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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\u003Cp id=\u0022p-1\u0022\u003EA panel of 4 experts explored clinical guidelines regarding pacing, implantable cardioverter-defibrillators, and cardiac resynchronization therapy. Two speakers also debated clinical, financial, and ethical questions related to continued use of cardiac resynchronization therapy in the setting of clinical improvement, such as an improved left ventricular ejection fraction.\u003C\/p\u003E\u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003Eatrioventricular block\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Ecardiac resynchronization therapy\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Egenerator replacement\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eimplantable cardioverter defibrillators\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Eleft ventricular ejection fraction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003Epacemaker\u003C\/li\u003E\u003C\/ul\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\u003Cp id=\u0022p-2\u0022\u003EThe basic goal of cardiac resynchronization therapy (CRT) is to restore left ventricular (LV) synchrony in patients with congestive heart failure and a widened QRS complex. A panel of 4 experts explored published clinical guidelines regarding pacing, the use of implantable cardioverter-defibrillators (ICDs), CRT, and the clinical manifestations of specific bradyarrhythmias.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EJean-Jacques Blanc, MD, Universit\u00e9 de Bretagne Occidentale, Brest, France, began with a discussion of whether biventricular or right ventricular (RV) pacing is the more appropriate treatment for patients with high-degree atrioventricular (AV) block. He reviewed data suggesting that in many patients, RV apical (RVA) pacing induces LV dysfunction with severe clinical implications [Manolis AS. \u003Cem\u003EPacing Clin Electrophysiol\u003C\/em\u003E. 2006]. While options have been proposed to mitigate the detrimental effects of RVA pacing, they are usually not applicable to patients with permanent AV block. Data suggest that biventricular pacing may be a plausible approach for some patients [Curtis AB et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E. 2013] but not for all [Blanc JJ. ESC. 2014].\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EAccording to Prof Blanc, current research does not support a comprehensive recommendation of one pacing strategy over the other. Instead, he urged practitioners to consider the algorithm shown in \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E.\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/28_suppl_2\/5\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Algorithm to Choose RV vs BiV PacingBiV, biventricular; EF, ejection fraction; RV, right ventricular.Reproduced with permission from JJ Blanc, MD.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1458722957\u0022 data-figure-caption=\u0022Algorithm to Choose RV vs BiV PacingBiV, biventricular; EF, ejection fraction; RV, right ventricular.Reproduced with permission from JJ Blanc, MD.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/28_suppl_2\/5\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/28_suppl_2\/5\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/15\/28_suppl_2\/5\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/17034\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \u003Cp id=\u0022p-5\u0022 class=\u0022first-child\u0022\u003EAlgorithm to Choose RV vs BiV Pacing\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EBiV, biventricular; EF, ejection fraction; RV, right ventricular.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EReproduced with permission from JJ Blanc, MD.\u003C\/p\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-8\u0022\u003EHe also recommended that patients with RVA pacing and an ejection fraction (EF) \u0026gt;\u200540% be evaluated regularly relative to LV function and heart failure status. If the parameters begin to deteriorate considerably, the clinician should propose an upgrade from RVA pacing to LV-based pacing, which has shown some success in several observational and randomized crossover studies [Tops LF et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2009].\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EHe summarized his presentation with 2 key points:\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\u003Cp id=\u0022p-10\u0022\u003EIn a select number of patients, LV-based pacing could be proposed as a first-line option to prevent the deleterious effects of RV pacing.\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\u003Cp id=\u0022p-11\u0022\u003EIn patients with AV block and RV pacing, the clinician should monitor pacing parameters and LV function and consider upgrading to a biventricular system if the patient\u2019s condition deteriorates.\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-12\u0022\u003EMichael Glikson, MD, Sheba Medical Center, Tel Hashomer, Israel, presented 2 case studies to determine whether each patient would be better served by CRT or RV pacing. Case 1 was a man, and case 2 was a woman. Both were aged 70 years with symptomatic sinus bradycardia at 45 beats per minute. The man had a PR interval of 220 milliseconds, a right bundle branch block (RBBB) of 130 milliseconds, a normal EF, and NYHA class 1, whereas the woman had a PR interval of 320 milliseconds, an RBBB of 180 milliseconds, an EF of 36%, and NYHA class 2.