Device-based therapies for decompensated heart failure.

PURPOSE OF REVIEW: Despite improvements in medical therapies, patients with heart failure continue to suffer significant morbidity and mortality. Acute decompensated heart failure (ADHF) remains a common and serious medical condition with a myriad of implications on patient survival and quality of life, and heart failure related readmissions persist [1-3]. RECENT FINDINGS: From the detection of prehospitalization decompensation and inpatient management of ADHF to stabilization of cardiogenic shock and durable mechanical circulatory support, device-based therapies are utilized across the spectrum of heart failure management. At present, there are numerous device-based therapies commonly used in clinical practice and many more devices in the early clinical-trial phase aimed at attenuation of ADHF. SUMMARY: In this review, we examine recent updates in the breadth and use of devices-based therapies in these three main domains: ambulatory heart failure, acute decompensated heart failure, and cardiogenic shock. Device-based therapies for decompensated heart failure will continue to grow in number, indication, and complexity, making recognition and familiarity with available technologies of increased importance for research and clinical practice.

Incremental Value of Global Longitudinal Strain to Michigan Risk Score and Pulmonary Artery Pulsatility Index in Predicting Right Ventricular Failure Following Left Ventricular Assist Devices.

BACKGROUND: The incremental utility of right ventricular (RV) strain on predicting right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation, beyond clinical and haemodynamic indices, is not clear. METHODS: Two hundred and forty-six (246) patients undergoing LVAD implantation, who had transthoracic echocardiograms pre and post LVAD, pulmonary artery pulsatility index (PAPI) measurements and Michigan risk score, were included. We analysed RV global longitudinal strain (GLS) using speckle tracking echocardiography. RVF following LVAD implantation was defined as the need for medical support for >14 days, or unplanned RV assist device insertion after LVAD implantation. RESULTS: Mean preoperative RV-GLS was -7.8±2.8%. Among all, 27% developed postoperative RVF. A classification and regression tree analysis identified preoperative Michigan risk score, PAPI and RV-GLS as important parameters in predicting postoperative RVF. Eighty per cent (80%) of patients with PAPI <2.1 developed postoperative RVF, while only 4% of patients with PAPI >6.8 developed RVF. For patients with a PAPI of 2.1-3.2, having baseline Michigan risk score >2 points conferred an 81% probability of subsequent RVF. For patients with a PAPI of 3.3-6.8, having baseline RV-GLS of -4.9% or better conferred an 86% probability of no subsequent RVF. The sensitivity and specificity of this algorithm for predicting postoperative RVF were 67% and 93%, respectively, with an area under the curve of 0.87. CONCLUSION: RV-GLS has an incremental role in predicting the development of RVF post-LVAD implantation, even after controlling for clinical and haemodynamic parameters.

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.

Frequency of screening for cardiac allograft vasculopathy: warranty period of initial low risk positron emission tomography.

AIMS: The short-term risk of moderate-severe cardiac allograft vasculopathy (CAV) after a low-risk positron emission tomography/computed tomography (PET/CT) is unknown, and therefore, there is no guidance on how frequently to perform screening. The aim of this study was to assess the rate of progression to moderate-severe CAV as part of an annual screening programme. METHODS AND RESULTS: Patients with no history of CAV 2/3 and a low-risk result on initial screening PET/CT (CAV 0/1) were enrolled in the study. The primary outcome was the progression to CAV 2/3 as part of an annual screening programme (within 6-18 months of initial scan). PET CAV results were graded according to a published and externally validated diagnostic criterion for CAV. Over the study period, 231 patients underwent an initial PET/CT and had a subsequent evaluation for CAV. In this cohort, 4.3% of patients progressed to CAV 2/3 at a median of 374 days (interquartile range 363-433). Initial PET CAV grade was the most significant patient characteristic associated with the progression of CAV, with 17% of patients with PET CAV 1 progressing to CAV 2/3 compared with 1.6% with PET CAV 0 (odds ratio 12.4, 95% confidence interval 3.06-50.3). CONCLUSION: The rate of progression to moderate-severe CAV at 1 year after the lowest-risk PET/CT is low, but approximately 1/6 patients with PET CAV 1 progress to CAV 2/3. Annual screening with PET/CT for select patients with PET CAV 0 may not be warranted. The optimal screening interval awaits confirmation of our findings in multi-centre registries.

Structural Interventions in Heart Failure: Mending a Broken Heart.

