Improvement In Heart Failure Symptoms Research Articles

Abstract 4113301: A Rare Cause of Recurrent Heart Failure Exacerbations After Transcatheter Aortic Valve Replacement: Ventricular Septal Defect and Significant Paravalvular Leak

Introduction: Ventricular septal defects (VSD) have been reported in <1% of cases following transcatheter aortic valve replacement (TAVR). A retrospective record review of VSD cases occurring after all TAVRs performed between January 2012 and September 2020 at one urban US tertiary hospital showed 0.37% incidence of these complications, mostly with small and restrictive VSD. Case Description: An 80-year-old woman with history of hypertension, HFpEF, and TAVR 8 months prior for severe aortic stenosis (AS) at an outside hospital presented with worsening dyspnea and peripheral edema over the past month. Blood pressure was 148/53mmHg, heartrate 83bpm, oxygen saturation 98% and auscultation revealed a harsh holosystolic murmur 4/6 loudest at left sternal border and bibasilar rales. Chest X-ray showed pulmonary edema and bilateral pleural effusions. NT-proBNP was 17,000pg/ml and troponin-I was negative. Echocardiogram showed EF55-60%, a membranous VSD, severe pulmonary hypertension, and moderate paravalvular leak (PVL). Coronary angiogram showed non-obstructive disease. Right heart catheterization confirmed significant left to right shunting. Treatment/Outcomes: Cardiothoracic surgery was consulted for multidisciplinary evaluation, and joint recommendation was for surgical aortic valve replacement and VSD closure which was successfully performed. One month follow-up echocardiogram showed normal aortic valve gradient without PVL and normal right ventricular pressure. Discussion/Conclusion: Numerous potential risks such as severe and uneven calcification of the native valve, an elliptic aortic annulus, excessive valve sizing, or elevated valve placement can lead to VSD. A recurrent element in many of these instances involves direct trauma to the septum caused by the implanted valve, exacerbated by subsequent annulus dilation. The presence of PVL is common post-TAVR and is an established independent prognostic factor, while VSD post-TAVR is uncommon, but may be associated with low implantation position relative to the aortic annulus or post-implantation balloon dilatation. Rarely, worsening VSD may require operative management. In this case, the improvement of heart failure symptoms and echocardiogram parameters after transthoracic surgery confirmed successful repair.

Evaluating the budget impact of Empagliflozin in managing heart failure with reduced ejection fraction: Proposing strategic policies for Malaysian public healthcare.

Sodium-glucose co-transporter-2 (SGLT2) inhibitors such as Empagliflozin, are increasingly recommended as part of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) in many developed nations. This recommendation is based on robust clinical evidence showing that adding Empagliflozin to GDMT improves heart failure symptoms, clinical outcomes, functional status, and overall quality of life. In Malaysia, where healthcare is predominantly public and heavily subsidized, the introduction of new treatments can significantly impact costs, requiring detailed economic assessments. This study evaluates the budget impact of incorporating Empagliflozin into GDMT for HFrEF from the perspective of the public healthcare system. A five-year budget impact model was developed, integrating local data such as population, drug use, costs, clinical outcomes, and healthcare expenses. In the current scenario (GDMT alone), the projected five-year expenditure is MYR 6.12 billion (USD 3.92 billion). With Empagliflozin, the total cost rises by 0.71% to MYR 6.16 billion (USD 3.95 billion), driven by drug acquisition costs of MYR 160.12 million (USD 102.64 million) and adverse event costs of MYR 211,543 (USD 135,604). However, these costs are offset by savings from reduced HF hospitalizations, fewer cardiovascular deaths, and improved renal outcomes. Sensitivity analysis identified hospitalization costs, the price of Empagliflozin, and cardiovascular deaths in diabetic patients as key factors influencing the budget impact. Policymakers can improve the affordability of Empagliflozin through strategies like price negotiations, cost-sharing, and focusing on high-risk groups to optimize healthcare expenditure while ensuring effective treatment access.

The impact of a dedicated heart failure clinic on patients with heart failure with reduced ejection fraction