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EHe then presented 4 possible options for pacing: (1) atrial pacing (AAI\/R), (2) dual-chamber RV pacing (DDD\/R), (3) DDD\/R plus RV pacing minimization (MVP) algorithms, or (4) CRT pacing. According to Prof Glikson, AAI\/R is not a good choice when compared with moderate AV delay management. AAI\/R is associated with 2% to 3% AV block per year in certain populations and has no outcome benefit. AAI\/R is also associated with twice the reoperative rate and does not appear to have an advantage outcome over DDD\/R with moderately prolonged AV delay (AVD) [Nielsen JC et al. \u003Cem\u003EEuropace\u003C\/em\u003E. 2012; Nielsen JC et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E. 2011]. He also confirmed the previous speaker\u2019s comments regarding the deleterious effects of RV apical pacing.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003ECompared with DDD\/R, DDD\/R plus MVP appears to prevent ventricular desynchronization and moderately reduces the risk of persistent AF in patients with sinus node disease [Sweeney MO et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E. 2007]. According to Prof Glikson, a patient with a very long PR interval and conduction system disease is not likely to see a clear advantage of DDD\/R plus MVP compared with simple DDD\/R pacing. A patient with conduction system disease is more prone to progress to complete AV block\u2014at which point no MVP algorithm will be useful.\u003C\/p\u003E\u003Cp id=\u0022p-15\u0022\u003ECompared with traditional pacing, there is little evidence that CRT provides a benefit for patients with preserved systolic function [Brignole M et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E. 2013]. Furthermore, there is limited support for any effect of CRT in RBBB, and the effect of CRT may be limited to patients with QRS \u0026gt;\u2005150 milliseconds and advanced congestive heart failure.\u003C\/p\u003E\u003Cp id=\u0022p-16\u0022\u003EProf Glikson closed his remarks by returning to his original 2 cases. On the basis of the evidence that he provided during his presentation, he concluded that the best treatment for case 1 would be DDD\/R plus MVP and for case 2, CRT.\u003C\/p\u003E\u003Cp id=\u0022p-17\u0022\u003EMaurizio Gasparini, MD, Humanitas Research Hospital, Rozzano-Milano, Italy, next spoke about how to determine whether an ICD should be replaced at the time of battery depletion. According to Prof Gasparini, if a conventional ICD was originally implanted for the correct indication, it would be unusual to deny the patient a replacement at the time that the battery needed to be changed, usually at 5 to 7 years. Some patients are too ill to undergo ICD replacement, while others might be deemed too well for ICD replacement. In some cases, the initial indication no longer meets guideline indications [Kini V et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2014]. In other cases, the EF may have been underestimated at the time of the initial implant [Kutyifa V et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E. 2013]. Prof Gasparini argued that in most cases, denying ICD replacement might also raise ethical and legal implications. Even in this case, however, the clinician should hold a thorough discussion with individual patients and their families.\u003C\/p\u003E\u003Cp id=\u0022p-18\u0022\u003EJagmeet Singh, MD, Harvard Medical School, Boston, Massachusetts, USA, rounded out the session with a presentation focusing on whether patients who have an implanted CRT defibrillator should receive a pacemaker or a defibrillator at the time of generator replacement if they have an improved left ventricular ejection fraction (LVEF). Although current guidelines for ICDs are based on an LVEF \u0026lt;\u200535%, Dr Singh emphasized that a onetime baseline risk is not an everlasting risk, that survival can be normal once the LVEF has normalized, that ICDs can pose harm, and that it is the responsibility of a clinician to revisit the indications for ICD implant. Recovery of LVEF post-CRT is associated with significantly reduced appropriate ICD therapy.\u003C\/p\u003E\u003Cp id=\u0022p-19\u0022\u003EAccording to Dr Singh, patients with improvement of LVEF \u2265\u200545% and those with primary prevention indication for ICD appear to be at lowest risk [Chatterjee NA et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E. 2015]. In addition, inappropriate ICD shocks are fairly common and significantly associated with worse outcomes. He also urged providers to use a more deliberative process at the time of generator change. Clinical situations change over a 6- to 8-year period prior to the need for generator change. However, defining response is still an issue, and it is important to define what the cutoff in LVEF should be. Dr Singh proposed that the decision not to replace an ICD be based on a patient\u2019s risk of sudden cardiac death as determined by 3 metrics:\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-2\u0022\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\u003Cp id=\u0022p-20\u0022\u003ELVEF \u0026gt;\u200545%\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\u003Cp id=\u0022p-21\u0022\u003EInitial indication for primary prevention\u003C\/p\u003E\u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\u003Cp id=\u0022p-22\u0022\u003ENo documented arrhythmias and no ICD therapy over the length of the device\u003C\/p\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2015 SAGE Publications\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/15\/28_suppl_2\/5.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzl7cd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzl7cd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}