Heart Failure Questionnaire Score Research Articles

Shenfu decoction as adjuvant therapy for improving quality of life and hepatic dysfunction in patients with symptomatic chronic heart failure

Ethnopharmacological relevanceShenfu decoction (SFD) is a water extract of the dried root or root stalk of Panax ginseng C. A. Mey (Asian ginseng) and the lateral root of Aconitum carmichaeli Debx (prepared by Fuzi, Heishunpian in Chinese). It has been used to treat heart failure for over a thousand years. The main active components of SFD, ginsenosides and higenamine, enhance heart contractility, increase the coronary blood supply, improve ischemic myocardial metabolism, scavenge free radicals and protect myocardial ultrastructure. Aim of the studyTo investigate the effect of SFD on quality of life (QOL) and hepatic function in symptomatic chronic heart failure (CHF) patients. Materials and methodsForty patients enrolled in the study were randomized into two groups: an SFD group (18 cases) and a control group (22 cases). All the patients received standard heart failure therapy, and the SFD group patients were also treated with Shenfu granules for 14 days as an adjunctive therapy. The effects of SFD on QOL, plasma alanine aminotransferase (ALT) level, cardiac function, left ventricular ejection fraction (LVEF) and tumor necrosis factor-α (TNF-α) level were studied. ALT threshold in hepatic injury are 21U/L for men and 17U/L for women. ResultsMinnesota Living with Heart Failure Questionnaire (MLHFQ) scores were improved by 35.27±10.72 vs. 23.87±11.96 in the SFD and control groups respectively (p<0.01). Subgroup analysis of the MLHFQ results demonstrated that both physical and emotional scores were significantly higher in the SFD group (21.00±5.66 vs. 16.75±6.25, p<0.05; 4.64±4.84 vs. 1.13±2.85, p<0.05). Circulating ALT was significantly decreased by SFD (13.3IU/L vs. 0.6IU/L, p<0.01). The grading of cardiac function and LVEF were increased by 1.6±0.5 vs. 1.1±0.3 and 18%±13% vs. 8%±8% in the SFD and control groups respectively (p<0.05 and p<0.05). The level of TNF-α declined more in SFD than control group (64.8±5.0 to 57.6±4.1, p<0.05; vs. 61.6±5.9 vs. 57.7±3.2. p>0.05). ConclusionCompared with standard heart failure treatment, oral SFD as an adjuvant therapy significantly improved QOL and hepatic injury in CHF patients.

Phrenic Nerve Stimulation for the Treatment of Central Sleep Apnea

ObjectivesThe aim of this study was to evaluate chronic, transvenous, unilateral phrenic nerve stimulation to treat central sleep apnea (CSA) in a prospective, multicenter, nonrandomized study. BackgroundCSA occurs predominantly in patients with heart failure and increases the risk for morbidity and mortality. Established therapies for CSA are lacking, and those available are limited by poor patient adherence. MethodsFifty-seven patients with CSA underwent baseline polysomnography followed by transvenous phrenic nerve stimulation system implantation and follow-up. Feasibility was assessed by implantation success rate and therapy delivery. Safety was evaluated by monitoring of device- and procedure-related adverse events. Efficacy was evaluated by changes in the apnea-hypopnea index at 3 months. Quality of life at 6 months was evaluated using a sleepiness questionnaire, patient global assessment, and, in patients with heart failure at baseline, the Minnesota Living With Heart Failure Questionnaire. ResultsThe study met its primary end point, demonstrating a 55% reduction in apnea-hypopnea index from baseline to 3 months (49.5 ± 14.6 episodes/h vs. 22.4 ± 13.6 episodes/h of sleep; p < 0.0001; 95% confidence interval for change: −32.3 to −21.9). Central apnea index, oxygenation, and arousals significantly improved. Favorable effects on quality of life and sleepiness were noted. In patients with heart failure, the Minnesota Living With Heart Failure Questionnaire score significantly improved. Device- or procedure-related serious adverse events occurred in 26% of patients through 6 months post therapy initiation, predominantly due to lead repositioning early in the study. Therapy was well tolerated. Efficacy was maintained at 6 months. ConclusionsTransvenous, unilateral phrenic nerve stimulation appears safe and effective for treating CSA. These findings should be confirmed in a prospective, randomized, controlled trial. (Chronic Evaluation of Respicardia Therapy; NCT01124370)

