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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
