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Reply to the Editor

study that was sanctioned by an Institutional Review Board or an ethics committee. It remains inappropriate to use biventricular pacing as part of routine clinical care until such time as a randomized study shows a favorable risk—benefit ratio. It would be inappropriate to perform a procedure that involved three experimental components (biventricular pacing, superior-approach transseptal catheterization, and chronic LV endocavitary pacing) as part of routine clinical care. Second, extending the use of biventricular pacing to an endocardial approach seems to be particularly imprudent. As the accompanying editorial suggests, data available to date suggests that the long-term use of left ventricular leads results in a high rate of systemic embolization.^ Third, the authors suggest that it has been established that biventricular pacing provides benefit to patients with dilated cardiomyopathy. The level of evidence that this is the case is currently relatively weak. At this time, there are only the results of nonrandomized trials. There are at least two important sources of bias in these studies. First, in these trials, every patient has a pacemaker implanted. This introduces the possibility of substantial placebo effect. Second, every patient is enrolled into a clinical study and followed closely. This could provide a beneficial effect to patients with heart failure by improving the follow-up in subtle ways. One of the hazards of reports like this article is that the technology will become self-perpetuating before adequate data are available to establish benefit. This is especially the case in the treatment of diseases like congestive heart failure, where the patient's condition compels the physician to violate one of the tenets of medicine: "Don't just do something doctor, stand there."