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Aims Optimal left ventricular (LV) lead position improves the response to cardiac resynchronization therapy (CRT). However, in some patients it is not possible to position the LV lead at an optimal pacing site. The aim of this study was to determine whether optimization of the pacing settings atrioventricular delay (AVD) and interventricular delay (VVD) can compensate for a non-optimal LV pacing site. Methods and results In 16 patients with heart failure [New York Heart Association class III (13) or IV (3), median QRS duration of 172 ms and median LV ejection fraction of 20%] the acute haemodynamic effect of biventricular pacing was assessed at ≥2 pacing sites by the increase in maximum rate of LV pressure rise (%d P /d t max). At each site the AVD and VVD were optimized. Biventricular pacing with nominal settings at a non-optimal LV pacing site improved d P /d t max by 12.8% (−0.5 to 23.2%). This could be further improved by 6.5 percentage points (1.2–13.9) by optimization of pacing settings ( P = 0.001) and by 9.9 percentage points (3.7–13.3, P = 0.004) by optimization of pacing site. Optimization of the LV pacing site and pacing settings together improved %d P /d t max by 16.2 per cent points (10.0–21.8, P < 0.001). Conclusion Optimization of the AVD and VVD can partly compensate for a non-optimal LV pacing site. However, a combination of an optimal LV pacing site and optimized pacing settings gives the best acute haemodynamic response.

This editorial refers to ‘Phenotypic expression is a prerequisite for malignant arrhythmic events and sudden cardiac death in arrhythmogenic right ventricular cardiomyopathy’ by A. Zorzi et al ., on pages 1086–1094. Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an inherited cardiomyopathy characterized by ventricular arrhythmias, predominantly right ventricular dysfunction, and sudden cardiac death (SCD). Sustained ventricular arrhythmias in ARVD/C are frequently stable monomorphic ventricular tachycardia (VT) episodes with left bundle branch block morphology, associated with structural heart disease due to fibro-fatty alteration. Sudden cardiac death due to ventricular fibrillation (VF) may occur at all disease stages, either as deterioration of monomorphic VT or as primary event. Importantly, SCD may occur as first manifestation of ARVD/C. Sudden cardiac death is frequently observed in young individuals. Quarta et al. 1 studied the age distribution in 45 individuals dying suddenly from pathologically proven ARVD/C. In half of these individuals, SCD occurred at ≤30 years of age, and in 14 of them at ≤20 years (youngest 14 years). In …

Aims The experiences of patients who received shocks from their implantable cardioverter defibrillator (ICD) and how these events affect their overall adjustment are poorly understood. Our goal was to evaluate quality of life and psychological well-being, and the prevalence of, and changes in, depression and anxiety of patients who did or did not experience defibrillatory shocks in the first 12 months after ICD implantation. In total 167 patients were monitored after discharge. Four self-administered questionnaires were used. The first assessment took place before ICD implantation, the remaining three at 1, 6 and 12 months after discharge. Results We classified patients into three shock groups and one no shock group. A small group of ICD recipients (26%) received ICD shock delivery, usually during the last 6 months of the study. Borderline significant differences were found within the groups over time regarding physical role limitations (P < 0:051). Those who experienced shocks throughout the year (group 1) felt more limited in their daily activities due to physical or mental problems. All groups reported an improvement in their health (P < 0:001). Overall quality of life did not change significantly after 6 months. Anxiety and depression did not change significantly over time. In total 22–66% of patients reported clinically significant depressive symptoms throughout the first year, and 31–83% clinically significant symptoms of anxiety. ICD recipients who had experienced a shock were significantly more anxious one-year postdischarge than those who had not received a shock. Conclusions Overall quality of life and psychological wellbeing did not change in ICD recipients, irrespective of whether they experienced defibrillatory shocks. The high prevalence of depression and anxiety can be interpreted as a response to the perceived physical and mental problems regarding daily activities. Our data indicate that patients who have experienced an ICD shock do not adapt well to living with an ICD, they are more anxious than ICD recipients who received no shocks. However, the anticipation of having another shock after experiencing one is less stressful than that of the first shock. We conclude that the lasting psychological distress will not dissipate spontaneously or naturally and that psychosocial interventions may be warranted.