Cardiac Physiologic Pacing for the Avoidance and Mitigation of Heart Failure
Publication Date: May 19, 2023
Last Updated: May 22, 2023
Epidemiology, Pathophysiology, and Detection of Electrical Dyssynchrony-induced Cardiomyopathy
Detection of electrical dyssynchrony-induced cardiomyopathy
In patients who have substantial RVP that cannot be minimized with programming, periodic assessment of ventricular function is recommended to detect PICM. (I, B-NR)
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In patients with chronic LBBB, periodic assessment of ventricular function is reasonable to detect cardiomyopathy. (IIa, B-NR)
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Indications for CPP in Patients with Indications for Pacemaker Therapy
Substantial ventricular pacing
In patients with an indication for permanent pacing with an LVEF 36%–50% who are anticipated to require substantial ventricular pacing, CPP is reasonable to reduce the risk of PICM. (IIa, B-NR)
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In patients with normal LVEF who are anticipated to require substantial ventricular pacing, it may be reasonable to treat patients with CPP to reduce the risk of PICM. (IIb, B-NR)
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In patients who are ventricular pacing-dependent undergoing HBP pacemaker implantation, placement of an additional backup lead may be reasonable to mitigate the risk of high pacing capture thresholds, lead dislodgment, loss of capture, or oversensing. (IIb, C-LD)
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Less than substantial ventricular pacing
In patients with an indication for permanent pacing with LVEF >35% who are anticipated to require less than substantial ventricular pacing, it is reasonable to choose traditional RV lead placement and minimize RVP. (IIa, B-R)
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In patients with an indication for permanent pacing with LVEF 36%–50% who are anticipated to require less than substantial ventricular pacing, a CSP lead with HBP or LBBAP may be considered as an alternative to an RVP lead. (IIb, C-LD)
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In patients with an indication for permanent pacing, LVEF 36%–50% and LBBB, and who are anticipated to require less than substantial ventricular pacing, CPP may be considered to potentially improve symptoms and LVEF. (IIb, C-LD)
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In patients who are undergoing permanent pacing with normal LVEF and are anticipated to require less than substantial ventricular pacing, an LBBAP lead may be considered as an alternative to an RVP lead. (IIb, C-LD)
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In patients with normal LVEF who are anticipated to require less than substantial ventricular pacing, CRT with BiV pacing is not indicated. (III - No Benefit, B-R)
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At time of surgery
In patients undergoing cardiac surgery who will likely require future CRT, intraoperative placement of a permanent epicardial LV lead can be useful. (IIa, B-R)
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In patients undergoing cardiac surgery who will likely require substantial ventricular pacing, intraoperative placement of a permanent epicardial LV lead may be considered to potentially reduce the risk of PICM. (IIb, C-EO)
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Indications for CPP in Patients with HF
LBBB, sinus rhythm, QRS duration ≥150 ms, NYHA class I–IV symptoms
In patients with LVEF ≤35%, sinus rhythm, LBBB with QRS duration ≥150 ms, and NYHA class II–IV symptoms on GDMT, CRT with BiV pacing is indicated to improve symptoms and reduce morbidity and mortality. (I, A)
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In patients with LVEF ≤35%, sinus rhythm, LBBB with QRS duration ≥150 ms, and NYHA class II–IV symptoms on GDMT, CSP with HBP with left bundle branch (LBBB) correction or LBBAP is reasonable if effective CRT cannot be achieved with BiV pacing based on anatomical or functional criteria. (IIa, C-LD)
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In patients with LVEF ≤30%, sinus rhythm, LBBB, QRS duration ≥150 ms and NYHA class I symptoms on GDMT, CRT with BiV pacing may be considered to reduce the risk of worsening HF and potentially improve LV remodeling. (IIb, B-R)
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In patients with LVEF 36%–50%, sinus rhythm, LBBB with QRS duration ≥150 ms, and NYHA class II–IV symptoms on GDMT, CPP may be considered to maintain or improve LVEF. (IIb, C-LD)
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In patients with LVEF ≤35%, sinus rhythm, LBBB with QRS duration ≥150 ms, and NYHA class II–IV symptoms on GDMT, CSP with HBP or LBBAP may be considered as an alternative to CRT with BiV pacing. (IIb, C-LD)
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LBBB, sinus rhythm, QRS duration 120–149 ms, NYHA class II–IV symptoms
In patients with select characteristics (eg, female sex) who have LVEF ≤35%, sinus rhythm, LBBB with QRS duration 120–149 ms, and NYHA class II–IV symptoms on GDMT, CRT with BiV pacing is recommended to reduce mortality and HF events and to improve LVEF. (I, A)
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In patients who have LVEF ≤35%, sinus rhythm, LBBB with QRS duration 120–149 ms, and NYHA class II–IV symptoms on GDMT, CRT with BiV pacing is reasonable to reduce mortality and HF and to improve LVEF. (IIa, B-R)
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Non-LBBB, sinus rhythm, QRS duration ≥150 ms, NYHA class II–IV symptoms
In patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS duration ≥150 ms, and NYHA class III or ambulatory class IV symptoms on GDMT, CRT with BiV pacing can be useful to improve functional class, cardiac structure, and LVEF. (IIa, A)
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In patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS duration ≥150 ms, and NYHA class II symptoms on GDMT, CPP may be considered to potentially improve mortality, heart failure hospitalization (HFH), LVEF, and/or functional class. (IIb, C-LD)
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In patients with LVEF ≤35%, sinus rhythm, non-LBBB with QRS duration ≥150 ms, and NYHA class II–IV symptoms on GDMT, CSP with HBP or LBBAP may be reasonable if effective CRT cannot be achieved with BiV pacing based on anatomical or functional criteria. (IIb, C-LD)
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Non-LBBB, QRS duration <150 ms, NYHA class I–IV symptoms
In patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with QRS duration 120–149 ms, and NYHA class III or IV symptoms on GDMT, the usefulness of CPP is not well established. (IIb, C-LD)
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In patients with LVEF ≤35%, NYHA class II to IV symptoms on GDMT, and QRS duration <120 ms, CRT with BiV pacing is not recommended. (III - No Benefit, B-R)
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In patients who have LVEF ≤35%, sinus rhythm, a non-LBBB pattern with a QRS duration <150 ms, and NYHA class I or II symptoms on GDMT, CRT with BiV pacing is not recommended. (III - No Benefit, B-R)
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PICM with high-burden RVP
In patients with a CIED with a decline in LV function or worsening of HF symptoms attributed to substantial ventricular pacing, CRT with BiV pacing is recommended to improve LV function and improve HF symptoms. (I, B-NR)
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In patients with a CIED with a decline in LV function or worsening of HF symptoms attributed to substantial ventricular pacing, revision of CIED to a CSP device can be beneficial to improve LV function and symptoms of HF. (IIa, B-NR)
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Survival <1 year
In patients with a life expectancy of <1 year, the decision to implant CPP should incorporate shared decision-making, taking into account the potential improvement in quality of life balanced against the risk of procedural complications. (I, C-EO)
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Indications for CPP in Atrial Fibrillation (AF)
CPP in AF
In patients with AF undergoing atrioventricular junction (AVJ) ablation with LVEF ≤50%, CRT with BiV pacing is reasonable to improve HFH, reverse structural remodeling, and improve quality of life, exercise capacity, LVEF, and potentially mortality. (IIa, B-R)
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In patients with AF who otherwise meet CRT implantation eligibility criteria, CRT with BiV pacing can be beneficial to improve quality of life, functional capacity, and LVEF. (IIa, B-NR)
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In patients with AF undergoing AVJ ablation, HBP with or without a backup ventricular pacing lead may be reasonable to improve or preserve LVEF and improve functional class. (IIb, C-LD)
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In patients undergoing AVJ ablation, it may be reasonable to implant an LBBAP lead. (IIb, C-LD)
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In patients with a high burden of ventricular pacing, HBP or LBBAP may be reasonable to decrease the risk of AF. (IIb, C-LD)
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Pre-procedure Evaluation and Preparation
Pre-procedure testing
In patients being considered for implantation of a CPP device, a 12-lead ECG is recommended to evaluate the heart rhythm, heart rate, AV conduction, and QRS duration and morphology to determine the appropriate type of CPP. (I, A)
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In patients planned to undergo implantation of a CPP device, pre-procedural echocardiographic screening for LVEF is recommended. (I, A)
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In patients indicated for CRT, use of an imaging modality (eg, echocardiogram, cardiac MRI or CT) may be considered to target LV lead placement. (IIb, B-R)
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In patients being considered for CRT, pre-procedural echocardiographic assessment of ventricular dyssynchrony is not useful to predict outcomes from CRT with BiV pacing. (III - No Benefit, A)
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Shared decision-making
In patients who may benefit from CPP, clinicians and patients should engage in a shared decision-making approach in which (1) information is shared on the evidence base for different types of CPP and (2) treatment decisions are based not only on the best available evidence but also on the patient’s goals of care, preferences, and values. (I, C-EO)
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Implant Procedure
Tools and techniques for CRT with BiV pacing
In patients undergoing CRT implant, a quadripolar LV lead is recommended to assist with lead stability, lower capture thresholds, avoid phrenic nerve pacing, and decrease need for lead repositioning. (I, B-R)
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In patients undergoing CRT implant, lead positioning and programming the device to deliver the narrowest QRS duration can be beneficial in improving LV structure and function. (IIa, B-NR)
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In patients undergoing CRT implant, LV lead placement to allow for pacing from a nonapical position is reasonable to improve CRT clinical and structural response. (IIa, C-LD)
