CRT devices, His bundle pacing, reducing complications focus of new ESC pacing guideline
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Among the features of the new European Society of Cardiology guideline on pacing and cardiac resynchronization therapy are recommendations on CRT device selection, His bundle pacing and reduction of device-related complications.
The guideline, to which the European Heart Rhythm Association contributed, was also designed to be harmonious with the ESC HF guideline, which was not always the case in the past, task force members said during a presentation at the ESC Congress.
“Unfortunately, there were some discrepancies between the two guidelines from the same scientific society and for the same indications,” Christophe Leclercq, MD, PhD, FESC, FEHRA, professor and head of the department of cardiology at the University of Rennes, France, and EHRA president, said during a presentation. “This year, the heart failure and pacing/CRT guidelines are published simultaneously, and we had a strong willingness for consistency.”
CRT-D vs. CRT-P
The task force gave a class I, level of evidence A recommendation to implantation of a CRT defibrillator (CRT-D) in patients who are candidates for an implantable cardioverter defibrillator and have an indication for CRT, Leclercq said. Use of individual risk assessment and shared-decision making should be employed in the decision, he said.
The guideline also outlines considerations for deciding between CRT-D and a CRT pacemaker (CRT-P) in patients with an indication for CRT. Leclercq noted that advanced age favors CRT-P and presence of myocardial fibrosis on cardiac MRI favors CRT-D. Other factors that favor CRT-P include nonischemic cardiomyopathy, short life expectancy, major comorbidities, poor renal function and patient preference, he said.
The guideline includes many new recommendations on His bundle pacing, about which much research has been conducted in recent years. The task force gave a class I recommendation to employing device programming specifically tailored to His bundle pacing in patients treated with it.
His bundle pacing should be considered in patients who are candidates for CRT but had an unsuccessful coronary sinus lead implantation, and certain patients receiving His bundle patients should be considered for a right ventricular lead as a backup for pacing, Leclercq said.
In addition, His bundle pacing may be considered in place of RV pacing in patients with atrioventricular block and left ventricular ejection fraction > 40% who are expected to need > 20% ventricular pacing, according to the new guidance.
The guideline states that leadless pacemakers should be considered as an alternative to transvenous pacemakers in patients with no upper-extremity venous access or with high risk for device pocket infection, but may be considered in other patients after shared decision-making that takes life expectancy into consideration, Leclercq said.
Minimizing complication risk
Christoph Thomas Starck, MD, FEHRA, professor and senior consultant cardiac surgeon at the German Heart Center, Berlin, said “the focus of all recommendations is minimizing complication risk,” noting that complication rates are reported to be as high as 5% to 15%, and 30-day mortality rates are reported to range from 0.8% to 1.4%.
The guideline gives a class I, level of evidence A recommendation to administering preoperative antibiotic prophylaxis within 1 hour of skin incision to reduce risk for device-related infections, and states chlorhexidine alcohol should be used instead of povidone-iodine alcohol, he said.
In patients undergoing a reintervention for an implanted device, use of an antibiotic-eluting envelope may be considered to reduce infection risk in accordance with results from the WRAP-IT trial, he said.
When implanting a pacemaker or defibrillator, heparin bridging of anticoagulated patients should no longer be performed, Starck said.
Pacemakers after TAVR
The guideline also includes an algorithm for managing conduction abnormalities in patients after transcatheter aortic valve replacement, Haran Burri, MD, director of the Cardiac Pacing Unit in the cardiology department at the University Hospital of Geneva, said.
“Between 3% and 26% of patients who have TAVI will be implanted with a pacemaker, and this very wide range reflects the heterogeneity of indications across different centers,” he said. “It is important to have a more homogenous approach.”
Patients with persistent high-degree atrioventricular block and new-onset alternating bundle branch block should receive a permanent pacemaker, while patients with preexisting right bundle branch block with a new conduction disturbance after the procedure should be considered for one, he said.
Reference:
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Glikson M, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Presented at: European Society of Cardiology Congress; Aug. 27-30, 2021 (virtual meeting).
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