Contemporary management of heart failure patients with reduced ejection fraction: the role of implantable devices and catheter ablation

Alexandros Briasoulis,Catrin Sohrabi,Emmanuel Androulakis,Gerasimos Siasos,Neil T Srinivasan,Nikolaos Papageorgiou,Syed Ahsan

doi:10.31083/j.rcm2202047

Abstract

Heart failure (HF) is a complex clinical syndrome characterised by significant morbidity and mortality worldwide. Evidence-based therapies for the management of HF include several well-established neurohormonal antagonists and antiarrhythmic drug therapy to mitigate the onset of cardiac arrhythmia. However, the degree of rate and rhythm control achieved is often suboptimal and mortality rates continue to remain high. Implantable cardioverter-defibrillators (ICDs), cardiac resynchronization (CRT), and combined (CRT-D) therapies have emerged as integral and rapidly expanding technologies in the management of select patients with heart failure with reduced ejection fraction (HFrEF). ICDs treat ventricular arrhythmia and are used as primary prophylaxis for sudden cardiac death, while CRT resynchronizes ventricular contraction to improve left ventricular systolic function. Left ventricular assist device therapy has also been shown to provide clinically meaningful survival benefits in patients with advanced HF, and His-bundle pacing has more recently emerged as a safe, viable, and promising pacing modality for patients with CRT indication. Catheter ablation is another important and well-established strategy for managing cardiac arrhythmia in HF, demonstrating superior efficacy when compared with antiarrhythmic drug therapy alone. In this article, we provide a comprehensive and in-depth evaluation of the role of implantable devices and catheter ablation in patients with HFrEF, outlining current applications, recent advances, and future directions in practice.

Highlights

Heart failure (HF) is a leading cause of morbidity and mortality worldwide
Common mechanisms that underly the development of Atrial fibrillation (AF) in HF include an elevation in left ventricular (LV) filling pressure secondary to systolic and diastolic dysfunction with concomitant atrial stretch, increased interstitial fibrosis leading to abnormal atrial conduction properties, dysregulation of intracellular calcium metabolism and alteration to depolarization patterns, and neurohormonal dysfunction [2]
Designed to investigate whether amiodarone or a conservatively programmed shock-only Implantable cardioverter-defibrillators (ICDs) would reduce the primary outcome of allcause mortality among 2521 patients with NYHA class II/III and left ventricular ejection fraction (LVEF) ≤35% [15], ICD implantation resulted in a 23% reduction in the risk of death from any cause and an absolute 7% decrease in mortality at a mean follow-up of 45.5 months

Summary

Introduction

Heart failure (HF) is a leading cause of morbidity and mortality worldwide. Cardiac arrhythmias, whether symptomatic or not, are common in all forms of HF. Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) are two of the most commonly encountered cardiac diseases that often co-exist and exacerbate one another [1]. Common mechanisms that underly the development of AF in HF include an elevation in left ventricular (LV) filling pressure secondary to systolic and diastolic dysfunction with concomitant atrial stretch, increased interstitial fibrosis leading to abnormal atrial conduction properties, dysregulation of intracellular calcium metabolism and alteration to depolarization patterns, and neurohormonal dysfunction [2]. Ventricular tachyarrhythmias including ventricular tachycardia (VT) or ventricular fibrillation (VF) are common in HF These pathologies result from myocardial hypertrophy and sustained mechanical stretch, leading to stretch-induced ventricular arrhythmogenicity, and myocardial fibrosis and scar formation post-myocardial infarction with the induction of re-entrant VT [4]

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