Effect of Aging on Human Mesenchymal Stem Cell Therapy in Ischemic Cardiomyopathy Patients

BackgroundThe role of patient age in the efficacy of mesenchymal stem cell (MSC) therapy in ischemic cardiomyopathy (ICM) is controversial. ObjectivesThis study sought to determine whether the therapeutic effect of culture-expanded MSCs persists, even in older subjects. MethodsPatients with ICM who received MSCs via transendocardial stem cell injection (TESI) as part of the TAC-HFT (Transendocardial Autologous Cells in Ischemic Heart Failure) (n = 19) and POSEIDON (Percutaneous Stem Cell Injection Delivery Effects on Neomyogenesis) (n = 30) clinical trials were divided into 2 age groups: younger than 60 and 60 years of age and older. Functional capacity was measured by 6-min walk distance (6MWD) and quality of life using the Minnesota Living With Heart Failure Questionnaire (MLHFQ) score, measured at baseline, 6 months, and 1 year post-TESI. Various cardiac imaging parameters, including absolute scar size, were compared at baseline and 1 year post-TESI. ResultsThe mean 6MWD was similar at baseline and increased at 1 year post-TESI in both groups: 48.5 ± 14.6 m (p = 0.001) for the younger and 35.9 ± 18.3 m (p = 0.038) for the older participants (p = NS between groups). The older group exhibited a significant reduction in MLHFQ score (−7.04 ± 3.54; p = 0.022), whereas the younger than 60 age group had a borderline significant reduction (−11.22 ± 5.24; p = 0.058) from baseline (p = NS between groups). Although there were significant reductions in absolute scar size from baseline to 1 year post-TESI, the effect did not differ by age. ConclusionsMSC therapy with TESI in ICM patients improves 6MWD and MLHFQ score and reduces myocardial infarction size. Importantly, older individuals did not have an impaired response to MSC therapy.

Biventricular pacing with ventricular fusion by intrinsic activation in cardiac resynchronization therapy.

We sought to evaluate the impact of biventricular (BiV) pacing with ventricular fusion by intrinsic atrioventricular nodal (AVN) conduction (BiV + intrinsic pacing) on clinical outcomes in patients with chronic heart failure (CHF) receiving cardiac resynchronization therapy (CRT).A total of 44 patients were randomized to receive either BiV or BiV + intrinsic pacing for one month. Echocardiographic optimization was performed for the BiV pacing mode, while the BiV + intrinsic pacing mode was achieved by titrating AV delay under electrocardiography (ECG) monitoring. Symptoms, quality of life, ECG, echocardiography, and cardiovascular events were recorded at baseline and the end of the follow-up for each pacing mode.Patients undergoing BiV + intrinsic pacing mode had shorter QRS duration compared to those with conventional BiV pacing (118.4 ± 21.6 ms versus 146.4 ± 5.3 ms, P < 0.0001). Also, these patients had improved echocardiographic left ventricular fractional shortening (LVFS) (17.4 ± 5.9 versus 15.7 ± 4.9, P = 0.019), higher left ventricular ejection fraction (LVEF) (35.5 ± 9.7 versus 32.7 ± 9.7, P = 0.048), longer 6-minute walk test (6MWT) (372.5 ± 80.9 m versus 328.7 ± 108.9 m, P = 0.0001), and better Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores (12.5 ± 6.6 versus 18.2 ± 12.3, P = 0.0001).Treating CHF patients with BiV+intrinsic pacing resulted in improved cardiac function and quality of life. BiV + intrinsic pacing can be used in CHF patients with sinus rhythm and normal AV nodal conduction to improve CRT efficacy.

Cardiac rehabilitation improves coronary endothelial function in patients with heart failure due to dilated cardiomyopathy: A positron emission tomography study.

