Cardiac resynchronization therapy in congestive heart failure: Ready for prime time?
OBJECTIVE
The aim of this article is to critically review the data accumulated to date on the application of cardiac resynchronization therapy (CRT) via biventricular pacing techniques to manage patients with advanced heart failure. The data from studies evaluating the effects of long-term right ventricular (RV) pacing are also briefly reviewed.


METHODS
MEDLINE and selective journal searches of English-language reports and a search of references of relevant papers were conducted.


RESULTS
Cardiac dyssynchrony as reflected by a prolonged QRS complex, often in the form of left bundle branch block, is encountered in about 30% of patients with moderate-to-advanced heart failure. Among these patients, 10% to 15% are candidates for CRT via biventricular pacing. Accumulated evidence from randomized controlled studies over the last few years has indicated a significant hemodynamic and clinical improvement conferred by CRT to class III or IV heart failure patients with idiopathic or ischemic dilated cardiomyopathy having a low left ventricular ejection fraction (</=35%) and a wide QRS complex (>/=120-150 ms). Newer data suggest a significant reduction in overall mortality and heart failure hospitalization, particularly when CRT is combined with automatic defibrillator backup. Technical advances with percutaneous methods accessing the tributaries of the cardiac veins have raised the success rate of implantation of left ventricular leads to >90%. Further confirmation from ongoing trials is awaited, and more data from cost-effectiveness studies are needed before CRT is considered for prime time therapy in the heart failure population. If the data confirm a survival benefit from CRT, use of this electrical therapy at earlier stages of heart failure might be contemplated. New evidence from recent studies suggests a deleterious effect of the long-standing practice of producing an iatrogenic left bundle branch block by conventional RV apical pacing in patients receiving permanent pacemakers. Thus, having already become poignantly aware of the harmful effects of spontaneous left bundle branch block, this emerging new evidence about RV apical pacing would dictate a change of attitude and direct our attention to alternate sites of pacing, such as the left ventricle and/or the RV outflow tract, if not for all patients then at least for those with left ventricular dysfunction.


CONCLUSIONS
CRT offers hemodynamic and clinical improvement to patients with moderate-to-advanced heart failure, and it might significantly prolong survival in selected patients, particularly if devices with defibrillation backup are used. Further confirmatory data from randomized mortality trials are needed, and issues of cost efficacy must be resolved before this vital therapeutic alternative is ready for prime time therapy of heart failure patients.
Manolis
Antonis S
AS
A' Department of Cardiology, Evagelismos General Hospital of Athens, Athens, Greece. asm@otenet.gr
D002037:Bundle-Branch Block / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D002304:Cardiac Pacing, Artificial; D017147:Defibrillators, Implantable; D006333:Heart Failure / Q000150:complications* / Q000401:mortality; D006801:Humans; D008133:Long QT Syndrome / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D010138:Pacemaker, Artificial; D016896:Treatment Outcome