Pieragnoli P, Ricciardi G, Colella A, Musilli N, Porciani M C, Giaccardi M, Padeletti L, Michelucci A
Department of Medical and Surgical Critical Care, University of Florence, Florence, Italy.
Minerva Cardioangiol. 2006 Dec;54(6):735-41.
Implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) have been introduced during the recent years to improve survival, decrease hospital readmissions and mortality, and to improve functional status and quality of life for patients with heart failure and left ventricular systolic dysfunction (LVSD). Studies which evaluated the use of CRT or ICD alone or compared CRT with CRT-ICD in patients with heart failure and LVSD are listed in this article. The results obtained are already influencing clinical practice in the US, where it has been estimated that 90% of patients receiving a CRT device now are being implanted with an ICD component. However, it is still today debated whether patients with LVSD and heart failure should be routinely offered a CRT-ICD. In fact, there are some issues that still should be solved before to establish indication for CRT-D in all heart failure patients with an indication for CRT: 1) a non complete agreement among the different societies which wrote recommendations for guidelines (a comparative table is reported); 2) a better identification of implantable patients and an amelioration of utilized devices; 3) economic and ethical ramifications of this therapy. Anyway still now the crucial question is: ''Can resynchronization be done in isolation or must be accompanied by an ICD device?''. To answer to this question we can only express which is, in our opinion, the actual position of many physicians who work in the field of pacing and electrophysiology: ''The lesson to be learned is that we still can not predict surely which patient will die of sudden death. Until a method of identifying the high risk patients can be developed, the safest strategy should be to advise a combined ICD-CRT device for patients with indication for CRT''.
近年来，植入式心脏复律除颤器（ICD）和心脏再同步治疗（CRT）已被应用于改善心力衰竭和左心室收缩功能障碍（LVSD）患者的生存率、降低住院再入院率和死亡率，并改善其功能状态和生活质量。本文列出了评估单独使用CRT或ICD，或比较心力衰竭和LVSD患者中CRT与CRT-ICD疗效的研究。所获得的结果已经在美国影响临床实践，据估计，目前接受CRT设备的患者中有90%植入了ICD组件。然而，对于LVSD和心力衰竭患者是否应常规使用CRT-ICD，至今仍存在争议。事实上，在为所有有CRT适应症的心力衰竭患者确定CRT-D适应症之前，仍有一些问题需要解决：1）撰写指南建议的不同学会之间尚未完全达成一致（报告了一个比较表）；2）更好地识别可植入患者并改进使用的设备；3）这种治疗的经济和伦理影响。无论如何，目前关键的问题是：“再同步治疗可以单独进行还是必须伴有ICD设备？”。为了回答这个问题，我们只能表达我们认为许多从事起搏和电生理领域工作的医生的实际立场：“要吸取的教训是，我们仍然无法确定地预测哪些患者会死于猝死。在开发出一种识别高危患者的方法之前，最安全的策略应该是为有CRT适应症的患者建议使用ICD-CRT联合设备”。