Endothelial dysfunction is common in patients with heart failure and is associated with poor clinical outcome. Cardiac rehabilitation is able to enhance peripheral endothelial function but its impact on coronary vasomotion remains unknown. We aimed to evaluate the effect of cardiac rehabilitation on coronary vasomotion in patients with heart failure. We prospectively enrolled 29 clinically stable heart failure patients from non-ischaemic dilated cardiomyopathy and without coronary risk factors. Myocardial blood flow was quantified using (15)-O water positron emission tomography at rest and during a cold pressor test, before and after 12 weeks of cardiac rehabilitation and optimization of medical therapy. Rest myocardial blood flow was significantly improved after the completion of rehabilitation compared to baseline (1.31 ± 0.38 mL/min/g vs. 1.16 ± 0.41 mL/min/g, p = 0.04). The endothelium-related change in myocardial blood flow from rest to cold pressor test and the percentage of myocardial blood flow increase during the cold pressor test were both significantly improved after cardiac rehabilitation (respectively from -0.03 ± 0.22 mL/min/g to 0.19 ± 0.22 mL/min/g, p < 0.001 and from 101.5 ± 16.5% to 118.3 ± 24.4%, p < 0.001). Left ventricular ejection fraction, plasma levels of brain natriuretic peptide, maximal oxygen consumption and the Minnesota Living with Heart Failure Questionnaire score were also significantly improved. The improvement was not related to uptitration of medical therapy. Coronary endothelial function is altered in patients with heart failure due to non-ischaemic dilated cardiomyopathy. In these patients, cardiac rehabilitation significantly improves coronary vasomotion.

Characterization and Prediction of Adverse Events From Intensive Chronic Heart Failure Management and Effect on Quality of Life: Results From the Pro-B-Type Natriuretic Peptide Outpatient-Tailored Chronic Heart Failure Therapy (PROTECT) Study

BackgroundSerious adverse events (SAEs) from heart failure (HF) therapy are frequent; however, techniques to identify at-risk patients are inadequate. Furthermore, the relationship between SAEs, quality of life (QOL), and cardiac structure are unknown. Methods and Results151 symptomatic patients with systolic HF were followed for a mean of 10 months. In this post hoc analysis, treatment-related SAEs included acute renal failure, dizziness, hypo/hyperkalemia, hypotension, and syncope. At 1 year, 21 treatment-related SAEs occurred. No difference in SAEs existed between the N-terminal pro-B-type natriuretic peptide (NT-proBNP)–guided arm and the standard of care arm (P = .20). At baseline, patients who suffered SAEs were less likely to be receiving beta-blockers (85.7% vs 97.7%; P = .009) and had worse functional class and lower chloride levels. Patients who experienced SAEs had less improvement in their Minnesota Living With Heart Failure Questionnaire scores and had a trend toward reduced echocardiographic reverse remodeling over the follow-up period. Univariable and multivariable analyses were conducted to develop a risk score for SAE prediction; patients in the highest risk quartile had the shortest time to first cardiovascular event (P = 0.01). ConclusionsNT-proBNP–guided HF care is safe. Experiencing treatment-related SAEs is associated with worse QOL and potentially reduced reverse remodeling. A risk score to prospectively predict SAEs in aggressive HF management was developed.

Ambulatory Extra-Aortic Counterpulsation in Patients With Moderate to Severe Chronic Heart Failure

