Advanced Left Heart Failure Research Articles

Bionic women and men - Part 3: Right ventricular dysfunction in patients implanted with left ventricular assist devices.

What is the topic of this review? Right heart dysfunction remains a major adverse event in patients with end stage heart failure undergoing left ventricular assist device placement. This article reviews the pathophysiology and clinical considerations of right heart failure in this patient population. What advances does it highlight? This review highlights the anatomic and physiological peculiarities of the interplay between left and right heart function in patients undergoing LVAD therapy. These would allow us to further advance our understanding of right ventricular function. The adaptation of the right ventricular (RV) output to a left ventricular assist device (LVAD) often determines the fate of patients with pulmonary hypertension secondary to left heart failure. Pre-existing right heart dysfunction in patients with advanced left heart failure is the consequence of increased (arterial) afterload and not simply the consequence of myocardial disease. If unaccounted for, it has the potential of accelerating into clinical right heart failure after LVAD, leading to significant morbidity and mortality. After LVAD implantation, the RV has to face increased flow generated by the LVAD, cardiac arrhythmias and exaggerated functional interactions between both ventricles. Understanding the key physiological mechanisms of RV dysfunction in patients with end-stage heart failure will allow us to predict and therefore prevent RV failure after LVAD implantation.

Management of combined pre- and post-capillary pulmonary hypertension in advanced heart failure with reduced ejection fraction.

Management of pulmonary hypertension (PH) has remained an unmet need in advanced left heart failure with reduced ejection fraction. In fact, patients are frequently denied heart transplant due to untreated pulmonary hypertension. The availability of mechanically circulatory devices and PH therapies has provided a ray of hope. PH specific therapies are currently not FDA approved for patients with left heart failure with reduced ejection fraction. However, clinicians have used these medications in anecdotal manner. With this review, we want to highlight the expanding use of PH specific therapy and mechanical circulatory devices in the management of PH in the setting of advanced heart failure with reduced ejection fraction.

Clinical Significance of Pulmonary Arterial Capacitance Calculated by Echocardiography in Patients With Advanced Heart Failure.

Advanced left heart failure (HF) often accompanies post-capillary pulmonary hypertension related to RV afterload. Although pulmonary arterial capacitance (PAC), a measure of pulmonary artery compliance, reflects right ventricular (RV) afterload, the clinical utility of PAC obtained by echocardiography (echo-PAC) is not well established in advanced HF.Methods and Results:We performed right heart catheterization in advanced HF patients (n=30), calculating echo-PAC as stroke volume/(tricuspid regurgitation pressure gradient-pulmonary regurgitation pressure gradient). The difference between the echo-PAC and catheter-measured PAC values was insignificant (0.21±0.17 mL/mmHg, P=0.23). Echo-PAC values predicted both pulmonary arterial wedge pressure (PAWP) ≥18 mmHg and pulmonary vascular resistance ≥3 Wood units (P=0.02, area under the curve: 0.88, cutoff value: 1.94 mL/mmHg). Next, we conducted an outcome study with advanced HF patients (n=72). Patients with echo-PAC <1.94 mL/mmHg had more advanced New York Heart Association functional class, higher B-type natriuretic peptide plasma levels, larger RV and lower RV fractional area change than those with echo-PAC ≥1.94 mL/mmHg. They also had a significantly higher rate of ventricular assist device implantation or death, even after adjustment for indices related to HF severity or RV function during a 1-year follow-up period (P<0.01). Decreased PAC as measured by echocardiography, indicating elevated PAWP and RV dysfunction, predicted poorer outcomes in patients with advanced HF.

Dramatic improvement of clinical and hemodynamic parameters of a heart transplant candidate with sildenafil treatment

Pulmonary hypertension (PHT) is classically defined as an increase in mean pulmonary arterial pressure ≥25 mm Hg at rest as assessed by right heart catheterization (1). It is associated with various clinical conditions. These clinical conditions are classified into five groups. The treatment modalities for group 1 pulmonary hypertension (pulmonary arterialhypertension (PAH)) have diversified enormously in the last de- cade, including prostanoids, endothelin receptor antagonists, and phos- phodiesterase type-5 inhibitors. Unfortunately, therapeutic options for group 2 patients (pulmonary hypertension associated with left-sided heart disease) haven't evolved much and the prognosis for this group still remains poor. However, sildenafil has been recently shown to have some acute beneficial effects in patients with left heart failure (HF) in some trials (2). In this case presentation we discuss a gentleman with advanced left heart failure who showed dramatic clinical and he- modynamic improvement with oral sildenafil treatment. A 55-year-old gentleman was admitted to our clinic for heart failure decompensation. His medical history included coronary artery bypass surgery, an Implantable Cardioverter Defibrillator (ICD) implantation for primary prevention six years later, and an upgrading of his ICD to Cardiac Resynchronization Therapy (CRT) with his ablation due to fre- quent inappropriate ICD shocks as a consequence of atrial fibrillation. His ejection fraction (EF) was calculated as 25% on transthoracic echo- cardiographic examination. His peak VO2 value was measured as 12 ml/kg/min via a cardiopulmonary stress test. Due to frequent hospi- talizations for decompensation and class 4 symptoms refractory to effective medical therapy, the patient was evaluated as a candidate for heart transplantation. A right heart catheterization (RHC) was per- formed to determine the patient's eligibility for transplantation. Pulmo- nary artery pressures and pulmonary vascular resistance were found to be in the ineligible/gray zone (Table 1). Vasoreactivity testing with do- butamine and nasal oxygen was performed to determine the reversibil- ity of the high pulmonary pressures. A partial decrease in pulmonary artery systolic pressure (about 15%) with stable systemic arterial pres- sure was noted. We decided to add oral sildenafil 50 mg (three times a day) to his ongoing treatment, referring to trials showing beneficial pulmonary hemodynamic effects in patients with advanced heart fail- ure. The patient reported dramatic symptomatic improvement and his

Role of Bosentan in Patients with High Transpulmonary Gradient (TPG) Secondary to Advanced Left Heart Failure (LHF) and Awaiting Left Ventricular Assist Device (LVAD) or Heart Transplant

Role of Bosentan in Patients with High Transpulmonary Gradient (TPG) Secondary to Advanced Left Heart Failure (LHF) and Awaiting Left Ventricular Assist Device (LVAD) or Heart Transplant

Determinants of Right Ventricular Failure in Patients Admitted With Acute Left Heart Failure

Pulmonary hypertension, which may lead to right ventricular (RV) failure, increases with left ventricular (LV) diastolic dysfunction severity. The prevalence and determinants of RV failure were analyzed in 120 patients admitted with acute left heart (LH) failure. Patients were divided into RV failure (n=50) and non-RV failure (n=70) groups. The prevalence of RV failure was found to be 42%. In both groups, two thirds of the patients had isolated LV diastolic dysfunction and the rest had combined LV systolic and diastolic dysfunction. Patients in the RV failure group were characterized by higher LV diastolic grade (2.2 ± 0.6 vs 1.84 ± 0.7; P=.0070), pulmonary artery systolic pressure (PASP; 57.8 ± 15.3 vs 50.14 ± 12.1 mm Hg; P=.0028), right atrial enlargement (92% vs 25.7%; P=.000001), and more-than-moderate tricuspid regurgitation (58% vs 27.1%; P=.0006). RV failure is a frequent finding in patients with advanced LH failure. It is strongly associated with the severity of LV diastolic dysfunction and the severity of PASP.