Abstract Introduction Heart failure (HF) is not a diagnosis but rather a syndrome with a variety of potential causes and once a patient has been diagnosed as having HF, the underlying etiology should be sought and treated. Thus, patients with HF should be engaged in a disease management program that includes a dedicated wider healthcare team which is critical for delivering the best care for patients. A dedicated HF clinic is one of the cornerstones of this ultimate management program. This clinic is specifically made to make sure of the proper management and follow-up of those patients. There is a scarce evidence of weather a dedicated HF clinic can alter the long-term outcomes of HF patients or not. Thus, the aim of this study is to search for the impact of a dedicated HF clinic on patients with HF with reduced ejection fraction (HFrEF) regarding the symptoms, management received according to latest guidelines, the patients’ quality of life and impact on health care resources. Patients and Methods This is a single center retrospective study that included patients presented to a dedicated heart failure clinic at a secondary care hospital through a one-year period. The study group included patients with diagnosis of HFrEF only who had one or more visit to the HF clinic. These patients served as their own control. Hospital admissions and emergency room visits in the 12-month period preceding enrollment was compared to the number in the following year after enrollment. Patients with incomplete data and those with ejection fraction >40% were excluded. Results The study included 48 patients with a mean age of 65 years, 70.8% of them were males. Most of the patients were hypertensive (77.1%), diabetic (75%) and with history of coronary artery disease (60.4%). Symptoms improved significantly in all patients, left ventricular volumes and ejection fraction improved (31±8.1% vs 40.7±10.5%) (P<0.0001). NT-ProBNP level improved significantly (5927 ng/L vs 3135 ng/L) (P = 0.03). The guideline directed medical therapy was used properly before and after the clinic. There was a significant improvement in the quality of life where the KCCQ-12 score improved from 71.25±13.2 to 83.3±13.3 (P<0.0001), six-minute walk test also improved significantly from 362±184 meters to 479±211 meters (P = 0.005). Regarding the economic impact, there was no significant difference in the number of unplanned visits (20.8% vs 10.4%) (P = 0.16) but there was a significant reduction in the number of HF hospitalizations within one year (20.8% vs 6.25%) (P = 0.038) Conclusion Dedicated HF clinics are very important now for the proper management of HF patients where it is proved that it can improve HF symptoms, improve the quality of life measurements, maintain the proper guideline directed therapy and reduce the economic burden of HF through reducing the number of HF hospitalizations.Clinical dataOutcomes

Transcatheter aortic valve implantation for severe aortic regurgitation using the J-Valve system: A midterm follow-up study.

Transcatheter aortic valve implantation (TAVI) is a well-established intervention for severe aortic valve stenosis. However, its application for severe aortic regurgitation (AR) is still under evaluation. This study aims to present the 3-year follow-up outcomes of the J-Valve system in managing severe AR. The aim of this study was to evaluate the mid-term efficacy and durability of the J-Valve system in the treatment of severe AR and to provide new information on this intervention. In this retrospective, single-center study, we evaluated the prognostic outcomes of patients with AR, who underwent treatment with the J-Valve system at Nanjing Drum Tower Hospital. Consecutive patients who were treated with the J-Valve were included in the analysis. The study focused on the echocardiographic follow-up to assess the effectiveness and durability of the J-Valve system in managing AR. From January 2018 to December 2022, 36 high-risk AR patients treated with the J-Valve system had a procedural success rate of 97.2%, with one case requiring open-heart surgery due to valve displacement. Significant improvements were observed in left ventricular diameter (from 63.50 [58.75-69.50] mm to 56.50 [53.00-60.50] mm, p < 0.001) and left atrial diameter (from 44.00 [40.00-45.25] mm to 39.00 [36.75-41.00] mm, p = 0.003) postsurgery. All patients completed the 1-year follow-up, with an overall mortality rate of 2 out of 36 (5.6%). Among the surviving patients, there was one case of III° atrioventricular block and one case of stroke, both occurring within 90 days postsurgery. After a 3-year follow-up, 15.0% of patients had mild or moderate valvular regurgitation, with no cases of moderate or severe paravalvular leak. Additionally, 89.5% of patients were classified as New York Heart Association class I or II, showing significantly enhanced cardiac function. The J-Valve system has shown positive therapeutic outcomes in treating AR, with notable effectiveness in managing the condition and significant improvements in heart failure symptoms and cardiac remodeling. However, due to the limited sample size and partial follow-up data, it is important to emphasize the need for further research with comprehensive long-term follow-up, to fully validate these results.

Post-COVID Myocarditis in Patients with Primary Cardiomyopathies: Diagnosis, Clinical Course and Outcomes.

