Guideline-directed interventional therapy (GDIT)
Every device, procedure and programme with a Class I–III recommendation in the 2026 ESC guideline (44 in all). GDIT candidacy is not gated by kidney stage; kidney-related caveats are listed where the sources give them.
“Guideline-directed interventional therapy (GDIT) includes all cardiac implantable electronic devices (CIED) and interventional therapies that have a recommendation in the guidelines.” — ESC 2026, p. 18
Sequencing with medical therapy
ESC 2026: implement FMT at RCT doses before device therapy (ICD after >=3 months of optimal FMT); exception: CRT planning may run simultaneously with FMT initiation in LBBB QRS >=150 ms, LVEF <=35% (IIb C), and early CRT planning in pure conduction-abnormality HF. GDIT commitment is generally lifelong.
Source wording (6)
“Pharmacotherapy remains the cornerstone of treatment for stage C HF and should be implemented at doses used in RCTs in patients with HF before considering device therapy, and alongside non-pharmacological interventions (Figure 1 and Table 11).”
“Initiation of FMT and planning for CRT implantation may be considered simultaneously in patients with symptomatic HFrEF, an LBBB with QRS ≥150 ms, and LVEF ≤35%, to improve symptoms and reduce morbidity and mortality, although reassessment of LVEF should be conducted prior to CRT implantation.”
“Initiation of FMT and planning for CRT implantation may be considered simultaneously in patients with symptomatic HFrEF, an LBBB with QRS ≥150 ms, and LVEF ≤35%, to improve symptoms and reduce morbidity and death, although reassessment of LVEF should be conducted prior to CRT implantation.”
“A 3-month period after uptitration of FMT before considering ICD implantation is reasonable.”
“In patients with HF, where no other cause of HF other than abnormal cardiac conduction can be found, and there is a low likelihood of LVEF improvement, planning for CRT implantation may be considered early—even before full FMT uptitration.”
“As with FMT, the commitment to GDIT is in most cases lifelong.”
ICD & CRT
Implantable and wearable defibrillators
Cardiac resynchronization therapy
Acute & advanced HF
Respiratory and kidney support in decompensated HF
Temporary mechanical circulatory support
Durable support and transplantation
Rhythm, coronary & valve
Atrial fibrillation
Coronary revascularization
Valve interventions
Rehabilitation, monitoring & other
Rehabilitation and exercise
Monitoring
Sleep apnoea and weight
No recommendation
- Conduction system pacing (His / LBBAP)
Discussed; no RCT with patient-centred outcomes, so no recommendation.
“Left bundle branch area pacing may prove to be a feasible alternative to CRT when implantation is challenging.”
“Therefore, no recommendations can currently be made.”
- Cardiac contractility modulation
Insufficient evidence for a recommendation.
“Current evidence for these CIEDs is insufficient to support guideline recommendations.”
- Baroreflex activation therapy
Insufficient evidence for a recommendation (long-term outcome data neutral).
“Similarly, baroreceptor activation therapy led to improvements in 6-min walk distance and QoL in an unblinded RCT, but long-term clinical outcome data were neutral.”
- Interatrial shunt device
RELIEVE-HF and REDUCE LAP-HF II neutral; possible harm in HFpEF; no recommendation.
“Importantly, patients with reduced LVEF had fewer adverse CV events with shunt treatment, whereas patients with HFpEF had more CV events.”
“Other implantable devices, for which recommendations have not been made, will be discussed at the end of this section.”
- Subcutaneous / extravascular ICD
Narrative only in ESC HF 2026; S-ICD is an alternative in haemodialysis per ESC CVD-CKD (IIb C).
“The S-ICD is comparable to transvenous ICDs in terms of efficacy, complication rates, and inappropriate shock rates.”
“Where an ICD is indicated, implantation of a subcutaneous defibrillator may be considered as an alternative to transvenous ICD if there is no need for either bradycardia pacing, cardiac resynchronization, or ATP in patients with CKD on haemodialysis to reduce the risk of SCD and CIED-related infections.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 63 Source
- Veno-arterial ECLS
No standalone recommendation; covered by the Class III row on temporary MCS in unselected AMI-CS and by the free-wall-rupture footnote.
“RCTs investigating the efficacy of ECLS in non-ischaemic CS have yet to be performed.”
- Device-based (CIED) remote monitoring
Little outcome evidence; no recommendation.
“However, there is currently little evidence that device monitoring improves clinical outcomes, although ongoing RCTs are awaited.”
- Tricuspid transcatheter/surgical intervention
Deferred to 2025 ESC/EACTS VHD guideline; no HF-guideline recommendation row.
“Indications for TR treatment are reported in the 2025 ESC/EACTS Guidelines for the management of valvular heart disease.”
- Primary MR surgery / TEER
Narrative only (surgical repair preferred; TEER at high surgical risk); deferred to VHD guideline.
“In severe primary MR with HF symptoms, surgical repair is preferred over replacement whenever feasible.”
“Mitral transcatheter edge-to-edge repair (TEER) should be considered in patients at high surgical risk.”
- Left atrial appendage closure
Deferred to 2024 ESC AF guideline.
“Left atrial appendage closure can be an option for selected patients as described in the 2024 ESC Guidelines for the management of atrial fibrillation.”
- PVC catheter ablation
Narrative only; deferred to 2022 ESC VA/SCD guideline.
“Catheter ablation of PVCs may improve LV function and, possibly, outcomes in patients with PVCs.”
- Bradycardia pacing
Indications same as without HF; CRT preferred when high pacing burden expected in HFrEF.
“Pacing indications in patients with HF do not differ from those without HF.”
“The 2021 ESC Guidelines on cardiac pacing recommend leadless pacemakers as an alternative to transvenous pacing in patients on haemodialysis to reduce infection risk.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 63 Source