Arrhythmia treatment, devices and advanced interventions in heart failure
THE CONTEXT
Selected patients with heart failure may benefit from amiodarone, defibrillators, cardiac resynchronisation, coronary revascularisation or transplantation.
Amiodarone
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Amiodarone is a potent anti-arrhythmic with little negative inotropic effect and may be valuable in patients with poor left ventricular function.
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Its use is directed at symptomatic arrhythmias; it should not be given as a preventative agent to asymptomatic patients.
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It is used to prevent symptomatic atrial arrhythmias and ventricular arrhythmias when other pharmacological options have been exhausted.
Implantable devices
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Implantable cardiac defibrillators reduce sudden death risk in patients with heart failure who have had, or are at high risk of, life-threatening ventricular arrhythmias.
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Marked conduction system disease, especially left bundle branch block, causes uncoordinated left ventricular contraction that exacerbates heart failure.
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Cardiac resynchronisation therapy overcomes dyssynchronous contraction by pacing the left and right ventricles simultaneously.
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Resynchronisation improves cardiac output and symptoms and reduces mortality.
Coronary revascularisation
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Coronary artery bypass surgery or percutaneous coronary intervention may improve function in myocardium that is hibernating because of inadequate blood supply.
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Revascularisation can be used in carefully selected patients with heart failure and coronary artery disease.
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Hibernating myocardium can be identified using stress echocardiography or specialised nuclear or magnetic resonance imaging.
Cardiac transplantation
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Cardiac transplantation is an established treatment for intractable heart failure. Coronary artery disease and dilated cardiomyopathy are the most common indications.
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Its use is limited by donor heart availability and the efficacy of modern drug and device therapies.
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It is generally reserved for young patients with severe symptoms despite optimal therapy.