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J Thorac Cardiovasc Surg 2008;136:280-282
© 2008 The American Association for Thoracic Surgery

Expert Commentary

Commentary on the American College of Cardiology/American Heart Association/Heart Rhythm Society 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Disorders

The Cleveland Clinic Foundation, Cleveland, Ohio

Received for publication May 27, 2008; revisions received May 27, 2008; accepted for publication May 29, 2008.

^_* Address for reprints: A. Marc Gillinov, MD, The Cleveland Clinic Foundation, Department of Thoracic/Cardiovascular Surgery, Desk F25, 9500 Euclid Avenue, Cleveland, OH 44195. (Email: gillinom@ccf.org).

The first 20% of the full text of this article appears below.

	Introduction

 
On May 15, 2008, The American College of Cardiology/American Heart Association/Heart Rhythm Society 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities were published online. Subsequently, the guidelines were concurrently published in the Journal of the American College of Cardiology, Circulation, and Heart Rhythm.¹ The guidelines were developed in collaboration with the American Association for Thoracic Surgery and the Society of Thoracic Surgeons. Focusing on 3 areas—pacemakers for bradyarrhythmias and heart failure management, cardiac resynchronization therapy (CRT), and implantable cardioverter defibrillators (ICDs)—these guidelines update the previous version published in 2002. The guidelines are comprehensive, and the reader is referred to appropriate sections for recommendations related to specific clinical presentations. This commentary will 1) provide a brief summary of several key recommendations, highlighting notable changes in the guidelines and their relevance to surgical practice, and 2) summarize the section on surgical considerations for device-based therapy.

	Key Recommendations

 
Pacemakers
Indications for pacemaker therapy (eg, sinus node dysfunction and acquired atrioventricular block) are well defined. The guidelines encourage optimization of pacemaker programming to minimize unneeded right ventricular pacing. It is recognized that right ventricular apical pacing may not be the best approach in many patients because this mode of pacing has adverse effects on left ventricular (LV) and left atrial structure and function and is associated with an increased incidence of atrial fibrillation and congestive heart failure when compared with dual-chamber pacing. The role of biventricular pacing in patients without heart failure is not yet well defined, although this may be a reasonable option in selected young patients who require lifelong pacing. Pacemaker implantation is discouraged for asymptomatic bradycardia, particularly when bradycardia occurs at night. Pacing is not indicated for prevention of atrial fibrillation.

Cardiac Resynchronization Therapy
The need for optimization of medical therapy before CRT implantation is emphasized. CRT . . . [Full Text of this Article]