Management Of Advanced Heart Failure Research Articles

Genotype, phenotype and outcomes of patients with hypertrophic cardiomyopathy referred for ablation of ventricular tachycardia

Abstract Background Sustained monomorphic ventricular tachycardia (SMVT) is the most common ventricular arrhythmia (VA) subtype in patients with hypertrophic cardiomyopathy (HCM) who have received an implantable cardioverter defibrillator (ICD). However, data on catheter ablation (CA) are limited and available series typically report results of non-genotyped patients with relatively mild hypertrophy and/or apical aneurysms. Purpose This study describes genotype, phenotype and outcome of consecutive HCM patients referred for CA ablation of refractory SMVT. Methods and results Nine out of 787 patients referred for catheter ablation of SMVT between 01/2016 – 10/2023 had a HCM phenotype, 8/9 with dominant septal hypertrophy, none with LV outflow tract obstruction, and only 1/9 with an apical aneurysm. The median maximal wall thickness was 25 mm (IQR 20,2 – 26,9 mm) and the median left ventricular ejection fraction 34 % (IQR 26-42%). Six patients had a class IV/V variant in the myosine binding protein C (MYBPC3) gene, in 3 no disease-causing variant was identified. All patients with MYBPC3 mutation presented with an electrical storm/incessant VT refractory to antiarrhythmic drugs (AAD), including amiodarone (6/6) and amiodarone + class I AAD (3/6). In an attempt to control VT, 4/6 patients with a MYBPC3 variant required ≥2 ablation including bail out strategies (transcoronary alcohol-ablation, bipolar ablation, half-saline), surgical substrate resection and intraoperative cryoablation (3/6) and radiotherapy (2/6). After a median follow-up of 25 months (IQR 2-75) after the last intervention, all patients with MYBPC3-variants had VT recurrence, 3/6 died and 1/6 underwent heart transplantation. In contrast, patients without class IV/V variants, did not require bail-out strategies; VT recurred in one (single episode) and one patient died, 24 months after CA. The time course of the disease, management and outcome for patients with and without disease causing mutation is illustrated, with the first ablation as center line (figure). Conclusions Only 1 % of patients referred for CA of SMVT to a high-volume center had a HCM phenotype. A MYBPC3 variant was identified in 67%, and, in contrast to prior reports, 89% had severe hypertrophy. VT free survival appears to be particularly poor in MYBPC3 variant carriers despite availability of all treatment modalities. In these patients, early screening for advanced heart failure management including heart transplantation is important.

The role of ventricular assist device in the management of advanced heart failure: a literature review

The ventricular assist device has become a reliable and enduring therapy for patients with end-stage heart failure, with over 22,000 implantations to date. Initially designed as a bridge-to-transplant option but now it has become permanent cure for patients with acute heart failure. VAD has significant advancements in medical management and technology, particularly with the introduction of newer-generation devices, have greatly enhanced patient outcomes. This progress has led to an increasing use of ventricular assist devices as a destination therapy. Nonetheless, the substantial burden of adverse events remains a critical challenge in the current state of ventricular assist device therapy, despite this, its viable alternative of heart transplantation as it has solved the complications of donor heart and proved significant success among patient with acute heart failure.

Mechanical circulatory support in patients with congenital heart disease: a european registry for patients with mechanical circulatory support (EUROMACS) study.

This study aims to explore characteristics and clinical outcomes of patients with congenital heart disease (CHD) in the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). This is a retrospective study of EUROMACS participants receiving MCS as bridge-to-transplant, possible bridge-to-transplant, or rescue therapy/bridge-to-recovery from 2011 to 2023 (n = 5,340). Adult and paediatric cohorts were analysed separately. The primary outcome was mortality on MCS; secondary outcomes included recovery, transplant and complications including bleeding, cerebrovascular events, and sepsis. Among adult patients, mortality at 1-year was 33.3% among the CHD cohort versus 22.1% in the non-CHD cohort. Adult CHD patients had higher hazards of mortality within the first year after MCS implantation (HR 1.98 95% CI 1.35-2.91, p < 0.001) and bleeding events (sdHR 2.10, 95% CI 1.40-3.16, p < 0.001) compared with non-CHD patients. Both associations remained significant after accounting for multiple mediators. Among paediatric patients, mortality at 1-year was 22.1% in the CHD cohort versus 17.3% in the non-CHD cohort (HR 1.39 95% CI 0.83-2.32, p = 0.213). Adult and paediatric patients with CHD on MCS have higher adverse event risk compared with non-CHD MCS patients, though children did not have greater risk of mortality. As the number of CHD patients requiring advanced heart failure management continues to grow, these findings can enhance informed decision-making.

