Comment on the European Society of Cardiology (ESC) Clinical Consensus Statement on the indication for conduction system pacing

Background: Right ventricular pacing (RVP) is the standard approach for bradyarrhythmia but is linked to adverse outcomes like pacing-induced cardiomyopathy and heart failure. Conduction system pacing (CSP), including His bundle pacing (HBP) and left bundle branch pacing (LBBP), offers a more physiologic alternative. However, its comparative effectiveness and safety versus RVP remain uncertain. Research question: Does CSP improve clinical outcomes compared to RVP in patients receiving their first pacemaker? Aims: To compare clinical and procedural outcomes of CSP versus RVP in adults undergoing first-time permanent pacemaker implantation. Methods: We performed a systematic review and meta-analysis comparing CSP (HBP or LBBP) with RVP. Searches were conducted in PubMed, Embase, and Cochrane Library through April 2025. Outcomes included heart failure hospitalization (HFH), all-cause mortality, new-onset AF, upgrade to cardiac resynchronization therapy (CRT), left ventricular ejection fraction (LVEF) at follow-up, and lead revision rates. Random-effects models in R software (v4.4.1) were used to estimate risk ratios (RRs) or mean differences (MDs) with 95% confidence intervals (CIs). Subgroup analyses by pacing type (LBBP vs. HBP) were conducted. Results: Twenty-one studies (3 RCTs and 18 observational studies) comprising 5,232 patients were included, of whom 2,360 (45%) underwent CSP. Seven studies evaluated HBP (1,822 patients), and 14 evaluated LBBP (3,399 patients). The mean follow-up was 20 months. CSP was associated with significantly lower risks of HFH (RR 0.44; 95% CI 0.31–0.62; p < 0.01; Figure 2), new-onset AF (RR 0.39; 95% CI 0.30–0.52; p<0.01; Figure 3), all-cause mortality (RR 0.67; 95% CI 0.53–0.85; p=0.01), and upgrade to CRT (RR 0.23; 95% CI 0.09–0.60; p<0.01). LVEF was significantly higher in the CSP group (MD 2.13%; 95% CI 0.48–3.79; p=0.01). No significant difference was observed in lead revision rates (RR 1.94; 95% CI 0.65–5.77; p=0.23). Subgroup analyses showed the superiority of LBBP over HBP for all outcomes (pinteraction<0.01), except for new-onset AF and LVEF improvement (pinteraction>0.05). HBP was associated with a higher lead revision rate than LBBP (pinteraction<0.01). Conclusion: CSP, particularly LBBP, is associated with improved clinical outcomes compared to RVP in patients undergoing initial pacemaker implantation. These findings support CSP as a more physiologic pacing strategy with a favorable safety and efficacy profile.

His bundle pacing improves left ventricular diastolic function in patients with heart failure with preserved systolic function

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

Objective: The feasibility of the conduction system pacing (CSP) upgrade as an alternative modality to the traditional biventricular pacing (BiVP) upgrade in patients with pacemaker-induced cardiomyopathy (PICM) remains uncertain. This study sought to compare two modalities of CSP (His bundle pacing (HBP) and left bundle branch pacing (LBBP)) with BiVP and no upgrades in patients with pacing-induced cardiomyopathy. Methods: This retrospective analysis comprised consecutive patients who underwent either BiVP or CSP upgrade for PICM at the cardiac department from 2017 to 2021. Patients with a follow-up period exceeding 12months were considered for the final analysis. Results: The final group of patients who underwent upgrades included 48 individuals: 11 with BiVP upgrades, 24 with HBP upgrades, and 13 with LBBP upgrades. Compared to the baseline data, there were significant improvements in cardiac performance at the last follow-up. After the upgrade, the QRS duration (127.81 ± 31.89 vs 177.08 ± 34.35ms, p < 0.001), NYHA class (2.28 ± 0.70 vs 3.04 ± 0.54, p < 0.05), left ventricular end-diastolic diameter (LVEDD) (54.08 ± 4.80 vs 57.50 ± 4.85mm, p < 0.05), and left ventricular ejection fraction (LVEF) (44.46% ± 6.39% vs 33.15% ± 5.25%, p < 0.001) were improved. There was a noticeable improvement in LVEF in the CSP group (32.15% ± 3.22% vs 44.95% ± 3.99% (p < 0.001)) and the BiVP group (33.90% ± 3.09% vs 40.83% ± 2.99% (p < 0.001)). The changes in QRS duration were more evident in CSP than in BiVP (56.65 ± 11.71 vs 34.67 ± 13.32, p < 0.001). Similarly, the changes in LVEF (12.8 ± 3.66 vs 6.93 ± 3.04, p < 0.001) and LVEDD (5.80 ± 1.71 vs 3.16 ± 1.35, p < 0.001) were greater in CSP than in BiVP. The changes in LVEDD (p = 0.549) and LVEF (p = 0.570) were similar in the LBBP and HBP groups. The threshold in LBBP was also lower than that in HBP (1.01 ± 0.43 vs 1.33 ± 0.32V, p = 0.019). Conclusion: The improvement of clinical outcomes in CSP was more significant than in BiVP. CSP may be an alternative therapy to CRT for patients with PICM. LBBP would be a better choice than HBP due to its lower thresholds.

