Posts Tagged ‘miracle’

Cadiac resynchrnonisation (CRT) therapy , is  the most famed  as well as  ridiculed treatment modality for refractory failure . It is facing a real tough time for survival now .(At least in class 4 CHF.)

Confident and  authentic data  are emerging  now , that CRT should not be  used  in advanced heart failure .(This is in total contrast with the original concept  ,  when CRT was introduced nearly  a decade ago !  more  of class 3 and 4 were enrolled ) . Bad outcomes are expected in advanced CHF. This is something similar to whipping the tired horse concept  which  found inotropes   to increase the mortality in severe heart failure .

The article in the current issue of circulation  shows  no mercy to CRT  in advanced CHF


So what  is  the answer to the ailing CRT industry ?

Go and catch class 1 and class 2 CHF population* .You will get plenty  , of course  it got ratified by MADIT -CRT trial .

* It is attractively called prevention of cardiac failure

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                                          CRT , cardiac resynchronisation therapy  is being  projected  as a revolutionary treatment for cardiac failure , where a failing heart is rewired electrically through multiple leads and make it contract  more effectively.The success rate of CRT was highly variable.The basic question here  is,  there should be a  significant  documentation of desynchronisation  prior to CRT , for resynchronisation to be effective. Further , the sites of  myocardial  stimulation ( Coronary sinus/LV epicardial) , dose of electricity and the sequence of stimulation and the  electrical delay  are very  critical. Achieving this into perfection  is not a simple job and is  real rocket science ! ( If we can achieve 5 % of what  the normal purkinje network do within the LV we can term it a huge success.) Let us hope we catch up with nature . Finally , it is ironical  the sites of LV pacing ,  electrophysiologists  select currently  is infact not selected by them but pre selected by the patients coronary venous anatomy ! .So as on date ,  one can imagine how scientific this treatment could be !

                                         Initially it was adviced for patients with only wide qrs later for even normal qrs patients.When people started using it indiscriminately  insurance companies started to rethink and thus came the   RETHINQ study in NEJM  and brought a full stop to CRT in normal qrs CHF.

How to identify who will benefit from  the costly CRT  ?

It is a million dollar question. So millions of dollars were spent to identify the correct tool to identify the true responders to CRT.Echo cardiography with sophisticated methods tissue doppler, tissue tracking and , 3 D echo ,velocity vector imaging were done .These methods are not only costly but also time consuming and  hugely expertise driven.

Does all this  efforts with  advanced echo techniques worthwhile ?

This simple question was addressed in PROSPECT study in circulation

Click to read the article

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