Multimodality Imaging in Advanced Heart Failure for Diagnosis, Management and Follow-Up: A Comprehensive Review.

Advanced heart failure (AHF) presents a complex landscape with challenges spanning diagnosis, management, and patient outcomes. In response, the integration of multimodality imaging techniques has emerged as a pivotal approach. This comprehensive review delves into the profound significance of these imaging strategies within AHF scenarios. Multimodality imaging, encompassing echocardiography, cardiac magnetic resonance imaging (CMR), nuclear imaging and cardiac computed tomography (CCT), stands as a cornerstone in the care of patients with both short- and long-term mechanical support devices. These techniques facilitate precise device selection, placement, and vigilant monitoring, ensuring patient safety and optimal device functionality. In the context of orthotopic cardiac transplant (OTC), the role of multimodality imaging remains indispensable. Echocardiography offers invaluable insights into allograft function and potential complications. Advanced methods, like speckle tracking echocardiography (STE), empower the detection of acute cell rejection. Nuclear imaging, CMR and CCT further enhance diagnostic precision, especially concerning allograft rejection and cardiac allograft vasculopathy. This comprehensive imaging approach goes beyond diagnosis, shaping treatment strategies and risk assessment. By harmonizing diverse imaging modalities, clinicians gain a panoramic understanding of each patient's unique condition, facilitating well-informed decisions. The aim is to highlight the novelty and unique aspects of recently published papers in the field. Thus, this review underscores the irreplaceable role of multimodality imaging in elevating patient outcomes, refining treatment precision, and propelling advancements in the evolving landscape of advanced heart failure management.

Continuous monitoring with implantable loop recorder detects arrhythmic risk in adults with systemic right ventricle following atrial switch

Abstract Background Patients with a systemic right ventricular circulation following atrial switch are at high risk of sudden death despite current monitoring strategies and advances in heart failure management. Arrhythmia represents a significant risk factor and early detection and intervention is of great value. The current surveillance approach with intermittent ambulatory monitoring is limited and cumbersome. Purpose We hypothesise that continuous rhythm monitoring with an implantable loop recorder (ILR) in the systemic right ventricle population will allow early detection of clinically significant arrhythmias. Methods Patients under follow up with a systemic right ventricular circulation following atrial switch were offered ILR implantation as an alternative to the standard of care (ambulatory 24-hour ECG). Patients with pre-existing intra-cardiac pacing devices or palliative were excluded. Following implantation, recordings made with symptoms or automatically following detection of significant arrhythmias. This included pauses over 3 seconds, atrioventricular block or supraventricular tachycardia. Transmission were reviewed daily and significant findings discussed in an adult congenital heart disease and electrophysiology MDT. Patients otherwise had routine clinical care. Results 24 patients had implantation of a loop recorder (67% of eligible cohort). They were aged 29-49 years (median 35 years) and 50% had additional lesions. Right ventricular function was normal in 42% and 29% had moderate or severe tricuspid regurgitation. 75% of the cohort were NYHA classification I. All but one patient were in sinus rhythm and 8 (33%) had previous intra-atrial re-entry tachycardia (IART). No patient had previously documented significant conduction disease. Implants were undertaken over 6 years without complications. 18 patients (75%) had automated or symptom activated recordings (52% automated) with a median of 2.8 recordings per patient (range 0 – 8 per patient) over 39.5 months (1.6 – 72.5 months). The recordings were clinically significant in 64% of the cohort (Table). This included 2 (9% of entire cohort) patients with atrioventricular block only, 11 patients (46%) with IART only and 4 patients (17%) with both IART and conduction disease (1 with atrioventricular block). These recordings resulted in 5 pacemaker implants (3 for atrioventricular block) and 2 further patients declined a device (1 subsequent death). 4 patients underwent, or are awaiting, ablation for IART. Risk scoring for sudden death did not predict arrhythmia events or atrioventricular block (1) (Figure). Conclusions Empirical ILR implantation in this low-risk systemic right ventricle cohort was well tolerated and detected a high burden of significant arrhythmias requiring intervention. Arrythmias were not predicted by risk scoring. This monitoring approach is an effective alternative to intermittent ambulatory surveillance however the impact on sudden death is unclear.

