2021 ESC Guidelines on Cardiac Pacing and Cardiac Resynchronisation Therapy

A plethora of new evidence has accumulated since the publication of the previous ESC pacing guidelines in 2013. The 2021 Guidelines on cardiac pacing and cardiac resynchronisation therapy include a few novel sections, such as evaluating patients before pacing, physiologic pacing, implantation, and perioperative management.

In his talk on general indications for pacing, Prof. Jean-Claude Deharo (Hospital La Timone of Marseille, France) introduced the new section included in the 2021 Guidelines on the evaluation of the patient with suspected or documented bradycardia, or conduction system disease, including novel diagnostic tools and what tests to perform in specific situations [1,2]. A simple but systematic approach is recommended, consisting of history, physical examination, ECG, and cardiac imaging. The next tests depend on the result of this evaluation:

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  • in patients with bradycardia or cardiac conduction disorders that occur during sleep, polysomnography/sleep study is recommended (class 1);
  • in patients with early onset of progressive cardiac conduction disease (<50 years) or a family history of inherited cardiac conduction disorder, genetic testing is recommended (class 2a);
  • in patients with clinical suspicion of potential causes of bradycardia, further laboratory tests should be performed (class 1);
  • in patients with suspected structural heart disease, scars or cardiomyopathy, further imaging (i.e. cardiac magnetic resonance, computed tomography, or positron emission tomography) is advised (class 2a);
  • in patients with unexplained syncope and bifascicular block, electrophysiologic study (EPS) or exercise testing (ET) for an exertion-induced block should be considered (class 2a); an empirical pacemaker is recommended in elderly and frail patients;
  • 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 (class 2b).
  • in patients with suspected or recurrent reflex syncope, carotid sinus massage is recommended (class 1); and tilt table should be considered for patients with recurrent reflex syncope (class 2a) finally,
  • in patients with exercise-induced symptoms, ET is recommended.

“If you do not have a diagnosis after following this scheme, long-term ambulatory electrocardiographic monitoring is recommended dependent on frequency of symptoms,” Prof. Deharo elaborated.

 

There are also a few new recommendations for cardiac pacing in patients with bradycardia and conduction system disease (all class 1):

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  • Pacing is indicated in symptomatic patients with the bradycardia-tachycardia form of sinus node dysfunction (SND) to correct bradyarrhythmias and enable pharmacological treatment unless ablation of the tachyarrhythmia is preferred.
  • Pacing is indicated in patients with atrial arrhythmia (mainly AF) and permanent or paroxysmal third- or high-degree atrioventricular block (AVB) irrespective of symptoms.
  • In patients with SND and dual-chamber pacemakers, it is recommended to minimise unnecessary ventricular pacing through programming.

Physiologic pacing is a whole new section in the guidelines, with growing evidence on His corrective pacing.

Prof. Christophe Leclercq (University Hospital of Rennes, Hospital Pontchaillou, Rennes, France) pointed out that several indications for cardiac resynchronisation therapy (CRT) in heart failure have been modified in agreement with the ESC Heart Failure Guidelines task force [3]:

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  • For example, in candidates for implantable cardioverter defibrillator (ICD) who have a CRT indication, implantation of a defibrillator with cardiac resynchronisation therapy (CRT-D) is recommended (class 1).
  • However, patients with a CRT indication can either receive a CRT-D or a CRT-pacemaker (CRT-P). Factors in favour of choosing CRT-P include age, short life expectancy, and major comorbidities.

Prof. Haran Burri (University Hospital of Geneva, Switzerland) covered the 2021 recommendations on the management of patients with pacemakers in specific conditions, namely after acute myocardial infarction (AMI), cardiac surgery, and transcatheter aortic valve implantation (TAVI) [4]. Implantation of a permanent pacemaker after an AMI is indicated with the same recommendations as in the general population when atrioventricular block does not resolve within a waiting period of at least 5 days after AMI. Most often, atrioventricular block resolves spontaneously within a few days and only a minority of patients require permanent pacing after AMI. “This is why we should wait for at least 5 days before we consider pacing,” Prof. Burri explained. The recommended waiting time before permanent pacemaker implantation in case of SND after cardiac surgery or heart transplantation is 6 weeks.

In the past few years, a lot of new data has become available on TAVI. The 2021 Guidelines make a class I recommendation for permanent pacing in patients with complete or high-degree atrioventricular block persisting for 24 to 48 hours after TAVI and those with new-onset alternating bundle branch block.

In contrast, ambulatory ECG monitoring or electrophysiologic study is recommended for patients with new post-TAVI left bundle branch block with a QRS over 150 ms or PR interval over 240 ms with no further prolongation during more than 48 hours post-procedure (class 2). The same recommendations are given for patients after TAVI with pre-existing conduction abnormalities with prolongation of QRS (>20 ms) or PR (>20 ms). There are many predictors given in the guidelines for permanent pacing after TAVI. Compared with the 2013 guidelines, more pacemaker patients can now undergo MRI.

Prof. Christoph Starck (German Heart Center Berlin, Germany) focused his talk on the novel guideline sections implantation, perioperative management, and long-term management [5]. Although mortality is low after the implantation of a pacemaker and cardiac resynchronisation therapy, any complications are as high as 5–15%. The most frequent complications are infections. Thus, administration of preoperative antibiotic prophylaxis within 1 hour of skin incision is recommended to reduce the risk of cardiovascular implantable electronic device (CIED) infections (class 1).

Numerous pragmatic recommendations are given on how to reduce complications. For example, the pacemaker device is placed in a pocket created under the skin, and the new guidelines state that rinsing the device pocket with saline before wound closure should be considered. Use of antibiotic-eluting envelopes is recommended in patients undergoing a re-intervention CIED procedure (class 2). Chlorhexidine alcohol should be considered over povidone-iodine alcohol (class 2a) Permanent pacemaker implantation should not be done in patients with a fever but should be delayed until the fever has been absent for at least 24 hours to reduce the risk of later device infection.

Follow-up for routine pacemaker and cardiac resynchronisation therapy, either in person alone or combined with remote device management is crucial: “Focus of all recommendations is minimising complication risk,” Prof. Starck concluded.

 

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   1. Glikson M, et al. Eur Heart J 2021;42(35):3427­–3520.
   2. Deharo JC. Evaluation and general indications for pacing. Session: 2021 ESC Guidelines on cardiac pacing and cardiac resynchronisation therapy, ESC Congress 2021, 27–30 August.
   3. Leclercq C. CRT, conduction system and alternative site pacing. Session: 2021 ESC Guidelines on cardiac pacing and cardiac resynchronisation therapy, ESC Congress 2021, 27–30 August.
   4. Burri H. Pacing in specific conditions. Session: 2021 ESC Guidelines on cardiac pacing and cardiac resynchronisation therapy, ESC Congress 2021, 27–30 August.
   5. Starck Ch. Implantation, complications, perioperative and long-term management. Session: 2021 ESC Guidelines on cardiac pacing and cardiac resynchronisation therapy, ESC Congress 2021, 27–30 August.

 

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Posted on 26 October 202126 October 2021