ObjectivesThe study sought to assess feasibility, safety, and potential efficacy of a novel implantable extra-aortic counterpulsation system (C-Pulse) in functional class III and ambulatory functional class IV heart failure (HF) patients. Background30% to 40% of HF patients suffer from poor functional status and quality of life (QoL) but are not in need of end-stage treatments. We undertook a multicenter single-arm study to assess the C-Pulse System in such patients. MethodsNew York Heart Association (NYHA) functional class III or ambulatory functional class IV HF patients were eligible. Safety was assessed continuously through 12 months. Efficacy measurements included changes from baseline to 6 and 12 months in NYHA functional class, Minnesota Living with Heart Failure (MLWHF) and Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, 6-min walk distance (6MWD), and exercise peak oxygen consumption (pVO2; 6 months only). ResultsTwelve men and 8 women (56.7 ± 7 years, 34 to 71 years of age) with ischemic (n = 7) or nonischemic (n = 13) cardiomyopathy were implanted. There was no 30-day mortality and no neurological events or myocardial infarctions through 12 months. At 6 months, there were 3 deaths (1 device-related). One-year survival was 85%. At 6 months, C-Pulse produced improvements in NYHA functional class (3.1 ± 0.3 to 1.9 ± 0.7, p = 0.0005), MLWHF (63.6 ± 19.9 to 40.2 ± 23.2, p = 0.0005), and KCCQ scores (43.6 ± 21.1 to 65.6 ± 21.5, p = 0.0002), but not 6MWD (275.5 ± 64.0 to 296.4 ± 104.9, p = NS) or pVO2 (14.5 ± 3.6 to 13.1 ± 4.4, p = NS). Improvements continued at 12 months, with 6MWD change becoming statistically significant (336.5 ± 91.8, p = 0.0425). ConclusionsUse of C-Pulse in this population is feasible, appears safe, and improves functional status and QoL. A prospective, multicenter, randomized controlled trial is underway. (C-Pulse IDE Feasability Study-A Heart Assist System; NCT00815880)

The Greek version of the 9-item European heart failure self-care behaviour scale: A multidimensional or a uni-dimensional scale?

ObjectivesTo evaluate the dimensionality of the Greek version of the European Heart Failure Self-care Behaviour Scale (Gr9-EHFScBS) in a Greek – Cypriot population. BackgroundEHFScBS is a valid and reliable scale which is widely used for assessing heart failure (HF) patients' self-care behaviors. MethodsEHFScBS was translated into Greek and was administered to 128 Greek-Cypriot HF patients. The internal consistency, construct validity and discriminant validity of the scale were assessed. ResultsConfirmatory factor analysis failed to capture the proposed theoretical structure. Further exploratory factor analysis provided a three-factor solution accounting for 53.35% of the variance, though the scale is better used as a whole. Cronbach's alpha was moderate 0.66, but deletion of any item decreased the alpha coefficient. Discriminant validity was supported by the poor correlation between EHFScBS and Minnesota Living with Heart Failure Questionnaire scores. ConclusionEven though results do not conform to the multidimensionality of the scale, assessment of the tool provided acceptable validity and reliability measures to support its usage among Greek speaking populations.

Activation of lymphocyte autophagy/apoptosis reflects haemodynamic inefficiency and functional aerobic impairment in patients with heart failure

Lymphocytopenia is associated with an adverse prognosis in heart failure (HF). The present study investigated whether lymphocytopenia results from activated lymphocyte autophagy/apoptosis, which reflects haemodynamic inefficiency and functional aerobic impairment in patients with HF. One hundred and twenty-seven patients with HF were divided into three groups: HF with non- (lymphocytes ≥2000 cells/μl; n=45), mild (lymphocytes between ≥1500 cells/μl and <2000 cells/μl; n=39) and severe (lymphocytes <1500 cells/μl; n=43) lymphocytopenia. Lymphocyte autophagy/apoptosis, ventilatory/haemodynamic efficiencies and generic/disease-specific quality of life were analysed in these patients with HF and 35 normal counterparts. The results demonstrated that patients with HF with severe lymphocytopenia had (i) increased G-protein-coupled receptor kinase-2 (GRK-2) levels, (ii) lower mammalian target of rapamycin (mTOR) levels with higher lysosome-associated membrane protein-2 (LAMP-2) expression and Acridine Orange (AO) staining, (iii) lower mitochondrial transmembrane potential with higher caspase-3 activation and phosphatidylserine (PS) exposure, and (iv) greater extents of adrenaline (epinephrine)-induced apoptosis in lymphocytes, and higher plasma noradrenaline (norepinephrine)/adrenaline, myeloperoxidase and interleukin-6 concentrations than patients with HF without lymphocytopenia and normal counterparts did. Moreover, lymphocyte caspase-3 activation was an effect modifier, which modulated the correlation status between lymphocyte count and GRK-2 level. Lymphocyte count was positively correlated with peak cardiac output and peak oxygen consumption (VO2peak) in patients with HF. In addition, HF with lymphocytopenia was accompanied by lower Short Form-36 physical/mental component scores and increased Minnesota Living with Heart Failure Questionnaire scores. Therefore, we conclude that increased sympathetic activation and oxidative stress/pro-inflammatory status cause lymphocytopenia by activating programmed lymphocyte death in patients with HF. Moreover, a low lymphocyte count correlates with reduced haemodynamics and aerobic capacity, which reflects poor generic/disease-specific quality of life in patients with HF.