The aim of this study was to evaluate the clinical course and outcomes of post-COVID myocarditis in patients with cardiomyopathies (CMP). This case series includes 10 patients with different CMPs who had COVID-19 (seven men; 48.4 ± 11.4 yr.): left ventricular non-compaction (n = 2), arrhythmogenic right ventricular CMP in combination with a heterozygous form of hemochromatosis (n = 1, HFE), restrictive CMP (n = 1, MyBPC3), laminopathy (n = 1, LMNA), dilated cardiomyopathy (n = 1, MYH7 + MyBPC3), Danon's disease (n = 1, LAMP2) and AL cardiac amyloidosis (n = 3). Myocardial morphological examination with immunohistochemical staining and PCR for SARS-CoV-2 and cardiotropic viruses was performed in six patients, while cardiac MRI and anti-cardiac antibody titres were evaluated in all patients. Post-COVID lymphocytic myocarditis was confirmed morphologically in six patients (with LVNC, RCM, ARCV, Danon's disease, and AL amyloidosis). Spike and nucleocapsid coronavirus proteins were detected in cell infiltrates, endothelium and cardiomyocytes in all biopsies; SARS-CoV-2 RNA was found in five out of six. In four patients, the diagnosis of myocarditis was based on MRI, high titres of anti-cardiac antibodies and clinical data. The mean time from COVID-19 to the diagnosis of myocarditis was 7 (5; 10.5) months. Myocarditis manifested with the onset/increase of arrhythmias and heart failure. Immunosuppressive therapy with corticosteroids was administered to six patients and led to an increase in ejection fraction and improvement of heart failure symptoms in five of them. CMPs are a favourable background for the development of post-COVID myocarditis. The onset or deterioration of heart failure and/or arrhythmias in patients with CMPs after COVID-19 requires the exclusion of myocarditis and, if present, the administration of immunosuppressive therapy.

Patients with paradoxical low-flow, low-gradient aortic stenosis gain the least benefit from TAVI among all hemodynamic subtypes.

Substantial controversy exists regarding the clinical benefit of patients with severe paradoxical low-flow, low-gradient aortic stenosis (PLF-LG AS) from TAVI. Therefore, we compared post-TAVI benefit by long-term mortality (all-cause, CV and SCD), clinical improvement of heart failure symptoms, and cardiac reverse remodelling in guideline-defined AS subtypes. We prospectively included 250 consecutive TAVI patients. TTE, 6mwt, MLHFQ, NYHA status and NT-proBNP were recorded at baseline and 6months. Long-term mortality and causes of death were assessed. 107 individuals suffered from normal EF, high gradient AS (NEF-HG AS), 36 from low EF, high gradient AS (LEF-HG), 52 from "classic" low-flow, low-gradient AS (LEF-LG AS), and 38 from paradoxical low-flow, low-gradient AS (PLF-LG AS). TAVI lead to a significant decrease in MLHFQ score and NT-proBNP levels in all subtypes except for PLF-LG. Regarding reverse remodelling, a significant increase in EF and decrease in LVEDV was present only in subtypes with reduced baseline EF, whereas a significant decrease in LVMI and LAVI could be observed in all subtypes except for PLF-LG. During a follow-up of 3-5years, PLF-LG patients exhibited the poorest survival among all subtypes (HR 4.2, P = 0.0002 for CV mortality; HR 7.3, P = 0.004 for SCD, in comparison with NEF-HG). Importantly, PLF-LG was independently predictive for CV mortality (HR 2.9 [1.3-6.9], P = 0.009). PLF-LG patients exhibit the highest mortality (particularly CV and SCD), the poorest symptomatic benefit and the least reverse cardiac remodelling after TAVI among all subtypes. Thus, this cohort seems to gain the least benefit.

Association of a device-based remote management heart failure pathway with outcomes: TriageHF Plus real-world evaluation.

Clinical pathways have been shown to improve outcomes in patients with heart failure (HF). Although patients with HF often have a cardiac implantable electronic device, few studies have reported the utility of device-derived risk scores to augment and organize care. TriageHF Plus is a device-based HF clinical pathway (DHFP) that uses remote monitoring alerts to trigger structured telephone assessment for HF stability and optimization. We aimed to evaluate the impact of TriageHF Plus on hospitalizations and describe the associated workforce burden. TriageHF Plus was a multi-site, prospective study that compared outcomes for patients recruited between April 2019 and February 2021. All alert-triggered assessments were analysed to determine the appropriateness of the alert and the workload burden. A negative-binomial regression with inverse probability treatment weighting using a time-matched usual care cohort was applied to estimate the effect of TriageHF Plus on non-elective hospitalizations. A post hoc pre-COVID-19 sensitivity analysis was also performed. The TriageHF Plus cohort (n=443) had a mean age of 68.8±11.2years, 77% male (usual care cohort: n=315, mean age of 66.2±14.5years, 65% male). In the TriageHF Plus cohort, an acute medical issue was identified following an alert in 79/182 (43%) cases. Fifty assessments indicated acute HF, requiring clinical action in 44 cases. At 30day follow-up, 39/66 (59%) of initially symptomatic patients reported improvement, and 20 (19%) initially asymptomatic patients had developed new symptoms. On average, each assessment took 10min. The TriageHF Plus group had a 58% lower rate of hospitalizations across full follow-up [incidence relative ratio: 0.42, 95% confidence interval (CI): 0.23-0.76, P=0.004]. Across the pre-COVID-19 window, hospitalizations were 31% lower (0.69, 95% CI: 0.46-1.04, P=0.077). These data represent the largest real-world evaluation of a DHFP based on multi-parametric risk stratification. The TriageHF Plus clinical pathway was associated with an improvement in HF symptoms and reduced all-cause hospitalizations.

