and Detection of...
...n of electrical dyssynchrony-induced cardio...
...patients who have substantial RVP that cannot be...
...with chronic LBBB, periodic assessment of ve...
Indications for CPP in Patients with Indications for Pacemaker Therapy
...tions for CPP in Patients with Indications for...
...Pacing Strategies in Patients Under...
Substantial ventricular...
...tients with an indication for perm...
...ients with normal LVEF who are anticipated...
...n patients who are ventricular pacing-dependent u...
...s than substantial ventricular pacing...
...patients with an indication for permanent paci...
In patients with an indication for permanent p...
...ents with an indication for permanent pacin...
...ho are undergoing permanent pacing wi...
In patients with normal LVEF who are an...
At time of surger...
...patients undergoing cardiac surgery wh...
...nts undergoing cardiac surgery who will lik...
Indications for CPP in Patients with HF
...ations for CPP in Patients with...
...ure 2. Pacing Strategies in Patients Without B...
...sinus rhythm, QRS duration ≥150 m...
...atients with LVEF ≤35%, sinus rhythm...
In patients with LVEF ≤35%, sinus rhyth...
...s with LVEF ≤30%, sinus rhythm, LBBB, QRS...
...atients with LVEF 36%–50%, sinus...
In patients with LVEF ≤35%, sinus rhy...
...sinus rhythm, QRS duration 120–149 ms, NYH...
...nts with select characteristics (eg, f...
...have LVEF ≤35%, sinus rhythm, LBBB with QRS d...
...Hazard Ratio (HR) by Height and QRS DurationCont...
...LBBB, sinus rhythm, QRS duration ≥15...
...patients who have LVEF ≤35%, sin...
...who have LVEF ≤35%, sinus rhythm, a non-LBBB p...
...LVEF ≤35%, sinus rhythm, non-LBBB wit...
...-LBBB, QRS durati...
...n patients who have LVEF ≤35%, sinus rhythm,...
...th LVEF ≤35%, NYHA class II to IV s...
...ho have LVEF ≤35%, sinus rhythm, a...
...ith high-burden RVP...
...patients with a CIED with a decline in LV funct...
...with a CIED with a decline in LV function...
...vival...
...nts with a life expectancy of...
Indications for CPP in Atrial Fibrillation (AF)
...ns for CPP in Atrial Fibrillation (AF)...
CPP in...
...tients with AF undergoing atrioventricular j...
...with AF who otherwise meet CRT implantation e...
...tients with AF undergoing AVJ ablation,...
...nts undergoing AVJ ablation, it may be reaso...
...ents with a high burden of ventricular pacing...
Figure 4. CPP in Patients With AFColors c...
Pre-procedure Evaluation and Preparation
...cedure Evaluation and Preparation...
...igure 5. Pre-procedure Evaluation...
...e-procedure testin...
...atients being considered for implantation...
...tients planned to undergo implanta...
...patients indicated for CRT, use of an imaging...
...ents being considered for CRT, pre-proce...
...decision-making...
...ho may benefit from CPP, clinicians and...
Implant Procedure
Implant Proce...
...6. Implant ProcedureColors correspond to the Cl...
...ls and techniques for CRT with...
...rgoing CRT implant, a quadripolar LV lead is r...
...undergoing CRT implant, lead positioning...
...rgoing CRT implant, LV lead placement...
...patients undergoing CRT implant, t...
...techniques for CSP...
...atients undergoing CSP with HBP or LBBAP...
...nts undergoing CSP with HBP or LBBAP, accurat...
...nts undergoing CSP with HBP or LBBAP, as...
...e 7. Selective and Nonselective HBPA. During se...
...re 8. Bundle Branch Block Correction With HBPA...
...Bundle Branch Pacing in Narrow QRSR-wave peak...
.... LBBP in LBBLBBP with LBB capture and LBB pote...
Table 3. Criteria for His Bundle PacingHaving t...
...Criteria for Left Bundle Branch Area Pacinga...
...eft Ventricular Septal Pacing Deep s...
...or Left Bundle Branch Area Pacing Evidence f...
...onsider alternative CPP sites (intraproce...
...dergoing CRT with BiV pacing implantation via...
...rgoing CRT with BiV pacing implantation vi...
...e 5. Reasons for Abandonment and/or Cros...