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In patients undergoing CRT implant, targeting lead placement at sites of late ventricular activation may be considered to improve CRT response. (IIb, C-LD)
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Tools and techniques for CSP
In patients undergoing CSP with HBP or LBBAP, 12-lead ECG is useful during implantation to assess conduction system capture most accurately. (I, C-EO)
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In patients undergoing CSP with HBP or LBBAP, accurate demonstration of conduction system capture thresholds (including bundle branch block [BBB] correction) and myocardial capture thresholds at implant is useful for appropriate programming of the device. (I, C-EO)
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In patients undergoing CSP with HBP or LBBAP, assessment of His bundle/left bundle current of injury using appropriate filter settings can be beneficial in achieving acceptable capture thresholds and lead stability. (IIa, C-LD)
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When to consider alternative CPP sites (intraprocedural crossovers)
In patients undergoing CRT with BiV pacing implantation via the CS, crossover to CSP with HBP or LBBAP is reasonable when the CS LV lead placement is unsuccessful or suboptimal. (IIa, C-LD)
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In patients undergoing CRT with BiV pacing implantation via the CS, crossover to surgical epicardial CRT with BiV pacing might be reasonable when the initial approach is unsuccessful or suboptimal. (IIb, C-LD)
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CPP Follow-up and Management
Follow-up evaluations
After implantation of a CPP device in patients with heart failure with reduced ejection fraction (HFrEF), a follow-up echocardiogram within 3–12 months is useful to determine reverse remodeling and the likelihood of improved survival and reduction in HFH. (I, B-NR)
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In patients with CPP, remote monitoring is beneficial for device and arrhythmia management. (I, B-NR)
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In patients with CPP and HF,
multidisciplinary management with HF (IIa, B-NR)
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device clinics for adjustment of medications and device programming can be useful to improve clinical outcomes. (IIa, C-EO)
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In patients with CRT and HFimpEF, continuation of GDMT is reasonable to reduce the risk of HF relapse and arrhythmias and treat hypertension. (IIa, C-LD)
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In patients with CRT and HFrEF, routine use of thoracic impedance alone to manage congestive HF is not recommended. (III - No Benefit, B-R)
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Optimization of CPP response
In patients with CRT, a 12-lead ECG is useful to confirm LV lead capture and facilitate optimization of LV pacing configurations. (I, C-EO)
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During in-office follow-up of patients with CSP, a multi-lead or 12-lead ECG is recommended to assess conduction system capture, including BBB correction. (I, B-NR)
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During in-office follow-up of patients with CSP, a comprehensive assessment that includes documentation of His/left bundle capture, BBB correction, and myocardial capture thresholds can be useful. (IIa, B-NR)
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In patients with HBP who have an increase in threshold of >1 V, more frequent in-office follow-up can be beneficial to determine the need for lead revision, especially in ventricular pacing-dependent patients. (IIa, C-EO)
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Replacement or upgrade considerations
In patients with HFimpEF, continuation of CRT with BiV pacing is recommended at the time of elective generator replacement. (I, C-LD)
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In patients who are thought to have benefited from CRT (including improvement, stabilization, or partial reversal of natural decline) in terms of symptoms, LVEF, or functional status, continuation of CRT with BiV pacing is recommended at the time of elective replacement based on patient-individualized risks and benefits of the procedure. (I, C-EO)
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In patients with CRT-D at the time of elective replacement, it is recommended that a decision for replacement vs revision to CRT-P should be based on patient-individualized risks and benefits of the procedure, and such shared decision-making should involve consideration of the previous response to CRT, appropriate implantable cardioverter-defibrillator (ICD) therapies for ventricular arrhythmias, continued risk of ventricular arrhythmias, inappropriate therapies, current lead performance factors, and the patient’s overall goals of care. (I, B-NR)
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In patients with CRT or CSP where high lead pacing threshold contributes to rapid battery drain, implantation of a new lead may be considered after shared decision-making with the patient at the time of generator replacement to reduce the risk associated with frequent generator replacements. (IIb, C-EO)
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Troubleshooting for unfavorable response
In patients with HFrEF with an unfavorable response to CRT with BiV pacing, continued efforts to optimize medical and device therapies are recommended to improve quality of life and long-term outcomes. (I, C-LD)
