Scaring myocardial scars: new targets for the electrical fairy?

Despite the impressive development of medical therapies for patients with myocardial dysfunction, sudden cardiac death (SCD) is still too frequent. In patients with severe cardiomyopathies the insertion of an implantable cardiac defibrillator (ICD) has been shown to reduce SCD risk (1). For primary prevention in patients with left ventricular ejection fraction (LVEF) below 35%, ICD is now recommended (2). However, only 30% to 50% of implanted patients received appropriate ICD firings, and up to 25% suffered from side effects in the first year after ICD insertion (3,4). In addition, because of steadily growing demand for ICD replacements (5), the financial burden of primary ICD insertion on our healthcare systems is increasing. Consequently, there is an urgent need to improve the benefit-risk ratio of ICD insertion.