Effectiveness of a Smartphone App-Based Intervention With Bluetooth-Connected Monitoring Devices and a Feedback System in Heart Failure (SMART-HF Trial): Randomized Controlled Trial.

Current heart failure (HF) guidelines recommend a multidisciplinary approach, discharge education, and self-management for HF. However, the recommendations are challenging to implement in real-world clinical settings. We developed a mobile health (mHealth) platform for HF self-care to evaluate whether a smartphone app-based intervention with Bluetooth-connected monitoring devices and a feedback system can help improve HF symptoms. In this prospective, randomized, multicenter study, we enrolled patients 20 years of age and older, hospitalized for acute HF, and who could use a smartphone from 7 tertiary hospitals in South Korea. In the intervention group (n=39), the apps were automatically paired with Bluetooth-connected monitoring devices. The patients could enter information on vital signs, HF symptoms, diet, medications, and exercise regimen into the app daily and receive feedback or alerts on their input. In the control group (n=38), patients could only enter their blood pressure, heart rate, and weight using conventional, non-Bluetooth devices and could not receive any feedback or alerts from the app. The primary end point was the change in dyspnea symptom scores from baseline to 4 weeks, assessed using a questionnaire. At 4 weeks, the change in dyspnea symptom score from baseline was significantly greater in the intervention group than in the control group (mean -1.3, SD 2.1 vs mean -0.3, SD 2.3; P=.048). A significant reduction was found in body water composition from baseline to the final measurement in the intervention group (baseline level mean 7.4, SD 2.5 vs final level mean 6.6, SD 2.5; P=.003). App adherence, which was assessed based on log-in or the percentage of days when symptoms were first observed, was higher in the intervention group than in the control group. Composite end points, including death, rehospitalization, and urgent HF visits, were not significantly different between the 2 groups. The mobile-based health platform with Bluetooth-connected monitoring devices and a feedback system demonstrated improvement in dyspnea symptoms in patients with HF. This study provides evidence and rationale for implementing mobile app-based self-care strategies and feedback for patients with HF. ClinicalTrials.gov NCT05668000; https://clinicaltrials.gov/study/NCT05668000.

Efficacy and Safety of Aficamten in Symptomatic Nonobstructive Hypertrophic Cardiomyopathy: Results From the REDWOOD-HCM Trial, Cohort 4

This open-label phase 2 trial evaluated the safety and efficacy of aficamten in patients with non-obstructive hypertrophic cardiomyopathy (nHCM). Patients with symptomatic nHCM (left ventricular outflow tract obstruction gradient ≤30 mmHg, left ventricular ejection fraction [LVEF] ≥60%, N-terminal pro-B-type natriuretic peptide [NT-proBNP] >300 pg/mL) received aficamten 5-20 mg once daily (doses adjusted according to echocardiographic LVEF) for 10 weeks. 41 patients were enrolled (mean ± SD age 56 ± 16 years; 59% female). At Week 10, 22 (55%) patients experienced an improvement of ≥1 New York Heart Association class; 11 (29%) became asymptomatic. Clinically relevant improvements in Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores occurred in 22 (55%) patients. Symptom relief was paralleled by reductions in NT-proBNP (56%; P < 0.001) and high-sensitivity cardiac troponin I (22%; P < 0.005). Modest reductions in LVEF (mean ± SD) of -5.4% ± 10 to 64.6% ± 9.1 were observed. Three (8%) patients had asymptomatic reduction in LVEF <50% (range: 41-48%), all returning to normal after 2 weeks of washout. One patient with prior history of aborted sudden cardiac death experienced a fatal arrhythmia during the study. Aficamten administration for symptomatic nHCM was generally safe and associated with improvements in heart failure symptoms and cardiac biomarkers. ClinicalTrials.gov Identifier: NCT04219826 LAY SUMMARY: Non-obstructive hypertrophic cardiomyopathy (nHCM) is a disease in which the heart muscle becomes abnormally thickened. There are no proven medical therapies. Aficamten is a new cardiac myosin inhibitor designed to target the underlying cause of HCM. REDWOOD-HCM Cohort 4 was the first study exploring the efficacy and safety of aficamten in people with symptoms from nHCM. Most patients reported improved health and functional status. There was also significant decrease in blood levels of biomarkers indicating excessive pressure within the heart and damage to heart muscle cells. These results support a larger placebo-controlled study of aficamten for people with nHCM (ACACIA-HCM).