Risk factors associated with higher mortality in patients with cardiac implantable electronic device infection.

Cardiac Implantable Electronic Devices (CIEDs) are widely used for the management of advanced heart failure and ventricular arrhythmias. CIED-Infection (CIED-I) has very high mortality, especially in the subsets of patients with limited health-care access and delayed presentation. The purpose of this study is to identify the risk-predictors mortality in subjects with CIED-I. We performed a retrospective cohort study of a regional database in patients presenting with CIED infections to tertiary care medical centers across Western New York, USA from 2012 to 2020. The clinical outcomes included recurrent device infection (any admission for CIED-I after the first hospitalization for device infection), septic complications (pulmonary embolism, respiratory failure, septic shock, decompensated HF, acute kidney injury) and mortality outcomes (death during hospitalization, within 30 days from CIED-I, and within 1 year from CIED-I). We studied associations between categorical variables and hard outcomes using χ2 tests and used one-way analysis of variance to measure between-groups differences. We identified 296 patients with CIED-I, among which 218 (74%) were male, 237 (80%) were white and the mean age at the time of infection was 69.2 ± 13.7 years. One-third of the patients were referred from the regional facilities. Staphylococcus aureus was responsible for most infections, followed by Enterococcus fecalis. On multivariate analysis, the covariates associated with significantly increased mortality risk included referral from regional facility (OR: 2.0;1.0-4.0), hypertension (Odds ratio, OR: 3.2;1.3-8.8), right ventricular dysfunction (OR: 2.6;1.2-5.1), end-stage renal disease (OR: 2.6;1.1-6.2), immunosuppression (OR: 11.4;2.5-53.3), and septic shock as a complication of CIED-I (OR: 3.9;1.3-10.8). Hypertension, right ventricular dysfunction, immunosuppression, and end-stage renal disease are associated with higher mortality after CIED-I. Disproportionately higher mortality was also noted in subjects referred from the regional facilities. This underscores the importance of early clinical risk-assessment, and the need for a robust referral infrastructure to improve patient outcomes.

Heart failure in systemic right ventricle: Mechanisms and therapeutic options.

d-loop transposition of the great arteries (d-TGA) and congenitally corrected transposition of the great arteries (cc-TGA) feature a right ventricle attempting to sustain the systemic circulation. A systemic right ventricle (sRV) cannot support cardiac output in the long run, eventually decompensating and causing heart failure. The burden of d-TGA patients with previous atrial switch repair and cc-TGA patients with heart failure will only increase in the coming years due to the aging adult congenital heart disease population and improvements in the management of advanced heart failure. Clinical data still lags behind in developing evidence-based guidelines for risk stratification and management of sRV patients, and clinical trials for heart failure in these patients are underrepresented. Recent studies have provided foundational data for the commencement of robust clinical trials in d-TGA and cc-TGA patients. Further insights into the multifactorial nature of sRV failure can only be provided by the results of such studies. This review discusses the mechanisms of heart failure in sRV patients with biventricular circulation and how these mediators may be targeted clinically to alleviate sRV failure.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Advanced and Acute Heart Failure.

The Korean Society of Heart Failure (KSHF) Guidelines provide evidence-based recommendations based on Korean and international data to guide adequate diagnosis and management of heart failure (HF). Since introduction of 2017 edition of the guidelines, management of advanced HF has considerably improved, especially with advances in mechanical circulatory support and devices. The current guidelines addressed these improvements. In addition, we have included recently updated evidence-based recommendations regarding acute HF in these guidelines. In summary, Part IV of the KSHF Guidelines covers the appropriate diagnosis and optimized management of advanced and acute HF.

