Biventricular pacing for dilated cardiomyopathy: Proper patient selection

Despite the impressive results of pharmacotherapy in patients with severe heart failure, the prognosis of these patients remains poor. For the subset of heart failure patients who have a bundle branch block and continue to have severe symptoms despite optimal medical therapy, biventricular pacing can provide significant symptomatic improvement, reduce hospitalization rates, and contribute to reverse remodeling. Patients with the most advanced heart failure and ventricular dysynchrony are the most likely to benefit from biventricular pacing. Reasonable requirements for biventricular pacing include NYHA class III or IV heart failure symptoms despite optimal medical therapy, LVEF ≤0.35, and a QRS duration ≥130 msec on the 12-lead ECG. Although sinus rhythm is preferable, patients with AF are potential candidates if the ventricular rate can be controlled. Patients with advanced heart failure and high-grade AV block, who need ventricular pacing, should be considered for addition of a left ventricular pacing lead. Additional studies are needed to identify optimal candidates for biventricular pacing.