Advanced heart failure is often accompanied by perturbations in cardiac chamber or valve geometries which result in worsening cardiac function and hemodynamics. Once limited to surgical procedures, recent developments in minimally invasive percutaneous techniques have demonstrated efficacy in patients with both reduced and preserved ejection fraction who are at an elevated surgical risk for perioperative events. This review highlights a subset of the interventions available in clinical practice or in development for the treatment of these valvular and structural alterations.

Exhaled Breath Analysis Using Selected Ion Flow Tube Mass Spectrometry and Disease Severity in Heart Failure.

Exhaled breath volatile organic compounds (VOCs) are elevated in heart failure (HF). The ability of VOCs to predict long term cardiovascular mortality and morbidity has not been independently verified. In 55 patients admitted with acute decompensated heart failure (ADHF), we measured exhaled breath acetone and pentane levels upon admission and after 48 h of diuresis. In a separate cohort of 51 cardiac patients undergoing cardiopulmonary exercise testing (CPET), we measured exhaled breath acetone and pentane levels before and at peak exercise. In the ADHF cohort, admission acetone levels correlated with lower left ventricular ejection fraction (LVEF, r = -0.297, p = 0.035). Greater weight loss with diuretic therapy correlated with a greater reduction in both acetone levels (r = -0.398, p = 0.003) and pentane levels (r = -0.309, p = 0.021). In patients with above-median weight loss (≥4.5 kg), patients demonstrated significantly greater percentage reduction in acetone (59% reduction vs. 7% increase, p < 0.001) and pentane (23% reduction vs. 2% reduction, p = 0.008). In the CPET cohort, admission acetone and pentane levels correlated with higher VE/VCO2 (r = 0.39, p = 0.005), (r = 0.035, p = 0.014). However, there were no significant correlations between baseline or peak exercise acetone and pentane levels and peak VO2. In longitudinal follow-up with a median duration of 33 months, patients with elevated exhaled acetone and pentane levels experienced higher composite adverse events of death, ventricular assist device implantation, or orthotopic heart transplantation. In patients admitted with ADHF, higher exhaled breath acetone levels are associated with lower LVEF and poorer outcomes, and greater reductions in exhaled breath acetone and pentane tracked with greater weight loss. Exhaled acetone and pentane may be novel biomarkers in heart failure worthy of future investigation.

Long-term outcomes in nonprogressors to cardiac resynchronization therapy.

BACKGROUND: Among patients with heart failure undergoing cardiac resynchronization therapy (CRT), patients with a minimal change in left ventricular ejection fraction (LVEF) have recently been defined as "nonprogressors" rather than as "nonresponders." Little is known regarding long-term outcomes of nonprogressors. OBJECTIVE: We sought to evaluate outcomes in patients undergoing CRT on the basis of echocardiographically determined response status. METHODS: We reviewed the medical charts of patients with an LVEF of ≤35% and a QRS duration of ≥120 ms undergoing CRT at the Cleveland Clinic, Johns Hopkins Hospital, and Johns Hopkins Bayview Medical Center between 2003 and 2014. Response to CRT was defined on the basis of LVEF change as follows: super-responders ≥20%, responders 6%-19%, nonprogressors 0%-5%, and progressors <0%. Survival free of left ventricular assist device (LVAD) implantation and heart transplantation was compared on the basis of response classification. RESULTS: A total of 1058 patients were included and had a mean follow-up 8.7 ± 5.4 years, over which time there were 606 end points (37 LVAD implants, 32 heart transplants, and 537 deaths). Survival free of LVAD and heart transplant differed significantly between response groups after CRT both in the mid-term (4 years) and in the long-term (8.7 ± 5.4 years), with super-responders achieving the best outcomes and progressors the worst (P < .001). In multivariate analysis, nonprogressors had superior outcomes to progressors (P = .02) at 4 years of follow-up. Over the duration of follow-up (8.7 ± 5.4 years), there was no significant difference in survival between those 2 groups (P = .18). CONCLUSION: Nonprogressors to CRT have superior medium-term outcomes but similar long-term outcomes to progressors and inferior outcomes to responders and super-responders.

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.

Economic Impact of Chronic Heart Failure Management in Today's Cost-Conscious Environment.

"Heart failure is a global pandemic that is becoming an increasingly common diagnosis due to aging of the population and increased longevity. Understanding the scope and costs of current heart failure management will lead to improved health economic decision making. Interventions to reduce spending in heart failure care have been centered on reduction of readmissions, improvement in transitions of care, and innovations in technology that have further improved quality of life. Technological advancements in outpatient monitoring offers the hope of further reducing morbidity, mortality, and cost in heart failure."

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.