BackgroundThere is currently no evidence of the best pacing mode for high-degree atrioventricular (AV) block occurring after transcatheter aortic valve implant (TAVI) in patients with preserved left ventricular systolic ejection fraction (LVEF).PurposeThe purpose of the trial was to compare a clinical combined endpoint achieved by left bundle branch pacing (LBBP) vs right ventricular (RV) pacing in patients with preserved LVEF post-TAVI at 12-month follow-up.MethodsPhysiological vs right ventricular pacing in patients with normal ventricular function post-TAVI (Phys-TAVI) was a pilot study designed as a single-center, prospective, randomized, parallel-controlled clinical trial. Adhered to CONSORT guidelines.Consecutive patients (n=24) post-TAVI with high-degree AV block and LVEF≥50% were randomized to LBBP or RV pacing. The primary endpoint was survival with an improvement ≥1point in NYHA class or ≥25% increase in the distance covered in the 6-minute-walking-test (6MWT). Secondary endpoints were change in LVEF, septal flash correction, mitral regurgitation, NTproBNP, heart failure hospitalization, score on symptoms (KCCQ-12 Kansas City Cardiomyopathy Questionnaire), and QRS duration.ResultsTwenty-four patients were included, 12 in each arm. Median stimulation 98.6% (75%-99%), no differences between groups. Both groups showed a similar incidence of the primary endpoint: 33.3% (n=4) in LBBP group vs 25% (n=3) in RV group (p=1). One patient in each group had died at 1-year follow-up.In relation to secondary endpoints, significant shortening in the QRS was observed in LBBP patients, as compared to RV pacing (median -39ms vs 0ms), p<0.001. Septal flash excursion was significantly lower for the LBBP group (median 0mm vs 2mm), p=0.03. None of the patients had LVEF<50% at 12-month follow-up.ConclusionSimilar midterm outcomes were obtained with LBBP and RV pacing in an elderly population with high-degree AV block and preserved LVEF after TAVI. The pilot Phys-TAVI trial showed the feasibility of LBBP in this population and set paves the way for larger randomized clinical trials with extended follow-up to test for differential clinical outcomes between pacing modalities.PhysTAVI trials results Endpoints Intention to treat analysis

