Cardiac implantable electronic device upgrades and downgrades: a Clinical Consensus Statement of the European Heart Rhythm Association (EHRA) of the ESC, the Asia Pacific Heart Rhythm Association (APHRS), Canadian Heart Rhythm Society (CHRS), Heart Rhythm Society (HRS), and the Latin American Heart Rhythm Society (LAHRS)

Abstract Cardiac implantable electronic device upgrade and downgrade procedures are increasingly being performed. Whilst the most appropriate guideline-recommended device may have been followed during a patient's initial procedure, the requirements of patients can change over time. This could be due to worsening of cardiac function due to detrimental effects of pacing itself or the diagnosis, development, or progression of another cardiac comorbidity. Device downgrades are also performed when a patient's clinical state changes and are often considered in patients with increased frailty and comorbidity. This clinical consensus statement aims to provide a framework for screening patients for device upgrade, pre-procedural planning considerations, available procedural strategies, namely a summary of techniques and approaches for vascular access, including ipsilateral and contralateral options, and a framework for when extraction to gain access may be appropriate. The document also provides advice on how to frame an ethical discussion with patients and carers on available options.