Should stimulation therapy for congestive heart failure be combined with defibrillation backup?

Biventricular pacing has been proposed to resynchronize ventricular contrac tion in patients with congestive heart failure (CHF) and interventricular c onduction delay. However, the sudden death rate is still high despite the i mprovement in cardiac performance. Devices combining biventricular pacing w ith implantable cardioverter defibrillator (ICD) backup are now under clini cal investigation to demonstrate whether they can decrease sudden death. Fr om the first implant of an ICD with biventricular transvenous pacing on Aug ust 1998 to April 2000, 96 patients underwent such implants: 67 (70%) recei ved pacemakers alone and 29 (30%), who had class I ICD indications, receive d combined pacemaker/ICD systems. During a mean follow-up of 283 +/- 170 da ys, 13 (14%) patients died: 5 of 29 (17%) in the ICD group and 8 of 67 (12% ) in the pacemaker group. A total of 15 patients (52%) had ICD shocks and 6 patients (21%) had 113 episodes of ventricular tachyarrhythmias, of which 96 (85%) were converted to sinus rhythm with antitachypacing, The echocardi ograms showed a narrowing of the delay between the onset of right and left ventricular outflow from 40 +/- 37 msec to 17 +/- 16 msec (p = 0.03) and a reduction of the mitral regurgitation area from 7 +/- 3.8 cm(2) to 5 +/- 4 cm(2) (p = 0.04) at 3 months. Functional class improved from 2.8 +/- 0.7 to 1.6 +/- 0.5 (p <0.001) 3 months after implant. Thus, ischemic patients wit h reduced left ventricular ejection fraction and ventricular tachyarrhythmi as seem good candidates for biventricular pacing with ICD backup. The sudde n death risk for those with idiopathic dilated cardiomyopathy, however, is difficult to stratify, and the choice of ICD backup has to be considered on the basis of patient safety, as well as of costs. (C) 2000 by Excerpta Med ica, Inc.