IntroductionThe diagnosis of heart failure with preserved ejection fraction (HFpEF) in pacemaker patients is challenging, as standard assessment criteria can be affected by artificial pacing. Although the European Society of Cardiology (ESC) guidelines and the Heart Failure Association Pre-test Assessment, Echocardiography & Functional Testing, and Final Etiology (HFA-PEFF) score provide recommendations for HFpEF diagnosis, the comparative performance of these methods in a pacemaker population has never been established.PurposeEvaluate the concordance between the European Society of Cardiology (ESC) guidelines for HF and the HFA-PEFF score for diagnosing HFpEF in pacemaker patients.MethodsCross-sectional, single-center screening study for HF in all patients submitted to a pacemaker implant with right ventricular apical pacing between January 2008 and December 2022. Patients underwent complete echocardiographic assessment, exercise echocardiography, NT-proBNP measurement, clinical examination, and pacemaker interrogation. We used the 2023 ESC guidelines to diagnose HF and evaluated concordance with the HFA-PEFF score using Cohen’s kappa and overall agreement. Concordance was categorized as poor (0–0.20), fair (0.21–0.40), moderate (0.41–0.60), good (0.61–0.80), and optimal (0.81–1). Diagnostic accuracy was evaluated by sensitivity, specificity, PPV, and NPV, with ESC criteria as the reference. ROC analysis was conducted to assess the discriminative ability of an HFA-PEFF score ≥5 for HFpEF diagnosis.ResultsA total of 342 patients (median age 78 ± 9 years, 60.1% male) were screened. 35.7% (n=122) had HFpEF, 6.1% (n=21) had HFmrEF, 3.8% (n=13) had HFrEF, and the remaining 54.4% (n=186) had no HF, according to ESC Guidelines. Using the HFA-PEFF score the prevalence of HFpEF was 32,9% (n=109). Concordance between the ESC Guidelines and HFA-PEFF score criteria was high, with a Cohen’s kappa value of 0.88 (95% CI: 0.83–0.94, P < 0.001), reflecting optimal agreement. The overall agreement rate was 94.4%, with the HFA-PEFF score showing a PPV of 87,7% and a NPV of 98,9%. Both criteria classified 107 patients as HFpEF and 183 patients as non-HF. Discrepancies were minimal, with only 2 cases classified as HFpEF by HFA-PEFF score but not by the ESC criteria and 15 cases classified as HFpEF by ESC guidelines but not by HFA-PEFF score. ROC analysis of the HFA-PEFF score revealed moderate discriminative ability for diagnosing HFpEF in our cohort, with a conventional and optimal cut-off of 5. At this threshold, the score achieved an AUC of 0.76 (95% CI: 0.71–0.80), with a sensitivity of 87.7% and specificity of 63.8%.ConclusionThis study found a high prevalence of HFpEF in pacemaker patients and strong concordance between the HFA-PEFF score and ESC guidelines, a previously unreported finding. The HFA-PEFF score appears to be a reliable tool for HFpEF screening, enhancing diagnostic accuracy and clinical decisions in this population.

New guideline on β blockers challenges ESC advice

IntroductionIn 2012, European Society of Cardiology (ESC) guidelines advised against performing PCI in non-infarct arteries (preventive PCI) in patients with ST-elevation myocardial infarction, STEMI (Level III recommendation). With the publication...

Funding Acknowledgements Type of funding sources: None. Background Atrioventricular node ablation (AVNA) with biventricular (BiV) pacing is an established treatment option for heart failure (HF) patients with drug refractory atrial fibrillation (AF) (1). However, compared to conduction system pacing (CSP) modalities, including His bundle pacing (HBP) and left bundle branch pacing (LBBP), BiV pacing delivers non-physiological ventricular activation (2). Purpose To compare clinical outcomes of BiV pacing and both CSP modalities in HF patients with symptomatic AF who underwent AVNA. Methods Consecutive AF patients with LV ejection fraction (LVEF &amp;lt;50%) who received either BiV pacing or CSP in conjunction with AVNA between May 2015 and July 2021 were retrospectively analysed. Procedural characteristics, electrocardiographic, echocardiographic, and clinical parameters were assessed at baseline and 6 months after the procedure. Results Fifty-five patients (male 43.6%, age 71 years (IQR 10), LVEF 39% (IQR 14)) were included. Thirteen patients (23.6%) received BiV pacing, 30 patients (54.5%) HBP and 12 patients (21.8%) LBBP. All groups had similar baseline characteristics, acute success rate and adverse events. Post-procedural QRS duration was significantly shorter (p&amp;lt;0.01) in CSP (118 ms (IQR 28)) than in BiV pacing (172 ms (IQR 18)). While NYHA class improved in both HBP (p&amp;lt;0.01) and LBBP (p=0.01), it did not improve in BiV group (p=0.1) At follow-up, end systolic volume (ESVi) decreased in both HBP (48±20 to 32±12 mL/m2, p&amp;lt;0.01) and LBBP (62±22 to 52±22 mL/m2, p=0.02), but did not differ in BiV pacing group (51±12 to 53±14 mL/m2, p=0.6). Similarly, LVEF increased in HBP (form 39% (IQR 16) to 53% (IQR 14), p&amp;lt;0.01) and LBBP (from 41% (IQR 23) to 40% (IQR 25), p=0.04), but did not change in BiV group (from 38% (IQR 5) to 37% (IQR 6), p=0.9). Significantly lower (p&amp;lt;0.01) pacing thresholds were achieved in LBBP (0.75 V at 0.5 ms (IQR 0.3)) than in HBP group (1.0 V at 0.5 ms (IQR 1)). Two patients in HBP group were switched to right ventricular pacing due to rise in HBP threshold. In the remaining patients threshold remained stable during follow-up. Conclusion Conduction system pacing modalities showed superior symptomatic and echocardiographic improvement compared to BiV pacing after AVNA. While LBBP offered lower and more stable pacing parameters, there were no differences in clinical outcomes and echocardiographic remodelling when compared to HBP.