Cardiac Structural and Functional Remodeling After Transcatheter Mitral Valve in Valve Implantation: Early Changes and Prognostic Significance

BackgroundTranscatheter mitral valve-in-valve (MViV) replacement has emerged as an alternative to redo mitral valve (MV) surgery for the management of failed bioprosthetic MVs. The degree of cardiac remodeling assessed by echocardiography has been shown to have prognostic implications in degenerative mitral regurgitation patients undergoing MV surgery. The impact of transcatheter MViV in patients with degenerative bioprosthetic MV failure on cardiac remodeling and its associated prognosis remains undescribed. ObjectivesThe aim of this study is to describe the early anatomic and functional changes of the left-sided chambers and right ventricle by echocardiography posttranscatheter MViV intervention and their impact on mortality outcomes. Additionally, we sought to analyze the outcome of heart failure in bioprosthetic MV failure patients undergoing transcatheter MViV replacement. MethodsWe analyzed consecutive patients undergoing MViV intervention for symptomatic bioprosthetic MV failure. Echocardiograms before intervention and within 100 days postintervention were analyzed. A chart review was performed to obtain baseline characteristics, follow-up visits, 30-day heart failure and 1-year all-cause mortality outcomes. ResultsA total of 62 patients (mean age 69 ± 13 years, 61% male) were included in the study. Most patients were undergoing MViV intervention for prosthetic mitral stenosis n = 48 (77.4%) and the rest for mitral regurgitation or mixed disease. Compared with baseline, significant reductions were observed in median left atrial volume (LAV; 103 [81–129] ml vs. 95.2 [74.5–117.5] ml, p < 0.01) and mean (SD) left atrial conduit strain (9.1% ± 5.2% vs. 10.8% ± 4.8%, p = 0.039) within 100 days postintervention. Early reduction in right ventricular free wall global longitudinal strain and fractional area change also occurred postintervention. No significant change in left ventricular chamber dimensions or ejection fraction was observed. During the 1-year follow up period, 5 (8%) patients died. While baseline LAV was not associated with 1-year all-cause mortality (OR 0.98 CI 0.95–1.01; p = 0.27), a change in LAV in the follow up period was associated with all-cause mortality at 1 year (OR 1.06 CI 1.01–1.12; p = 0.023). At 30 days postintervention, 65% of patients had an improvement in their New York Heart Association functional class. ConclusionIn this retrospective study of patients undergoing transcatheter MViV intervention for failed bioprosthetic MVs, early reverse remodeling of the left atrium occurs within 100 days postintervention and reduction in LAV is associated with reduced all-cause mortality at 1 year. In addition, there is significant improvement in heart failure symptoms at 30 days following intervention but further investigation into the longitudinal remodeling changes and long-term outcomes is needed.

Sex differences and survival after TAVI for severe aortic stenosis

Abstract Background There is still controversy about survival rates and clinical response of women versus men who undergo transcatheter aortic valve implantation (TAVI) for the treatment of severe aortic stenosis (SAS). Purpose Assess mortality and heart failure (HF) symptoms following TAVI for SAS, according to sex. Methods A retrospective analysis of a single-center database including all TAVI performed in 2011-2019 was performed. Clinical, echocardiographic, and blood-analysis data were determined, and all-cause mortality over the five years after the procedure was compared based on sex. A reduction of at least one New York Heart Association (NYHA) class after TAVI was the secondary endpoint. Results Of the 488 cases analyzed, 252 (51.6%) were women. They were older (84 vs. 80 years-old, p&amp;lt;0.001), had a lower body surface area, and had a higher estimated surgical risk, as determined by EuroSCORE II (4.5 vs. 3.8, p=0.011) and STS-mortality (4.46 vs. 3.44, p&amp;lt;0.001). However, they had a lower prevalence of diabetes mellitus, coronary artery disease, and peripheral artery disease, a lower estimated creatinine clearance, and a lower frequency of previous pacemaker implantation. Women had more frequently a phenotype of high gradient severe aortic stenosis, with lower functional aortic valve areas. While there was no difference in TAVI design, smaller valves were implanted in women. Median follow-up was 46 months and there was a 40% mortality rate over the five years after treatment, with no statistically significant differences according to sex in both univariate and multivariate analysis, after adjusting for estimated surgical risk. EuroSCORE II had a statistically significant association with the primary endpoint (hazard ratio 1.03 (1.01-1.05), p=0.004). Despite having a similar NYHA class before TAVI, women experienced a lower frequency of functional class improvement (61% vs. 72%, p=0.034). Conclusions Although women had a higher estimated surgical risk, no differences were found regarding survival after TAVI for SAS. However, improvement in HF symptoms was less frequent in this subset.Table 1Figure 1