The Effect of Multiple Micronutrient Supplementation on Left Ventricular Ejection Fraction in Patients With Chronic Stable Heart Failure: A Randomized, Placebo-Controlled Trial

This study sought to investigate the effect of a multiple micronutrient supplement on left ventricular ejection fraction (LVEF) in patients with heart failure. Observational studies suggest that patients with heart failure have reduced intake and lower concentrations of a number of micronutrients. However, there have been very few intervention studies investigating the effect of micronutrient supplementation in patients with heart failure. This was a randomized, double-blind, placebo-controlled, parallel-group study involving 74 patients with chronic stable heart failure that compared multiple micronutrient supplementation taken once daily versus placebo for 12 months. The primary endpoint was LVEF assessed by cardiovascular magnetic resonance imaging or 3-dimensional echocardiography. Secondary endpoints were Minnesota Living With Heart Failure Questionnaire score, 6-min walk test distance, blood concentrations of N-terminal prohormone of brain natriuretic peptide, C-reactive protein, tumor necrosis factor alpha, interleukin-6, interleukin-10, and urinary levels of 8-iso-prostaglandin F2 alpha. Blood concentrations of a number of micronutrients increased significantly in the micronutrient supplement group, indicating excellent compliance with the intervention. There was no significant difference in mean LVEF at 12 months between treatment groups after adjusting for baseline (mean difference: 1.6%, 95% confidence interval: -2.6 to 5.8, p = 0.441). There was also no significant difference in any of the secondary endpoints at 12 months between treatment groups. This study provides no evidence to support the routine treatment of patients with chronic stable heart failure with a multiple micronutrient supplement. (Micronutrient Supplementation in Patients With Heart Failure [MINT-HF]; NCT01005303).

A Randomized Controlled Trial of Catheter Ablation Versus Medical Treatment of Atrial Fibrillation in Heart Failure (The CAMTAF Trial)

Restoring sinus rhythm in patients with heart failure (HF) and atrial fibrillation (AF) may improve left ventricular (LV) function and HF symptoms. We sought to compare the effect of a catheter ablation strategy with that of a medical rate control strategy in patients with persistent AF and HF. Patients with persistent AF, symptomatic HF, and LV ejection fraction <50% were randomized to catheter ablation or medical rate control. The primary end-point was the difference between groups in LV ejection fraction at 6 months. Baseline LV ejection fraction was 32±8% in the ablation group and 34±12% in the medical group. Twenty-six patients underwent catheter ablation, and 24 patients were rate controlled. Freedom from AF was achieved in 21/26 (81%) at 6 months off antiarrhythmic drugs. LV ejection fraction at 6 months in the ablation group was 40±12% compared with 31±13% in the rate control group (P=0.015). Ablation was associated with better peak oxygen consumption (22±6 versus 18±6 mL/kg per minute; P=0.014) and Minnesota living with HF questionnaire score (24±22 versus 47±22; P=0.001) compared with rate control. Catheter ablation is effective in restoring sinus rhythm in selected patients with persistent AF and HF, and can improve LV function, functional capacity, and HF symptoms compared with rate control. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT01411371.

