Cardiac pacing and lead devices management: 25 years of research at EP Europace journal

Abstract

Aims: Cardiac pacing represents a key element in the field of electrophysiology and the treatment of conduction diseases. Since the first issue published in 1999, EP Europace has significantly contributed to the development and dissemination of the research in this area.

Methods: In the last 25 years, there has been a continuous improvement of technologies and a great expansion of clinical indications making the field of cardiac pacing a fertile ground for research still today. Pacemaker technology has rapidly evolved, from the first external devices with limited longevity, passing through conventional transvenous pacemakers to leadless devices. Constant innovations in pacemaker size, longevity, pacing mode, algorithms, and remote monitoring highlight that the fascinating and exciting journey of cardiac pacing is not over yet.

Conclusion: The aim of the present review is to provide the current 'state of the art' on cardiac pacing highlighting the most important contributions from the Journal in the field.

Keywords: CIED; Cardiac pacing; Leadless pacing; Pacemaker; State of the art.

Figure 1

Pacemaker implantations per million people in European Society Cardiology member countries. Adapted from Timmis A. et al. European Society of Cardiology: cardiovascular disease statistics 2021. Eur Heart J. 2022.

Figure 2

Optimal pacing mode in sinus node dysfunction and atrio-ventricular block. Adapted from ref. AF, atrial fibrillation; AV, atrioventricular; AVM, atrioventricular management [i.e. AV delay programming (avoiding values > 230 ms) or specific algorithms to avoid/reduce unnecessary ventricular pacing]; CRT, cardiac resynchronization therapy; SND, sinus node dysfunction; SR, sinus rhythm. (R) indicates that the programming of such a pacing mode is preferred only in the case of chronotropic incompetence. Reasons to avoid two leads include young age and limited venous access.

Figure 3

Example of a too-long PR interval enabled by the RVpm strategy, with severe mitral regurgitation at a PR interval = 560 ms.

Figure 4

Example of a too-short PR interval in an 80-year patient with normal systolic LV function and AV block 1st/intermittent 2:1 AV block, presenting with liver congestion and swelling ankles. (A) Absence of atrial systole and restrictive filling pattern, inferior vena cava unresponsive to breathing while being DDD paced (paced AV delay 180 ms, sensed AV delay 130 ms). (B) With RVpm and lower-rate 40-bpm atrial systole occurs at a variable diastolic filling time owing to unstable PR intervals 340–400 ms. (C) At a sensed AV delay 180 m, a consistent diastolic filling time with still truncated A wave and restrictive pattern is observed, unmasking the difficulty to achieve an optimal AV coupling in aged patients.

Figure 5

Example right ventricular pacing–induced cardiomyopathy in a SND disease patient with marked bradycardia and borderline PR interval, despite RVpm: see diastolic left ventricular filling pattern during sinus bradycardia (A). Atrial stimulation with RVpm results in an abnormally prolonged PR interval with E/A overlap and decreased LV preload (B): the patient was visited for swelling ankles and shortness of breath 6 months after implant. Tailored programming to maintain atrioventricular coupling (C) unveiled slightly abnormal diastolic LV function (E/A ∼ 0.7): 8 months later, the patient was hospitalized with HF and worsened LV ejection fraction at 36% due to RV stimulation. Adapted from Biffi M. et al., Expert Rev Med Devices 2021; 18:161–177.

Figure 6

Representation of the most physiologic pacing settings as learnt from the history of cardiac stimulation. Normal atrial activation and physiologic conduction to the ventricles, as enabled by selective His bundle pacing, are preferred to ensure the best cardiac performance (A). Atrioventricular coupling with a relatively short QRS duration (130–160) by either right ventricular or biventricular pacing is a less physiologic alternative in complete heart block (B), while minimization of ventricular stimulation is a viable alternative until the 230–260 PR range when intrinsic conduction is persistent for the majority of time (C). Progressively increasing paced QRS duration (right arrow) or lengthening of the intrinsic PR interval (left arrow) promotes non-physiologic pacing and worsens cardiac function mimicking VVI stimulation, that is the least physiologic setting (D). Adapted from Biffi M. et al., Expert Rev Med Devices 2021; 18:161–177.

Figure 7

The PADIT risk score. From ref. PADIT, Prevention of Arrythmia Device Prevention Trial.

Figure 8

Summary of key messages for prevention, diagnosis, and management of CIED infections. From ref. CIED, cardiac implantable electronic device; [18F] FDG PET/CT, fluorodeoxyglucose positron emission tomography–computed tomography; ICD, implantable cardiac defibrillator; ICE, intracardiac echocardiography; OAC, oral anticoagulation; w, week; WBC SPECT/CT, white blood cell single-photon emission computed tomography–computed tomography.

Figure 9

Management of conduction abnormalities after TAVI. From ref. AF, atrial fibrillation; AV, atrioventricular; AVB, atrioventricular block; BBB, bundle branch block; ECG, electrocardiogram; EPS, electrophysiology study; HV, His-ventricular interval; LBBB, left bundle branch block; LVEF, left ventricular ejection fraction; PM, pacemaker; RBBB, right bundle branch block; TAVI, transcatheter aortic valve implantation. ^a24–48-h post-procedure. ^bTransient high-degree AVB, PR prolongation, or axis change. ^cHigh-risk parameters for high-degree AV block in patients with new-onset LBBB include AF, prolonged PR interval and LVEF < 40%. ^dAmbulatory continuous ECG monitoring for 7–30 days. ^eEPS with HV ≥ 70 ms may be considered positive for permanent pacing. ^fWith no further prolongation of QRS or PR during 48-h observation.

Figure 10

Flowchart for evaluating MRI in CIED patients. From ref. MRI, magnetic resonance imaging; SAR, specific absorption rate. ^aConsider only if there is no imaging alternative, and the results of the test is crucial for applying life-saving therapies for the patients.

Figure 11

Programming of device parameters and timing of device check before and after MRI. From ref. AF, atrial fibrillation; MRI, magnetic resonance imaging. ^aIf available. ^bRate hysteresis; atrial anti-tachycardia pacing; premature ventricular complex and premature atrial contraction triggered pacing; AF therapies–rate smoothing; overdrive pacing; conducted AF response. ^cIn CIED with automatic MRI mode activation, the scan may be performed electively after the pre-scan follow-up and reprogramming after the intervention may not be necessary.

Figure 12

Algorithm for perioperative management of PM (including CRT-P) during surgery. From ref.^aReprogramming/magnet application is optional, if surgery is performed below the iliac crest and no full-body return electrodes are used; ^basynchronous mode (D00/V00/A00); rate response may be inactivated to avoid rapid pacing with patient mobilization or respiratory monitoring (if the PM has a minute-ventilation sensor); ^cabsence of intrinsic escape rhythm or heart rate, 50-bpm causing symptoms; ^dasystole or haemodynamically relevant bradycardia during electrocautery.

Figure 13

Risk stratification for CIED malfunction. From ref.