<INTERNATIONAL CIRCULATION>: Thank you very much professor Linde for the acceptance of this interview from International Circulation. And my first question is: the result of the REVERSE study has just been presented at the ESC congress that CRT as an effective therapy for severe heart failure and patients can improve clinical outcomes by NYHA class I/II HF patients. What is your opinion of this result?  Can we translate the result into all of the mild heart failure patients can use CRT therapy.

Prof. Linde:  Yes， for severe heart failure patients it’s all about getting better， and surviving， and having fewer complications.  In contrast， for patients with the mild heart failure patients it’s about not getting any worse than they are or staying asymptomatic for many years and this is how CRT can help.  In REVERSE in  spite of the fact that patients are mildly symptomatic， their left ventricular function was as poor as in the previous studies of severe heart failure patients.  In REVERSE we  were able to show that over time there is progressive reverse remodeling; very substantial after 6 months but it continues to improve over the following 12 months so that it can be envisioned that it will probably be a continuous process.  In  the 18 month the clinical composite response also was significantly in favor of CRT and that importantly translated into a signicant reduction in time to first heart failure hospitalization  and in time to death and time to first  heart failure related hospitalization. Thus in REVERSE the reverse left ventricular remodeling translated into better morbidity and mortality.  

<INTERNATIONAL CIRCULATION>: oh yeah and they will have more benefit from the early stage of the heart failure if we continue with this CRT therapy?

Prof. Linde: Yes， and the thing that is important is that of course the Pharmacological therapy shows that beta-blockers and ACE inhibitors   are the cornerstone of therapy so that has to be done first.

<INTERNATIONAL CIRCULATION>: I t’s Believe that dual chamber pacing may result in adverse affects on ventricular function for patients with sinus node disease.  What’s your opinion of the optimal pacing mode for these patients?

Prof. Linde: Well， according to the European guidelines， such patients should be given either Atrial  Inhibited pacing (AAI)， that is with no ventricular pacing at all or DDD pacing but with an algorithm that allows for minimal ventricular pacing， This is to avoid right ventricular pacing whenever possible that is in patients who do not have concomitant AV block. The message is， if possible， if the patient with sinus node disease has no sign of bundle branch block a AA I pacing (that is stimulation of only the right Atrium) can be used.  But if DDD pacing is used， minimal ventricular pacing algorithm must be utilised.)

<INTERNATIONAL CIRCULATION>: It is commonly believed that catheter ablation is an effective approach for AF patients to maintain sinus rhythm， but the mechanisms of AF are very complicated and there are many ablation techniques， so would you share with us your experience in choice of operation and long term follow-up?

Prof. Linde:  Well， for the patients with paroxysmal AF there is good evidence that catheter ablation is highly successful with high primary success rate as 70-80%. However， the long term trials remain a bit obscure.  Of course it depends on how you measure.  A lot of atrial fibrillation that comes after ablation may be sub-clinical， (the patient doesn’t know that there has been a recurrence) so for me it still remains an open question. To firmly establish long term results but there needs to be more follow up and more coordination of results between the different centers that do these procedures. Such long term will establish the long term role of this therapy which is definitely highly technical intervention and is not without complication. There is even the risk of death if  you penetrate the left atrium or the esophagus for example.  So there is a remaining need for more long term clinical studies in this field but it’s a very promising therapy of course.

<INTERNATIONAL CIRCULATION>:  in the follow up do you think the optimal medicine therapy is also important for the care of these patients?

Prof. Linde:  I think warfarin has to continue for at least six months for this precise reason， you never know if there is sub-clinical atrial fibrillation concerning antiarrhytmic drugs， well， the goal would be not to have to use these drugs of course because that’s what gives patients poor quality of life but I honestly do not have a strong recommendation except to be very generous with warfarin therapy for at least 6 months.

<INTERNATIONAL CIRCULATION>:  But warfarin has to be monitored by INR and it’s not very convenient for the patients 

Prof. Linde:  No， it’s not; I agree but nonetheless the risk of stroke because if the atrial fibrillation returns and you’re not aware of it the risk of stroke， that risk is higher than the inconvenience of going to INR， that’s how I see it. 

<INTERNATIONAL CIRCULATION>: ICD is an effective method to prevent sudden cardiac death. Then should we implant ICD for all the patients that need CRT therapy?

Prof. Linde:  The short answer to that is yes， provided the patient has a good life expectation of at least one or maybe even 2 years because you wouldn’t want to implant such a very， very costly therapy into somebody who might have Alzheimer’s disease or some cancer disease who is not anticipated to live with a fairly good quality of life for at least one year.  And this is exactly what the Europeans and the US guidelines tell us.  

 专家介绍：
Cecilia M Linde， MD PhD FESC
瑞典斯德哥尔摩Karolinska大学医院心脏科主任，主要研究方向为心律失常。为ESC的教材撰稿人之一，并且是2008 ESC年会的学术委员会成员之一，主要负责心律失常、起搏及再同步治疗等，并在会上作了重要临床试验REVERSE研究结果，以及慢性心力衰竭诊疗指南等主题报告。