The ‘10 commandments’ for the 2021 ESC guidelines on cardiac pacing and cardiac resynchronization therapy

The guidelines on cardiac pacing and cardiac resynchronization therapy provide an updated overview on indications for pacing, peri-operative management, and postoperative follow-up. A special emphasis is given to patient-centred care and shared decision-making. The following 10 commandments summarize main points. 1. Initial evaluation includes history taking, physical examination, laboratory testing, electrocardiogram (ECG), and cardiac imaging. Additional testing may be required in individual cases. 2. Correlating symptoms and bradycardia is important in sinus node dysfunction, while significant infranodal disease should prompt permanent pacemaker implantation regardless of symptoms. In patients with bifascicular block and syncope, pacing is based on electrophysiological study/implantable loop recorder (EPS/ILR) results or is empiric in selected patients. 3. Pacing for reflex syncope should be considered in patients >40 years with severe, recurrent, unpredictable syncope and asystolic pauses documented spontaneously or accompanied by symptoms during carotid sinus massage (CSM) or tilt test. 4. (Cardiac resynchronization therapy CRT) is recommended to patients with heart failure (HF) in sinus rhythm (SR) with left ventricular ejection fraction (LVEF) ≤35%, QRS duration ≥150 ms, and left bundle branch block (LBBB) QRS morphology despite OMT. With narrower QRS of 130–149 ms and non-LBBB morphology, the recommendation is weaker. 5. Patients with LVEF <40% and anticipated right ventricular (RV) pacing >20% or patients undergoing atrioventricular junction (AVJ) ablation with LVEF <50% should receive CRT. 6. His pacing should be considered in CRT candidates with unsuccessful coronary sinus (CS) lead and may be considered after ‘pace and ablate’ or as an alternative to RV pacing if LVEF >40%. A back-up RV lead should be considered in high-risk patients. 7. Leadless pacing should be considered in patients without upper venous access or in high risk of pocket infections. 8. Pacing after TAVI and cardiac surgery: Immediate epicardial lead should be considered in tricuspid valve (TV) surgery and in selected patients undergoing surgery for endocarditis. In patients with a biological TV replacement or repair, a CS or epicardial lead should be considered. After TAVI, pacing is recommended if AVB persists >24–48 h and should be considered in patients with further conduction disturbance and pre-existing RBBB. Long-term ambulatory ECG monitoring or EPS should be considered in selected patients. 9. Recommendations of ‘to do’ and ‘not to do’ regarding implantation practice and perioperative management should be followed. 10. During follow-up: Magnetic resonance imaging and radiation therapy can be performed safely following appropriate programming and follow-up. Remote monitoring is recommended in patients who have difficulties attending in-office visits or have a recalled device component, and should be considered for early detection of problems. Conflict of interest: Dr Michowitz reports consulting fee from EPD-Philips and honorary for lectures from Biosense-Webster outside this work; Dr Kronborg reports honorary for lectures from Bayer and Biotronik outside this work; Dr Glikson reports institutional grant from EPD and Biotronik and fee for advisory board from Boston Scientific and Medtronic outside this work; Dr Nielsen reports research grants from Novo Nordisk Foundation outside this work.