Biventricular pacing for heart failure

The completed trials of biventricular pacing in congestive cardiac failure are impressively encouraging as a novel therapy for the symptoms of a most devastating disease. The actual delivery of the LV pacing hardware and final patient selection criteria require further refinement, as it is clear that not all patients with heart failure respond favorably. What is clear is that all patients should be prescribed maximally tolerated, proven medical therapy before assessment as to the feasibility of biventricular pacing therapy. This should be the case until potentially proven otherwise in newly planned trials designed to assess the comparative efficacy of both approaches. It is difficult to see that the two approaches should be anything but complementary in their benefit. The expense and potential complication associated with any invasive procedure needs to be considered, however, and it would seem reasonable that all of these patients should be receiving maximally tolerated medical therapy before and after the implantation of a device. Finally, the effect of this therapy on mortality needs to be assessed and, consequently, the requirement for defibrillation capability considered in this population of patients with a known high incidence of sudden death.