The New Canadian Cardiovascular Society Algorithm for Antithrombotic Therapy of Atrial Fibrillation Is Appropriately Based on Current Epidemiologic Data

Conduction system pacing (CSP) is being increasingly adopted as a more physiological alternative to right ventricular and biventricular pacing. Since the 2021 European Society of Cardiology pacing guidelines, there has been growing evidence that this therapy is safe and effective. Furthermore, left bundle branch area pacing was not covered in these guidelines due to limited evidence at that time. This Clinical Consensus Statement provides advice on indications for CSP, taking into account the significant evolution in this domain.

Multimodal Imaging of an Incidental Anomalous Coronary Artery

Background The European Society of Cardiology (ESC) guidelines for the diagnosis and management of pericardial diseases identify predictive factors of poor prognosis and advise either in favour or against hospitalisation accordingly. Our aim is to evaluate the adequacy of hospitalisation criteria in a cohort of patients presenting to the emergency department (ED) with acute pericarditis. Methods Retrospective analysis of patients admitted in ED with acute pericarditis, from 2009 to 2019. All patients were evaluated by a cardiologist during ED stay who decided if the patient was to be discharged or hospitalized. Hospitalized and discharged patients were compared regarding primary outcome, defined by a composite of: need for pericardiocentesis and/or cardiac surgery, pericarditis recurrence and all-cause death. Clinical decision was then counterpoised with ESC guidelines. Results A total of 192 patients were included in the analysis (aged 46±18.5 years-old, 83.3% male) of which 87 (45.5%) were hospitalized. A total of 25% registered the primary outcome, mainly due to acute pericarditis recurrence, occurring in 21.9%. Predictors of recurrence were: glucocorticoid therapy (OR=11.93, 95% CI 3.13–45.5, p&amp;lt;0.001), fever at admission (OR=2.67, 95% CI 1.29–5.49, p=0.008), immunosuppression (OR=4.03, 95% CI 1.280–12.659, p=0.017) and increased cardiothoracic index (OR 3.85, CI 95% 1.67–8.86, p=0.002). Regarding hospitalisation/discharge decision, the ESC guidelines were respected in 72.9% of the cases. However, no significant difference in primary outcome was noted whether the ESC guidelines were respected or not (27.5% vs. 24.3%, p=0.707). Conclusions Discrepancy between current guidelines and clinical decision did not translate into a different outcome. Funding Acknowledgement Type of funding source: None