Korean Society of Heart Failure Guidelines for the Management of Heart Failure: Advanced and Acute Heart Failure.

The Korean Society of Heart Failure (KSHF) Guidelines provide evidence-based recommendations based on Korean and international data to guide adequate diagnosis and management of heart failure (HF). Since introduction of 2017 edition of the guidelines, management of advanced HF has considerably improved, especially with advances in mechanical circulatory support and devices. The current guidelines addressed these improvements. In addition, we have included recently updated evidence-based recommendations regarding acute HF in these guidelines. In summary, Part IV of the KSHF Guidelines covers the appropriate diagnosis and optimized management of advanced and acute HF.

Trends in contemporary advanced heart failure management: an in-depth review over 30 years of heart transplant service in Hong Kong.

The year 2022 marks the 30th anniversary of heart transplant service in Hong Kong (HK). In this study, we describe prevailing trends and outcomes of advanced heart failure (AHF), including heart transplantations (HTx), in HK over the past 30 years. Trends in heart failure prevalence in HK from 1993 to 2021 were analyzed based on data from the Hospital Authority Clinical Data and Reporting System. All AHF patients referred for HTx consideration between 1992 and 2021 were reviewed. The bridge-to-transplant (BTT) utilization of short-term mechanical circulatory support (ST-MCS) devices, including venoarterial extracorporeal membrane oxygenation (VA-ECMO) and durable left ventricular assist devices (LVADs), from 2010 to 2021 was reviewed. Overall, 237 heart transplants were performed in HK, with 10-year posttransplant and median survival of 68.1% and 18.7 years, respectively. An increase in AHF clinic referrals was correlated with increasing heart failure prevalence (R2=0.635, P<0.001). In total, 146 referrals were made for ST-MCS, and an observed increase in ST-MCS referrals was correlated with increasing VA-ECMO utilization (R2=0.849, P<0.001). Among 62 patients accepted for AHF therapy, those with durable LVAD implementation had better 1-year survival (71.5%) than those receiving an extracorporeal CentriMag (Levitronix) device as BTT (40%, P=0.008). In total, 143 LVADs were implanted, with 130 as BTT or bridge-to-candidacy (BTC) methods. The survival rate among the 130 BTT/BTC LVAD patients resembled that of HTx recipients (73.8% vs. 69.8% at 9 years, P=0.296). The burden of AHF management has increased and gained complexity over the past 30 years in Hong Kong.

Phenotype Characterization and Course of Patients With Arrhythmogenic Right Ventricular Cardiomyopathy and Biventricular Advanced Heart Failure: A Report of 3 Cases

Arrhythmogenic right ventricular cardiomyopathy (ARVC) may be complicated by heart failure. Management of advanced heart failure in this context is challenging. We reviewed our center's experience with advanced heart failure therapies in patients with ARVC. Three rapidly deteriorating patients with ARVC with biventricular heart failure were found. Their management and outcomes are presented. Data on ventricular fibrosis were available in 2 of them and are also included. The first patient underwent initially successful paracorporeal pulsatile biventricular assist device (BiVAD) implantation. However, a large ischemic stroke occurred 2 weeks later, and the patient died after 2 months. The second patient underwent urgent BiVAD implantation after extracorporeal membrane oxygenation support because of cardiogenic shock, but his course was complicated by multiorgan failure due to systemic infection and the patient died. The last patient, being at Interagency Registry for Mechanically Assisted Circulatory Support 3-4 profile, underwent heart transplant with uneventful recovery. Extensive fibrosis was present in both ventricles of 2 patients undergoing pathology examination. Patients with ARVC and advanced biventricular heart failure are characterized by extensive ventricular fibrosis and considerable risk, but data on their management are limited. Biventricular circulatory support is associated with suboptimal outcomes, and prioritization for heart transplant seems preferable.

SUPPORTIVE CARDIOLOGY: A QUALITY IMPROVEMENT PROJECT TO MEET THE GAPS IN LATE-STAGE HEART FAILURE CARE

Embedding a palliative approach into advanced heart failure management remains an important yet challenging aspect of the current care model. The aim of this project was to explore the gaps in the patient journey, identify opportunities for improvement, and empower patients, their supporters, and clinicians.