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In patients with an unfavorable response to CRT with BiV pacing, obtaining a posteroanterior and lateral chest X-ray is recommended to assess the LV lead position. (I, C-LD)
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In patients with an unfavorable response to CRT with BiV pacing and who have less than optimal LV pacing percentage, ablation or pharmacological suppression of frequent PVCs or better rhythm or rate control of AF is reasonable to improve cardiac function and patient symptoms. (IIa, C-LD)
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When to crossover to CSP, CRT, or epicardial options
In patients with suboptimal response to CRT with BiV pacing,
CSP with HBP or LBBAP can be useful when other approaches have been unsuccessful or not feasible. (IIa, C-LD)
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surgical epicardial lead implantation can be useful when other approaches have been unsuccessful or not feasible. (IIa, B-NR)
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Congenital Heart Disease
CHD
In patients with CHD on GDMT with a systemic LV, LVEF <45%, and ventricular dyssynchrony (as defined by a QRS duration z score of ≥3 or ventricular pacing ≥40%), CRT with BiV pacing is reasonable to reduce the risk of mortality or need for transplant. (IIa, C-LD)
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In patients with CHD and a systemic single ventricle who require pacing, apical pacing is reasonable in preference to nonapical pacing. (IIa, C-LD)
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In patients with CHD and a systemic single ventricle with symptomatic HF on GDMT, CRT with multisite ventricular pacing may be considered to maintain functional class or ventricular function. (IIb, C-LD)
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In patients with CHD and a systemic RV with symptomatic HF on GDMT associated with ventricular electrical delay or requiring substantial ventricular pacing, CRT with BiV pacing may be considered to improve or maintain functional class or ventricular function. (IIb, C-LD)
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In patients with CHD and a subpulmonary RV with RV dysfunction and RBBB, CRT with fusion-based pacing may be considered to improve RV function. (IIb, C-LD)
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In patients with congenitally corrected transposition of the great arteries (CCTGA) and AV block in whom anatomic repair has not been performed, CSP with HBP or LBBAP may be considered to improve functional status. (IIb, C-LD)
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CCP in Pediatric Populations without Congenital Heart Disease
CPP in pediatric patients with HF
In pediatric patients with complete AV block, pre-existing ventricular pacing, and symptomatic clinical HF on GDMT, CRT with BiV pacing is reasonable. (IIa, C-LD)
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In pediatric patients with complete AV block and evidence of clinical HF on GDMT, CPP may be considered. (IIb, C-LD)
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Pediatric patients with indications for pacemaker therapy
In pediatric patients undergoing pacemaker implantation for AV block, it is reasonable to either target an RV mid-septal, inflow, or outflow tract transvenous endocardial site, or use apical LV (systemic ventricle) epicardial pacing, in preference to RV apical endocardial or epicardial pacing sites. (IIa, C-LD)
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Recommendation Grading
Disclaimer
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.
Overview
Title
Cardiac Physiologic Pacing for the Avoidance and Mitigation of Heart Failure
Authoring Organization
Heart Rhythm Society
Publication Month/Year
May 19, 2023
Last Updated Month/Year
October 3, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
The purpose of this guideline is to evaluate these new advances with the goal of creating recommendations to guide electrophysiology practice in the use of CPP in patients with pacing or HF indications.
Target Patient Population
Patients who have or are at risk of heart failure (HF) also being considered for or undergoing a cardiac physiologic pacing (CPP) implantation procedure.
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D001281 - Atrial Fibrillation, D006333 - Heart Failure, D058998 - Remote Sensing Technology
Keywords
atrial fibrillation, heart failure, cardiac resynchronization therapy, congenital heart disease, CRT, remote monitoring, Cardiac physiologic pacing (CPP), His bundle pacing [HBP], left bundle branch area pacing [LBBAP], BiV pacing, electrical dyssynchrony-induced cardiomyopathy, Left ventricular septal pacing, Left bundle branch area pacing, Pacemaker Interrogation
Source Citation
Chung MK, Patton KK, Lau C-P, Dal Forno AR, Al-Khatib SM, Arora V, Birgersdotter-Green UM, Cha Y-M, Chung EH, Cronin EM, Curtis AB, Cygankiewicz I, Dandamudi G, Dubin AM, Ensch DP, Glotzer TV, Gold MR, Goldberger ZD, Gopinathannair R, Gorodeski EZ, Gutierrez A, Guzman JC, Huang W, Kron J, Kutyifa V, Link MS, Marine JE, Mullens W, Park S-J, Parkash R, Patete MF, Pathak RK, Perona CA, Rickard J, Schoenfeld MH, Seow S-C, Shen W-K, Shoda M, Singh JP, Slotwiner DJ, Sridhar AR, Srivatsa UN, Stecker EC, Tanawuttiwat T, Tang WH, Tapias CA, Tracy CM, Upadhyay GA, Varma N, Vernooy K, Vijayaraman P, Worsnick SA, Zareba W, Zeitler EP, 2023 HRS/APHRS/LAHRS Guideline on Cardiac Physiologic Pacing for the Avoidance and Mitigation of Heart Failure. HeartRhythm 2023.
This guideline has been copublished in the Journal of Arrhythmia.