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Cardiac resynchronisation therapy (CRT), by retiming the failing heart, improves symptoms, reduces hospitalisations and improves survival in patients with left ventricular dysfunction and QRS prolongation. However, not all patients “respond” to CRT. Successful CRT depends on appropriate patient selection, optimal lead positioning, device programming/optimisation and optimal medical therapy. This review article focuses on the importance of lead positioning in improving outcomes.

ObjectiveThe study aimed to evaluate the impact of a multidisciplinary inpatient heart failure team (HFT) on treatment, hospital readmissions and mortality of patients with decompensated heart failure (HF).MethodsA retrospective service evaluation was undertaken in a UK tertiary centre university hospital comparing 196 patients admitted with HF in the 6 months prior to the introduction of the HFT (pre-HFT) with all 211 patients seen by the HFT (post-HFT) during its first operational year.ResultsThere were no significant differences in patient baseline characteristics between the groups. Inpatient mortality (22% pre-HFT vs 6% post-HFT; p<0.0001) and 1-year mortality (43% pre-HFT vs 27% post-HFT; p=0.001) were significantly lower in the post-HFT cohort. Post-HFT patients were significantly more likely to be discharged on loop diuretics (84% vs 98%; p=<0.0001), ACE inhibitors (65% vs 76%; p=0.02), ACE inhibitors and/or angiotensin receptor blockers (83% vs 91%; p=0.02), and mineralocorticoid receptor antagonists (44% vs 68%; p<0.0001) pre-HFT versus post-HFT, respectively. There was no difference in discharge prescription rates of beta-blockers (59% pre-HFT vs 63% post-HFT; p=0.45).The mean length of stay (17±19 days pre-HFT vs 19±18 days post-HFT; p=0.06), 1-year all-cause readmission rates (46% pre-HFT vs 47% post-HFT; p=0.82) and HF readmission rates (28% pre-HFT vs 20% post-HFT; p=0.09) were not different between the groups.ConclusionsThe introduction of a specialist inpatient HFT was associated with improved patient outcome. Inpatient and 1-year mortality were significantly reduced. Improved use of evidence-based drug therapies, more intensive diuretic use and multidisciplinary care may contribute to these differences in outcome.

Purpose Although a substantial proportion of patients with heart failure (HF) have anemia, there is a paucity of data evaluating the impact of anemia on clinical outcome in CRT patients. Our goal was to examine the ability of baseline hemoglobin (Hb) level and change in Hb level over time to predict clinical 2-year outcome and echocardiographic response to CRT. Methods Three hundred consecutive CRT patients (median 72 years [interquartile range (IQR) 16 years], 19 % female) with baseline and follow-up hematological profiles available were examined. Baseline anemia was defined as Hb <12 g/dL in women and <13 g/dL in men, and patients were grouped into equal quartiles based on change in Hb. Two-year clinical outcome was determined using a composite endpoint that included HF hospitalization, left ventricular assist device (LVAD) placement, heart transplantation, and all-cause mortality. Echocardiographic reverse remodeling was examined at 6-month follow-up. Results One hundred fifty-one anemic patients were compared to 149 non-anemic patients. Changes in left ventricular dimensions and ejection fraction were similar for both groups. Univariate predictors of 2-year clinical outcome included baseline creatinine level, diuretic usage, and anemia; in multivariable regression, baseline anemia was an independent predictor for outcome (hazard ratio [HR] 1.79, 95 % confidence interval [CI] [1.22–2.63], p  = 0.003). The quartile with the most negative change in Hb concentration over time (≤−1.00 g/dL) had poorer event-free 2-year survival (HR 1.84, CI [1.13–3.00], p  = 0.014). Conclusions Baseline anemia and early postimplantation decline in Hb levels are associated with a worse 2-year prognosis in CRT patients, even though the magnitude of left ventricular reverse remodeling is similar compared to non-anemic patients.

Patients with heart failure die predominantly of progressive pump failure or sudden cardiac death. Therefore, it is attractive to believe that an implantable cardioverter defibrillator (ICD) will dramatically reduce mortality by reducing sudden death. However, unfortunately it is not that simple; sudden death is not the same as ICD-preventable death. While ICD prophylaxis always reduces arrhythmic death, it does not always reduce all-cause mortality due to competing risks. Importantly, an arrhythmia may be a marker for heart failure decompensation, with patients at increased risk of heart failure death following shock therapy. Randomized trials have now demonstrated the potential benefits of ICDs in selected patients with left ventricular dysfunction, yet they have also failed to demonstrate benefit in populations where one might have expected to see benefit (e.g., early post-myocardial infarction). Device therapy can offer heart failure patients much more than just a simple shock box. The addition of a left ventricular lead to allow biventricular pacing (cardiac resynchronization therapy) improves symptoms and prolongs life in selected patients with QRS prolongation. Newer technologies allow remote monitoring through the device, which offers the potential to recognize heart failure decompensation or arrhythmias early so that appropriate treatment can be instituted. However, deciding which patient should receive an ICD remains one of the most challenging questions in cardiovascular medicine.

Patients with advanced heart failure have a dismal prognosis and poor quality of life. Heart transplantation provides an effective treatment for a subset of these patients. This article provides cardiologists with up-to-date information about referral for transplantation, the role of left ventricular assist devices prior to transplant, patient selection, waiting-list management and donor heart availability. Timing is of central importance; patients should be referred before complications (eg, cardiorenal syndrome or secondary pulmonary hypertension) have developed that will increase the risk of, or potentially contraindicate, transplantation. Issues related to heart failure aetiology, comorbidity and adherence to medical treatment are reviewed. Finally, the positive role that cardiologists can play in promoting and facilitating organ donation is discussed.

Plasma concentrations of endothelin-1 (ET1), a potent vasoconstrictor peptide, are raised in patients with chronic heart failure, correlate with the symptomatic and hemodynamic severity of heart failure and predict prognosis. The debate over the better therapeutic agent in chronic heart failure is discussed.