Long-term outcomes from upgrade to cardiac resynchronisation therapy in ischaemic versus non-ischaemic heart disease

Background Cardiac resynchronisation therapy (CRT) can be necessary in patients with chronic heart failure, who have already been provided with transvenous cardiac implantable electrical devices. Upgrade procedures revealed controversial results, while long-term outcomes regarding underlying Ischaemic- (ICM) or Non-Ischaemic heart disease (NICM) have yet to be described. Methods The Mannheim Cardiac Resynchronisation Therapy Registry (MARACANA) was designed as a retrospective observational single-centre registry, including all CRT implantations from 2013-2021 (n = 459). CRT upgrades (n = 136) were retrospectively grouped to either ICM (n = 84) or NICM (n = 52) and compared for New York Heart Association classification (NYHA), paced QRS-width, left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE) and other heart failure modification aspects in the long-term (59.3 ± 5 months). Results Baseline-characteristics including paced QRS-width, upgrade indications or NYHA-classification were comparable for both groups (group comparison p>.05). The CRT upgrade improved NYHA (ICM: 2.98 ± 0.4 to 2.29 ± 0.7, NICM: 2.94 ± 0.5 to 2.08 ± 0.5) and the LVEF (ICM: 27.2 ± 6.6 to 38.25 ± 8.8, NICM: 30.2 ± 9.4 to 38.7 ± 13.8%) after five years, irrespective of underlying heart disease (each group p < .05, group comparison p>.05). Only ICM revealed significant improvements in TAPSE (15.9 ± 4.1 to 18.9 ± 4.1 mm) and narrowing of the paced QRS-width (185.4 ± 29 to 147.2 ± 16.3 ms) after five years (each p < .05). Conclusions Upgrade to CRT might improve heart failure symptoms and left-ventricular systolic function in the long-term, irrespective of underlying ischaemic or non-ischaemic heart disease.

T-TEER: description of adevelopment process

Tricuspid valve regurgitation (TR) is becoming increasingly more clinically important. While considered as an accompanying symptom of left heart pathologies in the past, TR is now seen as an independent and clinically significant condition. TR can lead to volume overload of the right ventricle, resulting in dilatation of the tricuspid valve annulus and worsening of the regurgitation. Undetected or untreated severe TR can lead to recurrent cardiac decompensation with hospitalization, reduced quality of life and death. Previous treatment options were limited to cardiac surgery and associated with high complication and mortality rates, especially in isolated TR. Therefore, many patients are considered inoperable so that the new interventional treatment measures nowadays often represent the only treatment option. Interventional treatment options such as the edge-to-edge procedure (T-TEER) with TriClip™ or the PASCAL™ system are very safe interventions that have already shown promising results, including reduction of TR, improvement in heart failure symptoms and the quality of life. The influence on the mortality and the necessity for hospitalization due to heart failure are currently being investigated in several randomized studies. Patient selection and timing of the intervention are crucial. Cardiovascular imaging plays adecisive role in selecting the appropriate method and timing of the intervention. The prognosis depends on factors, such as the severity of TR, right ventricular dysfunction, and pulmonary arterial hypertension. Overall, interventional TR treatment is apromising advancement in treatment from which many patients can benefit in the future.

Transcatheter Mitral Valve Repair with MitraClip®: A Nationwide Experience.

Transcatheter mitral valve repair (TMVr), using MitraClip®, is a safe and effective procedure for severe mitral valve regurgitation (MR). However, the therapeutic results of MitraClip® in Qatar remain to be elucidated. A total of 25 patients (mean age 60 ± 14.5 years, 64% males) with symptomatic severe MR and prohibitive surgical risks were enrolled in this study. The procedural success rate was 92% to achieve mild residual MR. There was no periprocedural death. All patients experienced significant improvement in heart failure symptoms and MR grade postprocedure with sustained improvement over 1-year follow-up. The TMVr procedure using the MitraClip® device was safe and resulted in meaningful and sustained functional status and echocardiographic parameter improvement.

Safety confirmation of induced pluripotent stem cell-derived cardiomyocyte patch transplantation for ischemic cardiomyopathy: first three case reports.

