Reversing heart failure by CRT: how long do the effects last?

Abstract

This editorial refers to ‘Long-term impact of cardiac resynchronization therapy in mild heart failure: 5-year results from the REsynchronization reVErses Remodeling in Systolic left vEntricular dysfunction (REVERSE) study’[†][1], by C. Linde et al. , on page 2592 Device-based treatment of advanced systolic heart failure by cardiac resynchronization therapy (CRT) is a fairly invasive procedure when compared with conservative pharmacological therapy. Despite all efforts to improve the safety, feasibility, and clinical efficacy of the implantation procedure, a small, but not negligible, perioperative risk and the possibility for long-term complications such as device infection and lead dislocation remain. Furthermore, the upfront costs at the time of implantation are comparatively high. However, the large amount of available evidence which has been accumulated over the last two decades from many well-controlled and randomized trials has proven that the procedure is highly cost-effective and efficient in well selected patients. The stimulus to place an additional pacing lead on the delayed activated left ventricular free wall in patients with left bundle branch block (LBBB) to improve cardiac haemodynamics was based on pathophysiological principles, well-performed animal experiments, and thoughtful clinical observations. However, what initially was meant to be a rescue therapy for end-stage heart failure patients,1,2 has, over time, transformed into a life-saving routine treatment which is now indicated as soon as a patient with depressed systolic function and LBBB develops symptoms of heart failure [e.g. New York Heart Association (NYHA) class ≥II].3 Part of the evidence to support this aggressive therapeutic approach in patients with mild symptoms of heart failure comes from the 12-month results of the REVERSE trial,4 which was the first prospective, randomized trial to include patients with less than NYHA class III–IV. Although the primary endpoint—a composite score of the clinical response of heart failure—failed to reach statistical significance … [1]: #fn-2