End-stage heart failure non-pharmacological therapy: Recent advances in pacemakers, pressure monitors, pumps and other devices

Heart failure is a common, expensive and fatal condition and yet, until recently, there was a paucity of treatment options for patients with end-stage heart failure (ESHF), other than pharmacotherapy or heart transplant. Recent advances mean there is now an array of non-pharmacological therapies available for such patients; two such examples are cardiac resynchronisation therapy (CRT) and implantable cardioverter defibrillators (ICDs), which improve pump function, symptoms, exercise capacity or reduce the risk of arrhythmic death, respectively. Furthermore, prior to transplant or if they are deemed unsuitable, patients now have the option of a left ventricular assist device (LVAD) or total artificial heart (TAH), where available, before heart transplant needs to be considered. The concept of remote monitoring is increasingly popular, and while recording parameters such as blood pressure and weight are not new, what is new is how implantable remote monitoring devices are now able to detect clinical decompensation before even the patient is symptomatic and relay this information onto the clinician. Other more novel therapies for ESHF include nerve stimulators to reduce sympathetic tone, the risk of arrhythmia and augment reverse cardiac remodelling and, perhaps the most novel of all, cardiac contractility modulation, stimulating the heart paradoxically during the absolute refractory period that serves to improve cardiac contractility.