The Dilemma of Providing Cardioverter/ Defibrillator Back-Up for all Patients with Heart Failure Eligible for Cardiac Resynchronization Therapy

A B S T R A C T Cardiac resynchronization therapy (CRT) achieved by biventricular pacing (CRT-P) has been proved to improve symptoms and prognosis of patients with refractory heart failure. Sudden cardiac death is quite common among patients with symptomatic heart failure and implantable cardioverter-defibrillator (ICD) therapy has been proved to effectively reduce sudden deaths in heart failure patients. Given the results of the recently published primary prevention trials and the high incidence of sudden cardiac death among CRT-P recipients, CRT combined with backup defibrillator therapy (CRT-D) seems a logical therapeutic option in patients eligible for CRT. However, the apparent beneficial effects of such an appealing combination do not alleviate the skepticism about the unselected use of CRT-D therapy. This skepticism is largely related to the high cost of this method, to the limited availability of human and financial resources and to our inability to appropriately define the selection criteria for CRT candidates, which are expected to influence the clinicians’ decisions when confronted with the dilemma of providing CRT-D therapy for all patients eligible for CRT.