Abstract 9240: Successful Implementation of ACCF/AHA Performance Measures for Adults With Heart Failure Reduces Mortality in South-East Asian Patients With Chronic Heart Failure

Background: Heart failure (HF) is a leading cause of hospitalization in Singapore (5541 discharges in Financial Year 2012/2013). The National Healthcare Group comprises 3 public hospitals with a total bed complement of about 2950 and receives 50% of HF admissions in the nation. We evaluated the recent outcomes of our 10-year Heart Failure Disease Management Program (HFDMP). Methods: Patients admitted with a clinical diagnosis of acute HF were recruited from Apr 2007 to Mar 2012. All patients were managed by cardiologists. A clinical carepath was used to standardize evidence-based care. Prognostically beneficial drugs such as Angiotensin-Converting Enzyme-Inhibitors and Beta-Blockers were commenced inpatient at low doses and up-titrated as tolerated in the outpatient HF clinic. Case Managers educate and counsel patients on managing their disease, and provide telephone follow-up. Performance measures were tracked as per ACCF/AHA Guidelines. Results: We recruited 2900 patients, of whom 2527 remained in the HFDMP for at least one year. Of these, 62.9% were male, age 67.6 ± 13.2 (range 17-103) years, and mean LVEF 31.4 ± 14.5%. Median baseline 6 minute walk test (6MWT) was 250.5m, Minnesota Living With Heart Failure Questionnaire (MLWHF) score 33.5, and NYHA Class 2. At 6 months, median 6MWT improved to 281.1m, MLWHF score fell to 25, and NYHA Class was 1.76 (all p &lt; 0.005). The 1-year mortality rate improved from 16.75% in 2007 to 11.46% in 2011 (Fig 1)despite stable readmission rates at 1, 6, and 12 months (Fig 2). Conclusion: HF treatment based on ACCF/AHA Performance Measures and implemented by a HFDMP results in real-world reduction in mortality without compromising on readmission rates.

Oral Chinese herbal medicine for improvement of quality of life in patients with chronic heart failure: a systematic review and meta-analysis

Chronic heart failure (CHF) is not only a leading cause of death, hospitalization, and rehospitalization, but also significantly decreases quality of life (QoL). This study aims to evaluate published clinical trials of oral Chinese herbal medicine (OCHM) for improvement of QoL in patients with CHF that employ the Minnesota Living with Heart Failure Questionnaire (MLHFQ) score as an outcome measure. A systematic literature search was performed using five databases up to June 2013 to identify randomized control trials (RCTs). RCTs involving OCHM plus conventional medicine treatment (CMT) with or without blinding, compared with CMT with or without placebo, with MLHFQ score as an outcome measure were identified. The methodological quality of RCTs was assessed independently using the Cochrane Handbook for Systematic Review of Interventions. RevMan 5.2.5 and Stata 11.0 were used for data analysis. Thirty-eight RCTs with a total of 3,170 participants were identified. The majority of the included trials were assessed to be of high clinical heterogeneity and poor methodological quality. The main results of meta-analysis showed improvement of total MLHFQ score when OCHM plus CMT compared with CMT with or without placebo [MD = -5.71 (-7.07, -4.36), p < 0.01]. There is some encouraging evidence of OCHM combined with CMT for the improvement of QoL in CHF patients. However, the evidence remains weak due to the small sample size, high clinical heterogeneity, and poor methodological quality of the included trials. Further, large sample size and well-designed trials are needed.

Clinical outcomes through 12 months in patients with degenerative mitral regurgitation treated with the MitraClip® device in the ACCESS-EUrope Phase I trial†

