Closing the door after the horse has bolted: device therapy in patients with end-stage heart failure.

The management of patients with severe chronic heart failure (CHF) because of left ventricular systolic dysfunction (LVSD) has been transformed by device therapy over the past decade. In patients with New York Heart Association Class III and IV symptoms and a broad QRS, cardiac resynchronization therapy (CRT) can extend life and improve symptoms, and in patients with less severe symptoms, implantable cardioverter defibrillators (ICDs) can treat life-threatening dysrhythmias, thereby reducing the risk of sudden death. However, questions remain including what to do with patients with less broad QRS complexes, those with less severe LVSD, and those with CHF in the presence of a standard right ventricular pacemaker. One additional group of CHF patients about which we know too little is those with features of CHF suitable for CRT, but who are currently in hospital with a decompensation. CHF is a syndrome that cannot be cured; an eventual decline in symptoms is inevitable whether it be slow and progressive or an acute decompensation. Hence most patients will eventually have severe heart failure, at which point invasive strategies such as CRT, ventricular assist devices (VAD), or cardiac transplantation might be considered. The problem for physicians looking after individual patients with severe CHF is whether these invasive treatments improve outlook enough to provide a return on the morbidity (and mortality) and cost with which they are associated. This decision-making process must include a recognition that, in some, the disease might be too advanced to benefit from a further escalation of treatment. The excellent data presented in this journal by Battcharya et al begin to shed some light, albeit in a registry rather than a randomized controlled trial, on patient