Current Challenges in Cardiac Device Management: Guidance for Practicing Clinicians: A Canadian Journal of Cardiology White Paper.

Cardiac implantable electronic devices (CIED) are medical devices that play a significant role in the management of heart disease by regulating cardiac rate and rhythm. CIEDs encompass pacemakers, implantable cardioverter defibrillators, cardiac resynchronisation devices (CRT), and implantable cardiac monitors. While robust evidence supports the use of these devices, there are several areas where technical developments have outpaced robust clinical trials, including: the role of primary prevention implantable cardioverter-defibrillators in the era of contemporary heart failure (HF) therapy, risk stratification in hypertrophic and dilated cardiomyopathies, the use of conduction system pacing, the impact of tricuspid regurgitation in the presence of a CIED, the role of CIEDs in structural valve interventions (such as percutaneous tricuspid valve interventions and transcatheter aortic valve implantation), and role of leadless CIED systems. Here, we critically appraise the literature associated with these evidence gaps, provide expert review and assessment based on the current evidence, and attempt to foster dialogue among key stakeholders, including clinicians, researchers, industry leaders, and policymakers, in order to generate the evidence needed to refine clinical decision-making and improve patient outcomes.