Temporary biventricular mechanical circulatory support utilizing a simple left ventricular apical cannulation technique

Surgical management of cardiogenic shock, utilizing mechanical circulatory support, can provide a bridge to recovery, a bridge to decision-making, and/or a bridge to transplantation. The management of advanced heart failure, employing either temporary or durable mechanical circulatory support, dominantly is directed towards supporting the left ventricular (LV) function. Unfortunately, right ventricular (RV) failure is not uncommon and significantly impacts morbidity and mortality. We demonstrate a technique to support biventricular failure, utilizing a simple LV apical cannulation technique, which may reduce thrombotic complications, and an RV cannulation strategy that offers the potential to improve recovery, in the form of early extubation, potential ambulation, and removal of the implanted device without having to reopen the patient's chest.

Abstract P013: Hypertension Is Associated With High Risk Of Heart Failure Mortality

Introduction: Heart failure is a growing public health issue with an estimated prevalence of 4-5million in the United States. Despite significant advances in heart failure management, the mortality rates remain high. This study investigates the risk factors that are associated with higher mortality rates in hospitalized patients with heart failure. Methods: We utilized the 2019 National Inpatient Sample (NIS) dataset sponsored by the Agency for Healthcare Research and Quality (AHRQ). Patients with heart failure (HF) were identified by using Clinical Classifications Software Refined (CCSR) for International Classification of Diseases, Tenth Revision, and Clinical Modification (ICD-10-CM). Variables of interest included complicated diabetes, complicated hypertension, peripheral vascular disease (PAD), intra-cardiac thrombi, and long term use of anticoagulation. Clinical outcomes included HF hospitalizations and effect of the different variables on HF mortality. Results: A weighted total of 5,675,784 HF related hospitalizations were recorded in 2019. A total of 753,994 (68.9%) had hypertension, 37,450 (0.66%) were on long term anticoagulation use, 651,035 (11%) had PAD, 36,575 (0.67%) had an intra-cardiac thrombi, and 2,080,710 (36%) had complicated diabetes. The mortality rate per 10,000 HF hospitalizations were analyzed. There were 4,707 deaths due to complicated hypertension as compared to 2,953 in the non-hypertensive population. 2,853 deaths due to intra-cardiac thrombi were found as compared to 2,208 deaths in patients without intra-cardiac thrombi. Mortality rate was found to be 1,649 in patients with long term anticoagulant as compared to 2,252 in patients not on anticoagulant. PAD lead to 2,432 deaths per 10,000 as compared to 2,183 deaths in patients without PAD. The mortality rate due to complicated diabetes was 2,368 as compared to 2,122 deaths in non-diabetic patients. Conclusion: Heart failure leads to a significant number of hospitalizations in the United States annually, as seen in 2019. Among all the factors studied, hypertension was found to be associated with highest risk of mortality. This study emphasizes the importance of strict blood pressure control in decreasing mortality associated with heart failure.

A Holistic View of Advanced Heart Failure.

Advanced heart failure (HF) may occur at any level of left ventricular (LV) ejection fraction (LVEF). The latter, which is widely utilized for the evaluation of LV systolic performance and treatment guidance of HF patients, is heavily influenced by LV size and geometry. As the accurate evaluation of ventricular systolic function and size is crucial in patients with advanced HF, the LVEF should be supplemented or even replaced by more specific indices of LV function such as the systolic strain and cardiac power output and size such as the LV diastolic diameters and volumes. Conventional treatment (cause eradication, medications, devices) is often poorly tolerated and fails and advanced treatment (mechanical circulatory support [MCS], heart transplantation [HTx]) is required. The effectiveness of MCS is heavily dependent on heart size, whereas HTx which is effective in the vast majority of the cases is limited by the small donor pool. Expanding the MCS indications to include patients with small ventricles as well as the HTx donor pool are major challenges in the management of advanced HF.