As an electrophysiologist, I am referred large numbers of patients with, or at risk of, arrhythmias as part of the heart failure complex. In this review I will concentrate on the role of pacemakers and defibrillators in heart failure, because these are my areas of greatest experience. Left ventricular assist devices and implantable hemodynamic monitors will not be reviewed. The first controversy for discussion is how to assess patients for suitability to receive these devices. Patients with heart failure are frequently fitted into a New York Heart Association (NYHA) class. The NYHA class is, however, a blunt instrument for decision-making that is based on a physician's or nurse's impression of how patients express their symptoms. Two patients with similar levels of symptomatology but with different responses to their symptoms may therefore receive different NYHA classifications and be candidates for different management approaches. Guidelines such as those from the European Society of Cardiology (ESC) offer valuable guidance on the use of cardiac resynchronization therapy (CRT).12 There are, however, issues in the use of CRT which the guidelines do not consider. Controversies that relate particularly to CRT include the identification of which patients benefit most from this technique and the characterization of its role in atrial fibrillation, in patients with bradycardia, and in non-responders. CRT has been available for approximately 10 years. An early meta-analysis of randomized controlled trials of CRT, including CONTAK-CD, InSync ICD, MIRACLE, and MUSTIC, showed that CRT reduced death from progressive heart failure by 51%, reduced heart failure hospitalization by 29%, and showed a trend to reduced all-cause mortality2 (Figures 12–3). Some of these trials included a defibrillator component, which made characterization of the effects of CRT alone problematic. Subsequent to these trials, the CARE-HF study was performed. CARE-HF observed that CRT produced a 37% reduction in all-cause mortality or unplanned hospitalization compared to medical therapy over 4 years (P < 0.0001)5 (Figure 4). All-cause mortality alone was reduced 36% by CRT when compared to optimal medical therapy (P = 0.0019). CARE-HT was the first major trial to demonstrate a definite improvement in all-cause mortality from CRT pacing. The COMPANION study included patients at higher risk than those in CARE-HF and investigated three treatment limbs – optimal pharmacological therapy, biventricular pacing, and biventricular defibrillation.3 COMPANION was not powered to detect a difference in outcome between the two types of biventricular device, but did appear to show that biventricular defibrillation was superior to medical therapy based on the secondary endpoint of all-cause mortality at 12 months (Figure 5). On the basis of these trials, the ESC guidelines recommend that “CRT using biventricular pacemakers can be considered [my italics] in patients with reduced ejection fraction and ventricular asynchrony (QRS width ≥120 ms) who remain symptomatic despite optimal medical therapy (NYHA III/IV) to improve symptoms, hospitalizations, and mortality”.12 From my viewpoint, this statement may require to be updated in the revised ESC guidelines and CRT should be performed much more commonly than presently. National guidelines from the Scottish Intercollegiate Guidelines Network (SIGN), which have been more produced recently (2007) than those from the ESC (2005), make a similar statement – namely, that CRT “should be considered” in patients with characteristics similar to those described in the ESC guidelines. The English National Institute for Clinical Excellence (NICE) Health Technology Appraisal of the place of CRT in heart failure (2007) states that: “CRT with a pacing device (CRT-P) is recommended as a treatment option for patients with heart failure who fulfill the following criteria. They are currently experiencing or have recently experienced NYHA class III-IV symptoms. They are in sinus rhythm either with a QRS duration 150 ms or longer … or with a QRS duration of 120–149 ms and mechanical dyssynchrony. They have a LVEF of 35% or less. They are receiving optimal pharmacological therapy.” The NICE guidelines therefore strongly recommend CRT for a precisely defined group of patients. The NICE guidelines also offer guidance on the use of CRT with a defibrillator (CRT-D). “CRT-D may be considered for people who fulfill the criteria for implantation of a CRT-P device and who separately fulfill the criteria for use of an ICD as recommended in NICE Technology Appraisal Guidance 95.” The latter criteria include wide QRS and poor LV function post-myocardial infarction. There is controversy over whether mechanical dyssynchrony is also required for the selection of patients for CRT. Considerable heterogeneity exists in the echocardiographic criteria adopted to define dyssynchrony, but a few small observational studies suggest that echocardiographic measurement of mechanical dyssynchrony may best identify patients who are likely to benefit from CRT.7 Further work is required in this area. What are the cost implications of using CRT-P and CRT-D? Based on data from the CARE-group using data from COMPANION, the incremental cost-effectiveness of CRT-P versus medical therapy was €7538 per quality-adjusted life-year (QALY), and the incremental cost-effectiveness of CRT-D versus CRT-P was €47 909.13 CRT-P was concluded to be relatively inexpensive, while CRT-D was of borderline cost-effectiveness. The patient's age comes into consideration in deciding who, among eligible patients, should receive CRT-D. In younger patients, CRT-D may be considered affordable in order to keep patients alive for as long as possible. In patients aged above 70 years, by contrast, other factors are more likely to cause death and the cost of CRT-D compared to CRT-P becomes prohibitive. The use of CRT in patients with atrial fibrillation (AF) is a contentious issue. The ESC guidelines do not specify a rhythm, but most other guidelines do specify the presence of sinus rhythm (SR) in their recommendations. Most trials have included only patients in SR, although the MUSTIC study included approximately equal numbers of patients in SR and AF. In MUSTIC, patients in SR improved significantly, whereas those in AF did not.4,8 For patients in SR, activation of the pacemaker was associated with an improvement in 6-min walking distance, which worsened when the device was inactivated. However, it is notable that only 37 of 64 patients in AF completed both limbs of the study. A long-term follow-up of patients in MUSTIC at 9 and 12 months found that all SR patients and 88% of AF patients were programmed to biventricular pacing.9 The two groups experienced similar magnitudes of improvement in