Developments in Cardiac Implantable Electronic Device Therapy: How can we improve clinical implementation?

Book excerpt: The use of cardiac implantable electronic devices (CIEDs) has substantially increased in the last decades. They have a significant impact on reducing morbidity and mortality of patients suffering from cardiac arrhythmias and heart failure. Several developments of technical issues have appeared over recent years to improve safety and efficacy. However, their role in daily clinical practice is still unclear. For instance, different leadless technologies, such as leadless pacemakers, subcutaneous defibrillators or wearables are only partly or not included in the current guideline recommendations. There are also several attempts to improve clinical response to cardiac resynchronization therapy with multipoint or fusion optimized technologies, it is however not clear which patients really benefit from these. The same is true for novel conduction system pacing modalities: His-bundle pacing seems to be the most physiological but manually challenging compared to left bundle branch area pacing, which latter restores only the physiologic activation of the left ventricle but may be easier to perform. The classical indications for primary prophylactic ICD are also questioned based on some new study results, highlighting the need for an improved, more detailed and individual risk stratification for better patient selection. We have important but somehow controversial study results regarding preventive antibiotic therapy (incremental perioperative antibiotics vs antibiotic-eluting envelope) during CIED implantation. Lead extraction tools are also expanding but randomized controlled trials regarding the best approach are completely missing in this field. The importance of remote monitoring is also constantly growing, especially in the current pandemic times, the best way of patient selection needs however more research.