Octogenarian with Severe Left Ventricular Dysfunction and Cardiac Resynchronization TherapyDefibrillator Device: Successful Anesthesia Management for Hip Arthroplasty

Cardiac resynchronization therapy has emerged as a key component in management of advanced heart failure with reduced ejection fraction in selected subset of geriatric patients. The burgeoning burden of comorbidities, complexity of these devices and aging population presenting for surgeries necessitates peri-operative physicians to be cognizant and confident to handle these challenging cases. Limited literature about anesthesia management of patients implanted with these devices add to the situational challenge. We present a case of elderly gentleman with ischemic cardiomyopathy and cardiac resynchronization therapy-defibrillator device who underwent hip replacement under general anesthesia. Understanding the disease and the device are the crucial and definitive exigencies to manage such cases.

Integrated palliative care in the management of advanced heart failure

Integrated palliative care in the management of advanced heart failure

Estimation of Left Ventricular Preload Using Left Ventricular Assist Device Flow Waveform Analysis in a Mock Circulatory Loop

<h3>Purpose</h3> Continuous flow left ventricular assist devices (cfLVADs) have an increasingly prominent role in the management of advanced heart failure. Adverse events post-implant are significant burdens, however, may be reduced with optimal patient hemodynamic and device function. Previous studies on cfLVAD flow waveform analysis have shown the slope of the early diastolic portion of the time-series flow waveform, diastolic dQ/dt, provides an estimate of left ventricular (LV) preload. Left ventricular preload sensitivity is important in maintaining optimal LV unloading and thus, optimal support. This study assessed the validity of the relationship between diastolic dQ/dt and LV preload using a mock circulatory loop (MCL). <h3>Methods</h3> A MCL was run with a HeartWare HVAD at 2800 RPM and repeated at 3200 RPM. Left atrial pressure (LAP; synonymous with LV preload) was decreased through incremental changes in pulmonary vascular resistance by 100 dynes/s/cm⁵, from 190 to 790 dynes/s/cm⁵. LAP data was recorded and stored whilst the HVAD flow waveform was digitised using WaveApp (proprietary software). Diastolic dQ/dt was calculated from each flow waveform using a customised MATLAB script. A linear regression model in SPSS was used to analyse the relationship between LAP and diastolic dQ/dt. Receiver operator characteristic (ROC) curves and sensitivity analyses were performed. <h3>Results</h3> Diastolic dQ/dt was significantly related to MCL-derived LAP (R² = 0.851, p < 0.001). ROC analysis found the diastolic dQ/dt model has favourable sensitivity and specificity characteristics for discerning LAP ≥ 15 mmHg (AUC = 0.955 (95% CI 0.893-1.000; p = 0.003)). <h3>Conclusion</h3> This study confirms the value of cfLVAD flow waveform analysis in estimating LV preload using diastolic dQ/dt, consistent with previous clinical studies. These findings contribute to the development of non-invasive, bedside monitoring and optimisation of patient ventricular unloading while supported by LVAD.

Advanced heart failure: state of the art and future directions.

Advanced heart failure is a clinical challenge that requires a pathophysiological-based approach. As the field has been the subject of multiple reviews, the objective of this paper is not to duplicate these publications but rather to offer practical tips for the clinical cardiologist to enable the optimal management of patients with advanced heart failure. Advanced heart failure is defined as a clinical syndrome characterized by severe and persistent symptoms, most commonly with severe ventricular dysfunction, despite optimized medical therapy. This review covers the management of the advanced heart failure patient from pharmacologic therapy with disease-modifying drugs, to the use of electrical therapy devices, percutaneous valve repair and finally to the role of left ventricular assist devices and heart transplantation. The review also explores future directions in the management of advanced heart failure, including translational perspectives for the treatment of this syndrome.

Importance of right heart catheterization in advanced heart failure management.

Patients with chronic congestive heart failure belong to a population with reduced quality of life, poor functional class, and increased risk of mortality and morbidity. In these patients, assessment of invasive hemodynamics both serves therapeutic purposes and is useful for stratification roles. The right heart catheterization has become a cornerstone diagnostic tool for patients in refractory heart failure or cardiogenic shock, as well as for the assessment of candidacy for heart replacement therapies, and the management of patients following mechanical circulatory assist device implantation and heart transplantation.