Percutaneous treatment with the MitraClip device represents an alternative option for selected patients with degenerative mitral regurgitation (DMR) considered ineligible for surgery due to contraindications or high surgical risk by an inter-disciplinary heart team. We describe 12-month outcomes following treatment with the MitraClip device in DMR patients. The MitraClip Therapy Economic and Clinical Outcomes Study Europe (ACCESS-EU) Study has completed the enrolment of 567 patients as of April 2011, 117 of whom were DMR. Baseline demographics, procedural and acute safety results at 30 days and survival at 12 months were evaluated in the DMR subset. Effectiveness results, defined by a reduction in MR, and improvement in clinical outcomes based on changes in New York Heart Association (NYHA) functional Class, 6-min walk test (6MWT) and quality-of-life data were also assessed. Furthermore, DMR patients were stratified into high- and low-risk subgroups (logistic European System of Cardiac Operative Risk Evaluation I (logEuroSCORE I ≥20% or <20%, respectively) and differentially evaluated. One hundred and seventeen DMR patients underwent the MitraClip procedure with a 94.9% rate (111 of 117) of successful clip implantation. Baseline characteristics and comorbidities included NYHA Class III/IV (74%), left ventricular ejection fraction (LVEF) <40% (9%), prior cardiac surgery (24%) and prior myocardial infarction (MI) (22%). Mean logEuroSCORE I was 15.5 ± 13.3%. Mortalities at 30 days and 12 months were 6.0 and 17.1%, respectively. At 12 months, 74.6% (53 of 71) of patients in follow-up achieved MR ≤grade 2+ and 80.8% (63 of 78) were in NYHA functional class I/II. Both Minnesota Living with Heart Failure questionnaire (MLHFQ) scores and 6MWT distance improved significantly at 12 months compared with baseline (P = 0.03 and P < 0.0001, respectively). The MitraClip procedure resulted in significant reductions in MR and improvements in clinical outcomes at 12 months in selected patients with severe DMR. MitraClip therapy may serve as a complementary non-surgical therapeutic option for DMR patients who are considered at high risk or ineligible for surgery by an inter-disciplinary dedicated heart team. Interventional treatment should be indicated following the discussion of patients in an inter-disciplinary conference of cardiologists and cardiac surgeons as suggested by current international guidelines.

Home-Based Telesurveillance Program in Chronic Heart Failure: Effects on Clinical Status and Implications for 1-Year Prognosis

Studies focusing on the effects of telemanagement programs for chronic heart failure (CHF) on functional status are lacking, and the prognostic value of the clinical response to the programs is unknown. In the Lombardy region of Italy, a home-based telesurveillance program (HTP) including multidisciplinary management and remote telemonitoring for patients with CHF was introduced in 2000 and was formally adopted, as part of the services delivered by the regional healthcare system, in 2006. This article reports the effect of the HTP on the functional status and quality of life and describes the main outcomes observed within 1 year from the end of the program. Six-month variations of New York Heart Association (NYHA) class, left ventricular ejection fraction (LVEF), 6-min walking distance (6MWD), and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score were evaluated in 602 CHF patients. Patients showing at least two of the following conditions-NYHA class reduction, increase in LVEF ≥5%, 6MWD >30 m, and a reduction of >24 points of MLHFQ-were defined as "responders." One-year events included unplanned cardiovascular readmissions and mortality. A significant improvement in NYHA class, LVEF, 6MWD, and MLHFQ was observed. Clinical events occurred in 24.1% of non-responders and in 15.9% of responders (p=0.03). An unfavorable response to the program, the presence of an implantable cardioverter defibrillator, and multiple comorbidities were predictors of poor outcome. The HTP was effective in improving CHF patient functional status, and an unsuccessful response to the intervention seems to be an independent marker of poor prognosis.

Noninvasive Assessment of LV Contraction Patterns Using CMR to Identify Responders to CRT

Type II activation describes the U-shaped electrical activation of the left ventricle (LV) with a line of block in patients with left bundle branch block (LBBB). We sought to determine if a corresponding pattern of contraction could be identified using cardiac magnetic resonance (CMR) cine imaging and whether this predicted response to cardiac resynchronization therapy (CRT). U-shaped LV electrical activation in LBBB has been shown to predict favorable response to CRT. It is not known if the degree of electromechanical coupling is such that the same is true for LV contraction patterns. A total of 52 patients (48% ischemic) scheduled for CRT implantation prospectively underwent pre-implantation CMR cine analysis using endocardial contour tracking software to generate time-volume curves and contraction propagation maps. These were analyzed to assess the contraction sequence of the LV. The effect of contraction pattern on CRT response in terms of reverse remodeling (RR) and clinical parameters (New York Heart Association functional class, 6-min walk distance and Heart Failure Questionnaire score) was assessed at 6 months. Two types of contraction pattern were identified; homogenous spread from septum to lateral wall (type I, n = 27) and presence of block with a subsequent U-shaped contraction pattern (type II, n = 25). Rates of RR in those with a type 2 pattern were significantly greater at 6 months (80% vs. 26%, p < 0.001) as was mean increase in 6-min walk distance (126 ± 106 m vs. 55 ± 60 m; p = 0.004). Cine CMR can identify a U-shaped pattern of contraction which predicts increased echocardiographic and clinical response rates to CRT in patients with LBBB.