walking distance, peak VO2, quality of life, NYHA class, and ejection fraction (Figure 6). Therefore, for every factor measured, AF patients appeared to do as well as SR patients in the long term. MUSTIC and some smaller studies represent the only trial evidence on which to base treatment in patients with AF. This raises the question of whether the potential benefits of CRT should be denied to AF patients in the absence of large-scale randomized studies. Opinions obtained from members of the Heart Rhythm UK suggest that most large centers are implanting CRT devices in a proportion of AF patients. There are two schools of thought on the type of AF patient who may benefit from CRT. In one school, CRT should be offered to the relatively small numbers of patients in whom rigorous rate control can be achieved by medical therapy and, if necessary, ablation of atrioventricular conduction to ensure biventricular pacing all of the time. According to the results of MUSTIC, this group may improve. This is called the “rate control” group. In the second school of thought, patients should be selected in whom stringent efforts will be made to restore and maintain SR. CRT may help by increasing the ejection fraction, lowering mitral regurgitation, and lowering left ventricular pressure. Cardioversion will be easier, and amiodarone and atrial catheter ablation may be added. This is called the “rhythm control” group. It is clear that the rate control group and the rhythm control groups encompass almost all patients with AF who fit CRT criteria. In other words, there is little agreement on which patients not to implant. Another controversial area is that, in every trial, there are patients classified as “non-responders”, who represent approximately 40% of the study population. In a proportion of these cases, however, the CRT device is stabilizing the patient who would otherwise deteriorate. Although the patient may complain of not feeling better, the device may actually be preventing deterioration or death. This situation illustrates the difficulty in measuring response. Other indices may need to be assessed, such brain natriuretic peptide levels, echocardiography/magnetic resonance imaging, and evidence of dyssynchrony, in order to identify patients who will benefit from CRT. CRT-D is an option in younger patients, especially those considered for future transplantation, while CRT-P may be provided in older patients to improve symptoms and reduce hospitalization. CRT-D may be considered in the presence of risk factors for sudden death, such as non-sustained ventricular tachycardia (VT) or T-wave alternans. The role of CRT-D in Class IV heart failure and AF requires clarification. Controversies that relate particularly to the use of implantable cardioverters-defibrillators (ICDs) include the identification of which patients will benefit from an ICD or from a CRT plus an ICD, whether the trial evidence for coronary artery disease can be extrapolated to dilated cardiomyopathy (DCM), and issues of deactivation at end of life. The ESC guidelines state that: “Implantation of an ICD in combination with biventricular pacing can be considered (my italics) in patients who remain symptomatic with severe heart failure (NYHA class III/IV) with LVEF [left ventricular ejection fraction] ≤35% and QRS duration >120 ms to improve morbidity or mortality”. “ICD therapy is recommended (my italics) to improve survival in patients who have survived cardiac arrest or who have sustained VT, which is either poorly tolerated or associated with reduced systolic LV function.” “ICD implantation is reasonable (my italics) in selected symptomatic patients with LVEF <30–35%, not within 40 days of a myocardial infarction, on optimal background therapy … to reduce sudden death.” The largest trial that has provided evidence to substantiate these statements is SCD-HeFT.1 SCD-HeFT randomized 2500 patients with symptomatic heart failure (NYHA II/III) and LVEF <35% to no antiarrhythmic therapy, amiodarone, or ICD with a 5-year follow-up. One half of the patients had an ischaemic etiology and one half had idiopathic DCM. Patients were relatively young (mean 60 years) and a proportion were overweight (mean 85 kg). Background medication use with an ACE inhibitor or angiotensin receptor blocker and beta-blocker was good, with rates approaching 90% and 80%, respectively, and use of spironolactone (31% at last follow-up) was reasonable. Loop diuretics were prescribed in the majority. Annual mortality over 5 years was 7.2% in the placebo group. Amiodarone had no influence on morality (hazard ratio [HR] 1.06. P = 0.529 vs placebo), but ICD significantly reduced the mortality rate (HR 0.77, P = 0.007 vs placebo) (Figure 7). Analysis of subgroups showed that the HR of mortality for ICD versus placebo was 0.54 in patients with NYHA II and 1.16 in those with NYHA class III, indicating that patients with Class II heart failure benefited while those with Class III tended to fare worse. Patients with an ischaemic or non-ischaemic etiology had HRs of 0.79 and 0.73, respectively, suggesting equal benefit from ICD. Further subgroup analyses indicated that patients with a low EF (≤30%) had the most to gain (HR 0.73, vs 1.08 for those with an EF >30%), as did those on beta-blocker therapy (HR 0.68, vs 0.92 for those not on beta-blocker therapy), which emphasizes that ICD therapy is not a substitute for good medical therapy. There have been problems in interpreting the outcomes of studies such as SCD-HeFT and MADIT-II.10 The reliance on subgroup analyses in these trials has reduced the power of these studies. Inaccuracies in measurement utilizing LVEF cutoff values and NYHA class has further hampered interpretation, and the relationship between the severity of the condition and the magnitude of improvement requires clarification. No “evidence base” exists on which to guide practice at end of life. Discussing these issues with the patient and relatives is difficult, but needs to be done openly and with sensitivity if any crisis or deterioration develops. Booklets and websites are a valuable source of information that patients can choose to look at, and base decisions on, at their own pace. In the UK, information for patients on websites is available from the British Heart Foundation (www.bhf.org) and the Arrhythmia Alliance (www.arrhythmiaalliance.org.uk). Primary prevention ICDs may be considered in stable heart failure patients who are already receiving optimal medical therapy. ICD should not be considered as a substitute for medical therapy. Ischaemic and non-ischaemic patients benefit equally from ICD, and the worse the LV function, the greater is the benefit. ICD may be considered as a bridge to transplant or, alternatively, as a means to keep the patient away from transplant.

