Keynote Message
Device therapy in heart failure (HF) is a fertile area of investigation and progress. All therapies are being developed for HF with reduced ejection fraction (HFrEF), and most target severe HF. However cardiac resynchronisation therapy (CRT), targeting HFrEF with large ECG QRS (and mainly patients with left bundle branch block) is proven to be effective as early as NYHA class II, beyond and on top of pharmacotherapy, and receives a high grade of guidelines recommendation (1A) for improving survival and reducing the rate of HF admission. Implantable cardiac defibrillator (ICD) is effective in reducing sudden death in patients with EF below 35%. It is usually combined with CRT in patients with large QRS. Questionable cost effectiveness issues make the use of ICD and CRT limited and more so, to wealthy countries.
In more advanced HFrEF, left ventricular assist device (LVAD) is effective in prolonging survival and decreasing disability and is mainly used as a bridge to heart transplant. It tends now also to be used as destination therapies in patients unlikely to receive a heart transplant.
A large array of other device therapies, based on a much lower level of evidence is currently competing for an increasing segment of HF population (i.e., patients remaining symptomatic despite optimal medical therapy). Penetration is still anecdotal. Autonomic modulation therapy is being tested with disappointing findings with vagal nerve modulation and renal sympathetic denervation and promising results with baroreceptors stimulation.
An even larger array of innovative technologies is being tested, culminating with the total artificial heart. This area is receiving a high level of interest by large and smaller Medtech companies and is very competitive. It is also facing increasing regulatory requirements of safety, efficacy and cost effectiveness, potentially limiting enthusiasm and investment in research and development.
Key References
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