On the Front Lines

Abstract

Andrea Natale, MD, FHRS, Consulting EditorView Large Image Figure ViewerDownload Hi-res image Download (PPT)It is better to debate a question without settling it than to settle a question without debating it.—From Joseph Joubert, French moralist and essayist, 1754–1824 Debates and controversies clarify and spur human understanding and are the essential fuel for scientific progress. So, it is fitting to mark the second anniversary of the Cardiac Electrophysiology Clinics with an issue devoted to Contemporary Debates and Controversies. In fact, because of the myriad contemporary issues worthy of discussion, this issue of the Clinics focuses on some of the contemporary controversies around device therapy for ventricular arrhythmias and the June 2012 issue will highlight issues surrounding ablative therapy. The implantable cardioverter defibrillator (ICD) was FDA approved over a quarter century ago, in 1985. Understanding defibrillation and proving the utility of the ICD for preventing sudden cardiac death (SCD) for various arrhythmic substrates were the focus of some of the initial research efforts. In the intervening years, we have also witnessed the development of cardiac resynchronization therapy (CRT) for refractory heart failure. While many landmark studies have established the utility of these therapies, many new questions have arisen. We have selected a few of these to highlight in the present issue of the Clinics. Some examples include the following:•The survival advantage of ICDs over conventional therapy seen in randomized clinical trials is usually not seen in the community once the devices become widely utilized for the given indication. The first article by Nair and colleagues explores this issue in depth.•ICD registries have collected enormous amounts of data on implant indication, timing, complications, etc. We are beginning to see new research from these data that will impact device therapy in the coming decades. Dr Hammill has outlined the important lessons we have learned from registries and additional insights we may gain by examining these data further.•Cardiac electrophysiology has grown in leaps and bounds over the last four decades. This success has been due to and has fueled further development of therapies that have enhanced the duration and quality of patients’ lives. As we push these boundaries, we must critically examine which patients benefit the most from these expensive interventions. Drs Kramer and Josephson point out some cautionary notes as we expand CRT indications to patients with narrower QRS complexes as well as to disease states, such as patients with end-stage renal disease, where the efficacy of ICD and CRT devices is unproven.•While the primary prevention strategy clearly works, cost pressures on health care systems demands a higher yield of appropriate ICD discharges while at the same time reducing inappropriate therapies. To shed light on this, Dr Dello Russo and colleagues report on the utility of scar mapping as a risk-stratifying tool to identify truly high-risk patients for SCD, thereby making ICD therapy more cost-effective. These examples illustrate some of the contemporary issues that our field is grappling with. The reader will get a better idea by examining the full table of contents. We endeavored to select topics that are germane to today’s practice and contributors who are thought leaders in the respective areas. We have learned much from our contributors and we hope that the readership will also benefit from their wisdom in these pages.