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.......................................................................................................................................................................... • In patients with permanent AF and permanent or paroxysmal AVB, single-lead ventricular pacing is indicated. • In patients with syncope and unexplained falls, the diagnosis should be ascertained using the available diagnostic methods before pacemaker treatment is considered. • In patients with symptomatic HF and LVEF <_35% despite OMT who are in SR and have LBBB QRS morphology, CRT is recommended when QRS duration is >_150 ms, and should be considered when QRS duration is 130149 ms. For patients with non- LBBB QRS morphology, evidence for benefit of CRT is less convincing, especially with normal PR and QRS duration <150 ms. CRT should not be used in patients with HF and QRS duration <130 ms, unless there is need for ventricular pacing. • Selection of patients for CRT based on imaging is limited to the measurement of LVEF, whereas the assessment of other factors, such as extent of myocardial scar, presence of mitral regurgitation, or RV systolic function, is important to anticipate potential non-responders who may need additional treatments (e.g. mitral valve intervention). • In patients with permanent AF, symptomatic HF, LVEF <_35%, and QRS >_130 ms who remain in NYHA class III or ambulatory IV despite OMT, CRT should be considered. • For patients with AF and CRT, AVJ ablation should be considered when at least 9095% effective biventricular pacing cannot be achieved. • For patients with high-degree AVB and an indication for cardiac pacing who have HFrEF (LVEF <40%), CRT rather than RV pacing is recommended. • HBP may result in normal or near-normal ventricular activation, and is an attractive alternative to RV pacing. To date, no data from randomized trials support that HBP is non-inferior to RV pacing with respect to safety and efficacy. Therefore, HBP may be considered for selected patients with AVB and LVEF >40%, who are anticipated to have >20% ventricular pacing. • In patients offered HBP, implantation of an RV lead used as ‘backup’ for pacing should be considered individually. • HBP may correct ventricular conduction in a subset of patients with LBBB and may therefore be used in lieu of biventricular pacing for HBP-based CRT in selected patients. • In patients treated with HBP, device programming tailored to specific requirements of HBP must be ensured. • Implanting a leadless pacemaker should be considered when no upper extremity venous access exists, when risk of device pocket infection is particularly increased, and in patients on haemodialysis. • Patients undergoing TAVI are at increased risk of developing AVB. Decisions regarding cardiac pacing after TAVI should be taken based upon pre-existing and new conduction disturbances. Ambulatory ECG monitoring for 730 days or EPS may be considered in patients post-TAVI with new LBBB or progression of pre-existing conduction anomaly, but not yet any indication for a pacemaker. • In patients undergoing surgery for endocarditis or tricuspid valve surgery who have or develop AVB under surgery, placement of epicardial pacing leads during surgery should be considered. • To reduce the risk of complications, pre-operative antibiotics must be administered before CIED procedures, chlorhexidinealcohol should be preferred for skin antisepsis, and cephalic or axillary vein access should be attempted as first choice. • Heparin bridging should be avoided in CIED procedures to minimize the risk of haematoma and pocket infection. • In patients undergoing a CIED reintervention procedure, using an antibiotic-eluting envelope may be considered to reduce the risk of infection. • In the majority of patients with a pacemaker or CRT, a wellindicated MRI can be performed if no epicardial leads, abandoned or damaged leads, or lead adaptors/extenders are present, and certain precautions are taken. • Radiation therapy can be offered to patients with a pacemaker or CRT if an individualized treatment planning and risk stratification is done beforehand and the device is interrogated as recommended around the period of radiation therapy. • Remote device management is valuable for earlier detection of clinical problems and technical issues, and may allow longer spacing between in-office follow-ups. • The principles of patient-centred care and shared decisionmaking should be used in the consultation both pre-operatively and during follow-up for patients considered for or living with a pacemaker or CRT.

15 Gaps in evidence

Clinicians responsible for managing pacemaker and CRT candidates, and patients, must frequently make treatment decisions without adequate evidence or consensus of expert opinion. The following is a short list of selected, common issues that deserve to be addressed in future clinical research.

• Best pre-implant evaluation programme, including when to apply advanced imaging methods to ensure optimal choice of CIED for each patient. • Benefit of implementing genetic testing of CIED patients and their relatives when conduction tissue disease is diagnosed. • Whether use of rate-adaptive pacing in general is beneficial in patients with SND. • Whether catheter ablation of AF without pacemaker implantation is non-inferior to pacemaker implantation with respect to freedom from bradycardia-related symptoms in patients with symptomatic conversion pauses after AF. • In patients with reflex syncope, studies of which pacing mode is superior are needed. • In patients with an indication for VVI pacing, the long-term efficacy and safety of choosing leadless pacing need to be documented in RCTs. • In patients with HF, it remains to be shown that CRT improves outcome in patients without LBBB. • In patients with permanent/persistent AF, HF, and BBB, any beneficial effects of CRT remain to be proven in RCTs. • There is a lack of RCTs documenting the effect of CRT in patients with HF treated with novel HF drugs including sacubitril/ valsartan, ivabradine, and sodiumglucose co-transporter-2 inhibitors. Downloaded from academic.oup.com/eurheartj/article/42/35/3427/6358547 by guest on 07 October 2026