With the expected increase in patients with heart failure and ischemic 15 cardiomyopathy, the development of myocardial regenerative medicine using cell transplantation as a novel treatment method is progressing. This first-in-human clinical trial aimed to confirm the safety of cardiomyocyte patch transplantation derived from allogeneic induced pluripotent stem (iPS) cells based on the results of several preclinical studies. The inclusion criteria were left ventricular ejection fraction of 35% or less; heart failure symptoms of New York Heart Association class III or higher despite existing therapies such as revascularization; and a 1-year observation period that included a 3-month immunosuppressive drug administration period after transplantation of iPS cell-derived cardiomyocyte patches to evaluate adverse events, cardiac function, myocardial blood flow, heart failure symptoms, and immune response. In the first three cases of this trial, no transplanted cell-related adverse events were observed during the 1-year observation period, and improvement in heart failure symptoms was observed. In addition, improvements in left ventricular contractility and myocardial blood flow were observed in two of the three patients. Regarding immune response, an increase in transplant cell-specific antibody titer was observed in all three patients after immunosuppressive drug administration. In one patient with poor improvement in cardiac function and myocardial blood flow, an increase in antibody titer against HLA-DQ was observed even before cell transplantation. Our case findings demonstrate that the transplantation of iPS cell-derived cardiomyocyte patches for ischemic cardiomyopathy can be safely performed; however, further investigation of the therapeutic effect and its relationship with an immune response is needed by accumulating the number of patients through continued clinical trials.

5-Year Prospective Evaluation of Mitral Valve-in-Valve, Valve-in-Ring, and Valve-in-MAC Outcomes: MITRAL Trial Final Results

BackgroundThe MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective trial to evaluate the safety and feasibility of balloon-expandable aortic transcatheter heart valves in patients with failed surgical bioprostheses or annuloplasty rings and severe mitral annular calcification treated with mitral valve-in-valve (MViV), valve-in-ring (MViR), or valve–in–mitral annular calcification (ViMAC). ObjectivesThe aim of this study was to evaluate 5-year outcomes among these patients. MethodsA multicenter prospective study was conducted among patients at high surgical risk at 13 U.S. sites. Patients underwent MViV (n = 30), MViR (n = 30), or ViMAC (n = 31) and were followed annually for 5 years. Kansas City Cardiomyopathy Questionnaire scores were obtained at baseline and follow-up visits. Echocardiograms were analyzed at independent core laboratories. ResultsA total of 91 patients underwent transcatheter mitral valve replacement (February 2015 to December 2017). The mean age was 74.3 ± 8.9 years. At 5-year follow-up, the lowest all-cause mortality was observed in the MViV group (21.4%), 94.7% of patients were in NYHA functional class I or II, and the mean mitral gradient was 6.6 ± 2.5 mm Hg. The MViR and ViMAC groups had higher all-cause mortality (65.5% and 67.9%), most survivors were in NYHA functional classes I and II (50% and 55.6%), and mean mitral gradients remained stable (5.8 ± 0.1 and 6.7 ± 2.5 mm Hg). Significant improvements in Kansas City Cardiomyopathy Questionnaire scores were observed when all 3 arms were pooled. ConclusionsMViV, MViR, and ViMAC procedures were associated with sustained improvement of heart failure symptoms and quality of life among survivors at 5 years. Transcatheter heart valve function remained stable in all 3 groups. Patients treated with MViV had excellent survival at 5 years, whereas survival was lower in the MViR and ViMAC groups, consistent with underlying disease severity. Patients with more residual mitral regurgitation had higher mortality.

Effects of a low carbohydrate diet on heart failure symptoms and quality of life in patients with diabetic cardiomyopathy: A randomised controlled trial pilot study

Background and aimsHeart failure, insulin resistance and/or type 2 diabetes mellitus coexist in the syndrome that is diabetic cardiomyopathy. Patients with diabetic cardiomyopathy experience high symptom burden and poor quality of life. We tested the hypothesis that a low carbohydrate diet improves heart failure symptoms and quality of life in patients with diabetic cardiomyopathy. Methods and resultsWe conducted a 16-week randomised controlled pilot trial comparing the effects of a low carbohydrate diet (LC) to usual care (UC) in 17 adult patients with diabetic cardiomyopathy. New York Heart Association classification, weight, thirst distress and quality of life scores as well as blood pressure and biochemical data were assessed at baseline and at 16 weeks.Thirteen (n = 8 LC; n = 5 UC) patients completed the trial. The low carbohydrate diet induced significant weight loss in completers (p = 0.004). There was a large between-group difference in systolic blood pressure at the end of the study (Hedges's g 0.99[-014,2.08]). There were no significant differences in thirst or quality of life between groups. ConclusionThis is the first clinical trial utilising the low carbohydrate dietary approach in patients with diabetic cardiomyopathy in an outpatient setting. A low carbohydrate diet can lead to significant weight loss in patients with diabetic cardiomyopathy. Future clinical trials with larger samples and that focus on fluid and sodium requirements of patients with diabetic cardiomyopathy who engage in a low carbohydrate diet are warranted. Clinical trial registration numberAustralian New Zealand Clinical Trial Registry (ANZCTR): ACTRN12620001278921. Date of registration26th November 2020.

