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Recommendations for cardiac pacing after cardiac surgery and heart transplantation High-degree or complete AVB after cardiac surgery: a period of clinical observation of at least 5 days is indicated to assess whether the rhythm disturbance is transient and resolves. However, this observation period can be shortened in the case of complete AVB with low or no escape rhythm when resolution is unlikely. I C Patients requiring pacing after mechanical tricuspid valve replacement: implantation of a transvalvular RV lead should be avoided. III C Recommendations for cardiac pacing after TAVI Permanent pacing is recommended in patients with complete or high-degree AVB that persists for 24 - 48 h after TAVI. I B Permanent pacing is recommended in patients with new-onset alternating BBB after TAVI. I C Prophylactic permanent pacemaker implantation is not indicated before TAVI in patients with RBBB and no indication for permanent pacing. III C Recommendations for cardiac pacing in patients with congenital heart disease In patients with congenital complete or high-degree AVB, pacing is recommended if one of the following risk factors is present: i. Symptoms ii. Pauses >3 the cycle length of the ventricular escape rhythm iii. Broad QRS escape rhythm iv. Prolonged QT interval v. Complex ventricular ectopy vi. Mean daytime heart rate <50 b.p.m. I C Recommendations for cardiac pacing in rare diseases In patients with neuromuscular diseases such as myotonic dystrophy type 1 and any second- or third-degree AVB or HV >_70 ms, with or without symptoms, permanent pacing is indicated.f I C Recommendations regarding device implantations and peri-operative management Administration of pre-operative antibiotic prophylaxis within 1 h of skin incision is recommended to reduce the risk of CIED infection. I A Heparin bridging of anticoagulated patients is not recommended. III A Permanent pacemaker implantation is not recommended in patients with fever. Pacemaker implantation should be delayed until the patient has been afebrile for at least 24 h. III B Recommendations for performing magnetic resonance imaging in pacemaker patients In patients with MRI-conditional pacemaker systems,g MRI can be performed safely following the manufacturer’s instructions. I A Recommendations regarding temporary cardiac pacing Temporary transvenous pacing is recommended in cases of haemodynamic-compromising bradyarrhythmia refractory to intravenous chronotropic drugs. I C Recommendation when pacing is no longer indicated When pacing is no longer indicated, the decision on management strategy should be based on an individual riskbenefit analysis in a shared decision-making process together with the patient. I C Recommendations for pacemaker and cardiac resynchronization therapy-pacemaker follow-up Remote device management is recommended to reduce the number of in-office follow-up visits in patients with pacemakers who have difficulties in attending in-office visits (e.g. due to reduced mobility or other commitments, or according to patient preference). I A Remote monitoring is recommended in the case of a device component that has been recalled or is on advisory, to enable early detection of actionable events in patients, particularly those who are at increased risk (e.g. in case of pacemaker dependency). I C Recommendation regarding patient-centred care in cardiac pacing and cardiac resynchronization therapy In patients considered for a pacemaker or CRT, the decision should be based on the best available evidence with consideration of individual riskbenefits of each option, the patient’s preferences, and goals of care, and it is recommended to follow an integrated care approach and use the principles of patient-centred care and shared decision-making in the consultation. I C

AF = atrial fibrillation; AVB = atrioventricular block; AVJ = atrioventricular junction; BBB = bundle branch block; b.p.m. = beats per minute; CIED = cardiovascular implantable electronic device; CRT = cardiac resynchronization therapy; CRT-D = defibrillator with cardiac resynchronization therapy; CSM = carotid sinus massage; DDD = dual-chamber, atrioventricular pacing; ECG = electrocardiogram; EPS = electrophysiology study; HF = heart failure; HFrEF = heart failure with reduced ejection fraction; HV = Hisventricular interval; ICD = implantable cardioverter-defibrillator; ILR = implantable loop recorder; LBBB = left bundle branch block; LV = left ventricular; LVEF = left ventricular ejection fraction; MI = myocardial infarction; MRI = magnetic resonance imaging; NYHA = New York Heart Association; OMT = optimal medical therapy; RBBB = right bundle branch block; RV = right ventricular; SAS = sleep apnoea syndrome; SND = sinus node dysfunction; SR = sinus rhythm; TAVI = transcatheter aortic valve implantation. aClass of recommendation. bLevel of evidence. cCSM should not be undertaken in patients with previous transient ischaemic attack, stroke, or known carotid stenosis. Carotid auscultation should be performed before CSM. If a carotid bruit is present, carotid ultrasound should be performed to exclude carotid disease. dComplete blood counts, prothrombin time, partial thromboplastin time, serum creatinine, and electrolytes. eIn asymptomatic narrow QRS complex and 2:1 AVB, pacing may be avoided if supra-Hisian block is clinically suspected (concomitant Wenckebach is observed and block disappears with exercise) or demonstrated at EPS. fWhenever pacing is indicated in neuromuscular disease, CRT or an implantable cardioverter-defibrillator should be considered according to relevant guidelines. gCombination of MRI conditional generator and lead(s) from the same manufacturer. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/35/3427/6358547 by guest on 07 October 2026