Conduction system pacing (CSP) modalities, including His-bundle pacing (HBP) and left bundle branch pacing (LBBP), are increasingly used as alternatives to biventricular (BiV) pacing in heart failure (HF) patients scheduled for pace and ablate strategy. The aim of the study was to compare clinical outcomes of HF patients with refractory AF who received either BiV pacing or CSP in conjunction with atrio-ventricular node ablation (AVNA). Fifty consecutive patients (male 48%, age 70 years (IQR 9), left ventricular ejection fraction (LVEF) 39% (IQR 12)) were retrospectively analysed. Thirteen patients (26%) received BiV pacing, 27 patients (54%) HBP and 10 patients (20%) LBBP. All groups had similar baseline characteristics and acute success rate. While New York Heart. Association (NYHA) class improved in both HBP (p < 0.001) and LBBP (p = 0.008), it did not improve in BiV group (p = 0.096). At follow-up, LVEF increased in HBP (form 39% (IQR 15) to 49% (IQR 16), p < 0.001) and LBBP (from 28% (IQR 13) to 40% (IQR 13), p = 0.041), but did not change in BiV group (p = 0.916). Conduction system pacing modalities showed superior symptomatic and echocardiographic improvement compared to BiV pacing after AVNA. With more stable pacing parameters, LBBP could present a more feasible pacing option compared to HBP.