2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure

Abstract

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

Keywords: Cardiac resynchronization therapy; Conduction system pacing; Guideline; His bundle pacing; Left bundle branch area pacing.

Figure 1

Algorithm for pacing strategies in patients undergoing pacemaker implantation for bradycardia indications. Colors correspond to the class of recommendation in Table 1. BiV = biventricular; CRT = cardiac resynchronization therapy; HBP = His bundle pacing; LBBAP = left bundle branch area pacing; LBBB = left bundle branch block; LV = left ventricle/ventricular; LVEF = left ventricular ejection fraction; RV = right ventricle/ventricular; RVP = right ventricular pacing.

Figure 2

Algorithm for pacing strategies in patients without bradycardia indications who have HF. Colors correspond to the class of recommendation in Table 1. BiV = biventricular; CIED = cardiovascular implantable electrical device; CRT = cardiac resynchronization therapy; HBP = His bundle pacing; HF = heart failure; LBBAP = left bundle branch area pacing; LBBB = left bundle branch block; LVEF = left ventricular ejection fraction; NYHA = New York Heart Association; PICM = pacing-induced cardiomyopathy; QRSd = QRS duration; RVP = right ventricular pacing.

Figure 3

Cardiac resynchronization therapy hazard ratio by height and QRS duration. Contour lines depict the cardiac resynchronization therapy hazard ratio for different combinations of height (y-axis) and QRS duration (x-axis). The lighter blue color corresponds to greater cardiac resynchronization therapy benefit (ie, lower hazard ratio). Reprinted with permission from Linde et al.

Figure 4

Algorithm for cardiac physiologic pacing in patients with atrial fibrillation. Colors correspond to the class of recommendation in Table 1. AF = atrial fibrillation; AVJ = atrioventricular junction; BiV = biventricular; CRT = cardiac resynchronization therapy; HBP = His bundle pacing; LBBAP = left bundle branch area pacing; LVEF = left ventricular ejection fraction.

Figure 5

Preprocedure evaluation and preparation. Colors correspond to the class of recommendation in Table 1. AV = atrioventricular; BiV = biventricular; cMRI = cardiac magnetic resonance imaging; CPP = cardiac physiologic pacing; CRT = cardiac resynchronization therapy; CSP = conduction system pacing; CT = computerized tomography; ECG = electrocardiogram; Echo = echocardiogram; HF = heart failure; LV = left ventricle/ventricular; LVEF = left ventricular ejection fraction.

Figure 6

Implant procedure. Colors correspond to the class of recommendation in Table 1. BiV = biventricular; CPP = cardiac physiologic pacing; CRT = cardiac resynchronization therapy; CS = coronary sinus; CSP = conduction system pacing; ECG = electrocardiogram; HBP = His bundle pacing; LBBAP = left bundle branch area pacing; LV = left ventricle/ventricular.

Figure 7

Selective and nonselective His bundle pacing. A: During selective His bundle pacing (HBP), paced QRS duration and morphology are identical to baseline. His-V₆ R-wave peak time (RWPT) is the same as stimulus to V₆ RWPT. B: Transition from nonselective (ns) HBP to right ventricular (RV) myocardial pacing is shown. Pseudodelta waves are seen during ns His capture. During RV myocardial–only capture, slur/notch is seen in 1, L, and V₄–V₆; stimulus to V₆ RWPT is 105 ms; and stimulus to V₆ RWPT is 80 ms during ns HBP, which is the same as His-V₆ RWPT. Adapted with permission from Vijayaraman et al. aVF = augmented vector foot; aVL = augmented vector left; aVR = augmented vector right; HBP = His bundle pacing; ns = nonselective.

Figure 8

Bundle branch block correction with His bundle pacing. A: Selective His bundle pacing (HBP) with left bundle branch block (LBBB) correction is shown. B: Nonselective HBP with right bundle branch block (RBBB) correction is shown. Note the output-dependent transition from nonselective correction of RBBB to nonselective HBP without RBBB correction to right ventricular myocardial–only capture. Adapted with permission from Vijayaraman et al. aVF = augmented vector foot; aVL = augmented vector left; aVR = augmented vector right; HBP = His bundle pacing; LBBB = left bundle branch block; RBBB = right bundle branch block.

Figure 9

Left bundle branch pacing (LBBP) in narrow QRS. R-wave peak time in lead V6 (V₆ RWPT) measured from the left bundle branch (LBB) potential at baseline is the same as stimulus to V₆ RWPT during LBB capture, but significantly longer with loss of LBB capture (left ventricular [LV] septal pacing). Adapted with permission from Jastrzebski et al. ns = nonselective.

Figure 10

Left bundle branch pacing in left bundle branch block. Left bundle branch pacing (LBBP) with left bundle branch (LBB) capture and LBB potential during corrective His bundle pacing (HBP) is shown. V₆ R-wave peak time measured from stimulus during LBB capture (selective [s] and nonselective [ns]) is 25 ms shorter than during corrective HBP and left ventricular septal-only pacing (LVSP). Reprinted with permission from Vijayaraman and Jastrzebski. aVF = augmented vector foot; aVL = augmented vector left; aVR = augmented vector right; HBP = His bundle pacing; LBB = left bundle branch; LBBP = left bundle branch pacing; LVSP = left ventricular septal–only pacing; ns = nonselective; s = selective.

Figure 11

Patient follow-up and management after implantation with a CPP device. Colors correspond to the class of recommendation in Table 1. AF = atrial fibrillation; BBB = bundle branch block; BiV = biventricular; CPP = cardiac physiologic pacing; CRT = cardiac resynchronization therapy; CRT-D = cardiac resynchronization therapy–defibrillator; CRT-P = cardiac resynchronization therapy–pacemaker; CSP = conduction system pacing; ECG = electrocardiogram; Echo = echocardiogram; GDMT = guideline-directed medical therapy; HBP = His bundle pacing; HF = heart failure; HFimpEF = heart failure with improved ejection fraction; LBBAP = left bundle branch area pacing; LV = left ventricle/ventricular; PA = posterior-anterior; PVC = premature ventricular contraction.

Figure 12

Patients with congenital heart disease. Colors correspond to the class of recommendation in Table 1. AV = atrioventricular; BiV = biventricular; CCTGA = congenitally corrected transposition of the great arteries; CRT = cardiac resynchronization therapy; CSP = conduction system pacing; HBP = His bundle pacing; HF = heart failure; LBBAP = left bundle branch area pacing; LV = left ventricle/ventricular; LVEF = left ventricular ejection fraction; RBBB = right bundle branch block; RV = right ventricle/ventricular.

Figure 13

Cardiac physiologic pacing in pediatric populations. Colors correspond to the class of recommendation in Table 1. AV = atrioventricular; BiV = biventricular; CPP = cardiac physiologic pacing; CRT = cardiac resynchronization therapy; HF = heart failure; LV = left ventricle/ventricular; RV = right ventricle/ventricular.