Left cardiac sympathetic denervation for treatment of symptomatic systolic heart failure patients: a pilot study

To evaluate the feasibility, safety, and potential beneficial effects of left cardiac sympathetic denervation (LCSD) in systolic heart failure (HF) patients. In this prospective, randomized pilot study, inclusion criteria were New York Heart Association (NYHA) functional class II or III, left ventricular ejection fraction (LVEF) ≤40%, sinus rhythm, and resting heart rate >65 b.p.m., despite optimal medical therapy (MT). Fifteen patients were randomly assigned either to MT alone or MT plus LCSD. The primary endpoint was safety, measured by mortality in the first month of follow-up and morbidity according to pre-specified criteria. Secondary endpoints were exercise capacity, quality of life, LVEF, muscle sympathetic nerve activity (MSNA), brain natriuretic peptide (BNP) levels and 24 h Holter mean heart rate before and after 6 months. We studied clinical effects in long-term follow-up. Ten patients underwent LCSD. There were no adverse events attributable to surgery. In the LCSD group, LVEF improved from 25 ± 6.6 to 33 ± 5.2 (P = 0.03); 6 min walking distance improved from 167 ± 35 to 198 ± 47 m (P = 0.02). Minnesota Living with Heart Failure Questionnaire (MLWHFQ) score physical dimension changed from 21 ± 5 to 15 ± 7 (P = 0.06). The remaining analysed variables were unchanged. During 848 ± 549 days of follow-up, in the MT group, three patients either died or underwent cardiac transplantation (CT), while in the LCSD group six were alive without CT. LCSD was feasible and seemed to be safe in systolic HF patients. Its beneficial effects warrant the development of a larger randomized trial. Trail registration: NCT01224899.

Heart Rate Control in Patients With Chronic Atrial Fibrillation and Heart Failure

The goal of this study was to determine whether aggressive heart rate (HR) control in patients with both chronic atrial fibrillation (AF) and heart failure (HF) is associated with improved outcomes. HR control is one of the mainstays in management of patients with AF. However, rate control can be challenging in patients with HF. This study was designed as an interventional clinical trial, using patients with chronic AF and left ventricular systolic dysfunction with left ventricular ejection fraction ≤40% (n=20) as their own controls. Intervention consisted of increasing doses of metoprolol succinate to achieve target resting HR <70 beats per minute. Clinical data were collected at baseline and after intervention, with paired t test used to evaluate statistically significant change. After 3 months of intervention, average resting HR decreased from 94±14 beats per minute to 85±12 beats per minute. Average metoprolol succinate dose at the end of the study was 121 mg. None of the outcomes improved significantly after the intervention, including exercise tolerance (meters walked on 6-minute walk test 326±83 vs 330±86), quality of life (Minnesota Living With Heart Failure Questionnaire score of 42.5±19 vs 38±21), and brain natriuretic peptide (242±306 pg/mL vs 279±395 pg/mL). Aggressive HR control was difficult in this group of patients with chronic AF and HF due to patient intolerance of increasing doses of β-blockade, and not associated with improved outcomes. Further studies are needed to establish guidelines for target HR in patients with chronic AF who also have significant HF.

Changes in the Minnesota Living With Heart Failure Questionnaire Score and Clinical Outcomes in a Large Contemporary Population of Ambulatory Heart Failure Patients in the Canadian Heart Failure Network

Changes in the Minnesota Living With Heart Failure Questionnaire Score and Clinical Outcomes in a Large Contemporary Population of Ambulatory Heart Failure Patients in the Canadian Heart Failure Network

057 A randomised controlled trial of catheter ablation vs medical treatment of atrial fibrillation in heart failure (the CAMTAF trial)

IntroductionAlthough atrial fibrillation (AF) has deleterious effects in patients with heart failure (HF), rhythm control using medication has limited efficacy. Catheter ablation (CA) of AF is effective in restoring sinus...