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Cardiac Physiologic Pacing for the Avoidance and Mitigation of Heart Failure

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2 Top 10 Take-Home Messages 1. 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. 2. 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. 3. 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. 4. 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. 5. 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). 6. 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. 7. New recommendations for left bundle branch area pacing are made for patients with normal LVEF (class of recommendation [COR] 2b) needing a pacing device. Introduction

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