1. Committee for Practice Guidelines (CPG) 1Committee for Practice Guidelines (CPG) 1Guidelines for Cardiac Pacing and CRT Slide-SetGuidelines for Cardiac Pacing and CRT Slide-SetCardiac Pacing and CRT Guidelines Slide-set © European Society of CardiologyCardiac Pacing and CRT Guidelines Slide-set © European Society of Cardiology 11
Guidelines for Cardiac Pacing and
Cardiac Resynchronisation Therapy
The Task Force for Cardiac Pacing and
Cardiac Resynchronisation Therapy of the
European Society of Cardiology
Developed in collaboration with the
European Heart Rhythm Association

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Authors/Task Force Members
Angelo Auricchio (Switzerland)
Jean-Jacques Blanc (France)
Jean-Claude Daubert (France)
Helmut Drexler (Germany)
Hugo Ector (Belgium)
Maurizio Gasparini (Italy)
Cecilia Linde (Sweden)
Francisco Bello Morgado (Portugal)
Ali Oto (Turkey)
Richard Sutton (UK)
Maria Trusz-Gluza (Poland)
Chairperson: Panos E. Vardas (Greece)

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Introduction
• The guidelines for the appropriate use of pacemaker
devices presented in this document, a joint ESC and
EHRA initiative, aim to provide for the first time in
Europe an up to date specialists' view of the field.
• The guidelines cover two main areas: the first
includes permanent pacing in bradyarrhythmias,
syncope, and other specific conditions, while the
second refers to ventricular resynchronisation as an
adjunct therapy in patients with heart failure.

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Classes of Recommendations

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Levels of Evidence

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1. Pacing for Arrhythmias

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1.1. Sinus node disease
Recommendations for cardiac pacing in sinus node disease

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Pacemaker mode selection in sinus node disease

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1.2. Atrioventricular and intraventricular
conduction disturbances
Recommendations for cardiac pacing in acquired AV block

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1.2. Atrioventricular and intraventricular
conduction disturbances
Recommendations for cardiac pacing in chronic bi- and tri-fascicular block

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Pacemaker mode selection in acquired atrioventricular
block, chronic bifascicular and trifascicular block

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1.3. Recent myocardial infarction
Recommendations for permanent cardiac pacing in conduction
disturbances related to acute myocardial infarction

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1.4. Reflex syncope
The main causes of reflex syncope

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Recommendations for cardiac pacing
in carotid sinus syndrome

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Recommendations for cardiac pacing
in vasovagal syncope

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1.5. Paediatrics and congenital heart diseases
Recommendations for cardiac pacing in
paediatrics and congenital heart disease

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1.5. Paediatrics and congenital heart diseases
Recommendations for cardiac pacing in
paediatrics and congenital heart disease

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1.5. Paediatrics and congenital heart diseases
Recommendations for cardiac pacing in
paediatrics and congenital heart disease

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1.6. Cardiac transplantation
Recommendations for cardiac pacing
after cardiac transplantation

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2. Pacing for Specific Conditions

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2.1. Hypertrophic cardiomyopathy
Recommendations for cardiac pacing
in hypertrophic cardiomyopathy

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3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure
• State-of-the-art management of congestive heart failure (CHF), besides
alleviating symptoms, preventing major morbidity, and lowering mortality,
increasingly strives to prevent disease progression, in particularly the
transition between asymptomatic LV dysfunction and overt CHF.
• The clinical effects of long-term CRT were firstly evaluated in non-
controlled studies, in which a sustained benefit conferred by biventricular
pacing was measured. Randomized multi-centre trials with crossover or
parallel treatment assignments were subsequently conducted to ascertain
the clinical value of CRT in patients with advanced CHF and in sinus
rhythm, with or without indications for an implantable cardioverter-
defibrillator (ICD). Meta-analyses were also published.
• The usual study enrolment criteria were: 1) CHF in New York Heart
Association (NYHA) functional Class III or IV despite optimal
pharmacological treatment; 2) LV ejection fraction (EF) < 35%, LV end-
diastolic diameter > 55 mm, and QRS duration ≥ 120 or 150 ms.
Evidence-based clinical effects of CRT

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• Pacing for heart failure can be applied either by biventricular pacing or,
in selected cases, by left ventricular pacing alone. The following
recommendations consider cardiac pacing for heart failure delivered
through biventricular pacing, since this mode is supported by the
greatest body of evidence. This, however, does not preclude other
pacing modes, such as LV pacing, to correct ventricular dyssynchrony.
• Ventricular conduction delay continues to be defined according to QRS
duration (QRS ≥ 120 ms). It is recognised that ventricular conduction
delay may not result in mechanical dyssynchrony. Dyssynchrony is
defined as an uncoordinated regional contraction-relaxation pattern.
Although from the theoretical point of view it may be more appropriate to
target mechanical dyssynchrony, rather than electrical conduction delay,
no large controlled study has prospectively assessed the value of
mechanical dyssynchrony in heart failure patients undergoing pacing for
heart failure.
3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure
Recommendations

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3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure

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3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure

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3. Cardiac Resynchronisation Therapy (CRT)
in Patients with Heart Failure