A Systematic Review of the Design, Method of Implantation and Early Clinical Outcomes of Transcatheter Tricuspid Prostheses.

Intervention for tricuspid regurgitation (TR) tends to happen concurrently with and is addressed during mitral valve surgery. Isolated TR interventions, however, are not unusual and are becoming more common. The purpose of this study was to provide a general overview of the transcatheter tricuspid valve implantation (TTVI) devices, taking into account the several design variations, and to unify the implantation technique, existing clinical results, and potential future directions for TR replacement therapy. The major databases, namely Pubmed via Medline, Embase, and Cochrane library, were systematically searched from the date of conception until 10 February 2023, in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) standards. Eleven studies were isolated from a total cohort of 5842 publications. All the transcatheter tricuspid prostheses were circular in design yet categorized into annular tricuspid valve implantation (ATVI) and caval valve implantation (CAVI) groups. Bleeding (25.2%), severe access site and vascular issues requiring intervention (5.8%), device migration or embolization (3.6%), and paravalvular leak (38%) are among the early TTVI-related complications that have been observed. The CAVI group experienced 3 of 28 bleeding cases and 2 of 4 device migration cases. Following the intervention with a transcatheter tricuspid prosthesis, this review discovered an early favorable outcome and a general improvement in heart failure symptoms. However, there was a lot of variation in their design, implantation technique, and early clinical outcomes. Understanding the design variations, difficulty of implantation and learning from this review's key findings could help with the future development of catheter-based tricuspid valves. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022312142.

Aficamten: A Breakthrough Therapy for Symptomatic Obstructive Hypertrophic Cardiomyopathy.

Aficamten is a novel cardiac myosin inhibitor that has demonstrated its ability to safely lower left ventricular outflow tract (LVOT) gradients and improve heart failure symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM). Based on the REDWOOD-HCMopen label extension (OLE) study, participants receiving aficamten had significantly reduced resting and Valsalva LVOT gradient within 2 weeks after initiating treatment, with ongoing improvements over 24 weeks, and recent evidence suggests effects can sustain up to 48 weeks. While beta-blockers, calcium channel blockers, and disopyramide have shown some benefits in managing HCM, they have limited direct impact on the underlying disease process in patients with obstructive HCM. Aficamten achieves its therapeutic effect by reducing hypercontractility and improving diastolic function in obstructive HCM. Mavacamten was the first cardiac myosin inhibitor approved for symptomatic obstructive HCM. However, aficamten has a shorter human half-life (t1/2) and fewer drug-drug interactions, making it a preferable treatment option. This review evaluates the long-term clinical value and safety of aficamten in patients with obstructive HCM based on available data from completed and ongoing clinical trials. Additionally, the molecular basis of sarcomere-targeted therapy in reducing LVOT gradients is explored, and its potential in managing obstructive HCM is discussed.

An updated meta-analysis of cardiac resynchronization therapy with or without defibrillation in patients with nonischemic cardiomyopathy.

Cardiac resynchronization therapy (CRT) is a major device therapy used to treat patients suffering from heart failure (HF) and electrical asynchrony. It can improve HF symptoms, reduce HF hospitalization time, and improve long-term survival in HF with and without implantable cardioverter (ICD) therapy. However, the benefit of defibrillator therapy in CRT-eligible patients with nonischemic cardiomyopathy (NICM) remains unknown. As a result, we conducted a systematic review and meta-analysis to compare clinical outcomes in patients with NICM and HF who were treated with implantable CRT defibrillators (CRT-D) vs. a CRT pacemaker (CRT-P) alone. We searched the electronic databases PubMed, Embase, and Cochrane for all studies comparing CRT-D vs. CRT-P treatment in patients with NICM. The time frame was from 1990 to September 2022. All-cause mortality and cardiovascular mortality were the primary clinical outcomes of interest to us. To pool adjusted hazard ratios (HRs) and 95% confidence intervals (CIs), a random-effects model with inverse variance was used. A pooled meta-analysis included two randomized controlled trials (RCTs), each with 1,200 CRT-eligible patients with NICM (592 with CRT-D and 608 with CRT-P) and nine cohort studies representing 27,568 CRT-eligible patients with NICM (16,196 with CRT-D and 11,372 with CRT-P). The adjusted HR for all-cause mortality for CRT-D vs. CRT-P was 0.90 (95% CI, 0.81-0.99). In a subgroup analysis of two RCTs and nine cohort studies, the adjusted HR for all-cause mortality was 0.72 (95% CI, 0.43-1.19) and HR 0.92 (95% CI, 0.83-1.03) for CRT-D vs. CRT-P, respectively. With the addition of defibrillation leads, we found a significantly lower risk of all-cause mortality in patients with NICM, but this association was not found in subgroup analyses of RCTs and observational studies.