Acute Hemodynamic Effects of Sacubitril-Valsartan In Heart Failure Patients Receiving Intravenous Vasodilator and Inotropic Therapy.

BACKGROUND: Prior study has demonstrated that transitioning patients in acutely decompensated heart failure with a low cardiac output directly from intravenous (i.v.) vasoactive (ie, vasodilators or inotropes) drugs to sacubitril-valsartan (S/V) can be done safely with tolerance to the 1-month follow-up. Here, we further characterize the hemodynamic impact of S/V after patients have been optimized on vasoactive therapy. METHODS AND RESULTS: In a single-center, retrospective analysis, 25 patients with cardiac index of less than 2.2 L/min/m2 were admitted to the cardiac intensive care unit and newly initiated on angiotensin receptor-neprilysin inhibitor therapy with the guidance of invasive hemodynamic monitoring. Hemodynamic data were gathered and compared upon cardiac intensive care unit admission, after optimization with i.v. vasoactive therapy, and after S/V initiation and weaning off i.v. THERAPY: All patients who tolerated S/V (n = 20) were weaned off vasoactive medications before transfer out of cardiac intensive care unit. Patients maintained their significant improvement in cardiac index and reduction in SVR/PVR on transition from i.v. inotropic and vasodilator therapy to oral S/V. There was an increase in pulmonary artery pulsatility index with S/V therapy compared with the i.v. vasoactive phase of care. CONCLUSIONS: Patients in the cardiac intensive care unit can be successfully bridged from vasoactive i.v. therapy to oral S/V with sustained improvement in cardiac index garnered from vasoactive agents. We also observed improvement in the pulmonary artery pulsatility index and maintenance of left and right ventricular unloading with S/V. These encouraging findings merit further prospective study.

Metabolic Biomarkers in Heart Failure.

Metabolomics is the study of small, organic molecules within biochemical pathways. With advancement of technology, nuclear magnetic resonance, gas chromatography, and mass spectrometry have allowed for the discovery and analysis of large databases of metabolites implicated in heart failure. Metabolomics also explores the patient and environment interactions and unlocks the link between environmental exposures and the development of cardiovascular disease. Although a relatively new field, metabolomics is poised to become a clinically impactful field that develops novel biomarkers and explores new therapeutic interventions in heart failure.

Contemporary Controversies in Digoxin Use in Systolic Heart Failure.

Digoxin remains one of the oldest therapies for heart failure; however, its safety and efficacy have been controversial since its initial use. Questions that remain include the clinical efficacy of digoxin when added to contemporary medical therapy, when and if it should be added, and how to minimize adverse effects. In this review, we will summarize recent data on the use of digoxin in systolic heart failure and address some of the controversies regarding the role of digoxin in the modern era of heart failure treatment.

Morbid Obesity as a Therapeutic Target for Heart Failure.

PURPOSE OF REVIEW: This review will define morbid obesity and relationship between morbid obesity and heart failure syndromes. It will delve into unique challenges facing patients with dual diagnoses of heart failure and morbid obesity and examine the data that obesity should be a target in the treatment of heart failure. RECENT FINDINGS: Emerging literature has indicated the safety and efficacy of surgical weight loss in patients with heart failure. Furthermore, bariatric surgery with associated weight loss has been associated with improvements in heart failure symptoms and reverse remodeling on echocardiography. In patients with advanced heart failure, bariatric surgery has led to improvement in heart failure to obviate the need for cardiac transplantation or sufficient weight loss for cardiac transplant eligibility. In heart failure patients who are morbidly obese, treatment of obesity is an effective therapeutic target with a myriad of potential benefits.

How to Optimize Patient Selection and Device Performance of the Newest Generation Left Ventricular Assist Devices.

PURPOSE OF REVIEW: This review will discuss key differences of third-generation left ventricular assist devices (LVADs), identify patient selection considerations to optimize post-implant clinical outcomes, and summarize key echocardiographic and hemodynamic parameters to guide device optimization. RECENT FINDINGS: There are major engineering differences between the third-generation LVADs which contribute to unique pump operational characteristics. Improved hemocompatibility has led to reduction in hemocompatibility-related adverse events (HRAEs), particularly for the Heartmate 3 pump. Having an optimal hemodynamic profile compared with not while on LVAD support defined by either echocardiography or right heart catheterization is associated with a more favorable event-free survival. With attentive patient selection, use of current third-generation LVADs, and appropriate use of echocardiography and invasive ramp studies, LVAD therapy will continue to improve survival and quality of life in select patients with advanced heart failure.