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August 29, 2021
3 minutes to read
Source / Disclosures
Published by:
Glikson M, et al. ESC 2021 guidelines for cardiac pacing and cardiac resynchronization therapy. Presented at: Congress of the European Society of Cardiology; August 27-30, 2021 (virtual meeting).
Disclosures: Burri claims to have received institutional scholarship, research grants, and / or speaker fees from Abbott, Biotronik, Boston Scientific, Medtronic, and Microport. Leclercq reports interventions and advice for Abbott, Biotronik, Boston Scientific, Medtronic and Microport. Starck reports receiving research support from Abbott and Biotronik; consultancy for AngioDynamics, Biotronik, Boston Scientific, Cook Medical, Medtronic and Spectranetics; speaking for AngioDynamics and LivaNova; reimbursement of travel expenses for LivaNova and Medtronic; and an honorarium and scholarship from Cook Medical.
Features of the European Society of Cardiology’s new guideline on cardiac resynchronization therapy and stimulation include recommendations on CRT device selection, beam stimulation, and reduction of device-related complications.
The guideline, to which the European Heart Rhythm Association contributed, was also designed to be in harmony with the ESC HF guideline, which was not always the case in the past, task force members said at the time. a presentation at the ESC congress.
“Unfortunately, there were discrepancies between the two recommendations from the same scientific society and for the same indications,” he added. Christophe Leclercq, MD, PhD, FESC, FEHRA, professor and head of the cardiology department at the University of Rennes, France, and president of the EHRA, said during a presentation. “This year the guidelines on heart failure and pacing / CRT are being released simultaneously, and we had a strong desire for consistency.”
CRT-D vs CRT-P
The working group gave a recommendation of class I, level of evidence A for the implantation of a CRT defibrillator (CRT-D) in patients candidates for an implantable automatic defibrillator and with an indication for CRT, said Leclercq . The use of individual risk assessment and shared decision making should be used in the decision, he said.
The guideline also describes the considerations to be taken into account in deciding between a CRT-D and a CRT pacemaker (CRT-P) in patients with an indication for CRT. Leclercq noted that advanced age favors CRT-P and the presence of myocardial fibrosis on cardiac MRI favors CRT-D. Other factors that promote CRT-P include non-ischemic cardiomyopathy, short life expectancy, major comorbidities, poor kidney function, and patient preference, he said.
The guideline includes many new recommendations on stimulating its beam, on which much research has been carried out in recent years. The working group gave a class I recommendation for the use of device programming specifically adapted to stimulation of its beam in patients treated with it.
Pacing its bundle should be considered in patients who are candidates for CRT but have failed coronary sinus lead implantation, and some patients receiving patients from its bundle should be considered for a right ventricular lead as a backup for stimulation, Leclercq said.
Additionally, His bundle pacing may be considered instead of RV pacing in patients with atrioventricular block and left ventricular ejection fraction> 40% who are expected to require ventricular pacing> 20%. , according to the new guidelines.
The guideline states that leadless pacemakers should be considered as an alternative to transvenous pacemakers in patients without venous access to the upper limbs or at high risk of device bag infection, but may be considered in others. patients after shared decision-making that takes life expectancy into account. consideration, said Leclercq.
Minimize the risk of complications
Christoph Thomas Starck, MD, FEHRA, senior consultant cardiac surgeon at the German Heart Center in Berlin, said that “the goal of all recommendations is to minimize the risk of complications,” noting that complication rates are reportedly as high as 5% to 15%, and that 30-day death rates are reported. between 0.8% and 1.4%.
The guideline gives a Class I level of evidence A recommendation to administer preoperative antibiotic prophylaxis within 1 hour of skin incision to reduce the risk of device-related infections, and states that chlorhexidine alcohol should be used at the place of povidone-iodine alcohol, he said.
In patients undergoing reoperation for an implanted device, the use of an antibiotic wrap may be considered to reduce the risk of infection according to the results of the WRAP-IT trial, he said.
When implanting a pacemaker or defibrillator, heparin bypass surgery of patients on anticoagulants should no longer be performed, Starck said.
Pacemakers after TAVR
The guideline also includes an algorithm for the management of conduction abnormalities in patients after catheter aortic valve replacement, Haran Burri, MD, said the director of the Cardiac Stimulation Unit of the Cardiology Department of the University Hospitals of Geneva.
“Between 3% and 26% of patients with TAVI will have a pacemaker implanted, and this very wide range reflects the heterogeneity of indications between different centers,” he said. “It is important to have a more homogeneous approach.
Patients with persistent high-degree atrioventricular block and newly-onset alternate bundle branch block should receive a permanent pacemaker, while patients with pre-existing right bundle branch block with new limb disturbance. conduction after the procedure should be considered for one, he said.
Reference:
European Society of Cardiology
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