Progressive Chronic Heart Failure Research Articles

Консенсус експертів Всеукраїнської асоціації кардіологів України і Всеукраїнської асоціації фахівців із серцевої недостатності щодо нового індивідуалізованого підходу до лікування пацієнтів із прогресуючим перебігом хронічної серцевої недостатності

From the perspective of evidence-based medicine, it is recommended that each patient receive all the components of guideline-directed medical therapy (GDMT) that have been proven to have a positive impact on morbidity and mortality. Individualization of treatment is considered a useful tool for achieving GDMT in patients with tolerability issues. Tailoring the treatment approach to the individual characteristics of patients with progressive chronic heart failure (CHF), as well as incorporating innovative strategies targeting different pathways of CHF with vericiguat, can lead to improved prognosis in patients with CHF. The VICTORIA algorithm was developed to identify patients with advanced HF for whom vericiguat may be most effective. The core concept of the VICTORIA algorithm is that most patients with HF are elderly individuals with multiple comorbidities who require pharmacotherapy, leading to a significant increase in the risk of side effects, tolerability issues, and drug interactions. Consequently, the majority of patients are not prescribed drugs at target doses. In such cases, vericiguat will be the drug of choice to either replace or supplement the current treatment.

Dosiahnennia arytmolohii u prohnozuvanni zloiakisnykh arytmii pid chas khvorob sertsia za kraini desiatyrichchia (ohliad literatury; rezultaty vlasnykh doslidzhen)

Introduction. With severe heart diseases, ventricular arrhythmias and atrial fibrillation can occur. The aim of the study. To analyze the achievements of arrhythmology in the field of predicting malignant arrhythmias over the past decades cardiology and to present the own results. Materials and methods. Literature surway of 34 articles supplemented with own results directed towards prediction of cardiac arrhythmia including the malignant arrhythmias. Results. Conducted investigation identified the following signs predicting the arrhythmias development: left ventricular hypertrophy, blockage of the bundle of His left limb, severe hypertension, diabetes. Left ventricle and left atrial remodeling are predictors of atrial fibrillation development. In patients with coronary arteries disease, predictors of atrial fibrillation development are increased heart volume and size, as well as decreased left ventricle ejection fraction. In 5 monographs on cardiac arrhythmias, predictors of prognosis and algorithms for the development of malignant cardiac arrhythmias are presented in details. Together with professor O. Sychov it was elaborated original classification of supraventricular extrasystoles. Conclusion. Over the past decades, a number of prognostic criteria for malignant cardiac arrhythmias and sudden cardiac death were elaborated. These include: pronounced left ventricle hypertrophy, blockage of the left limb bundle of His, severe form of hypertension, progressive chronic heart failure, the occurrence of T. Killip II and more, ventricular extrasystole 3-5 grades according to B. Laun, ventricular tachycardia of the “pirouette” type, reduction of the left ventricle ejection fraction is less than 40.0 %, thickening of the left ventricle posterior wall and interventricular membrane 14 mm and more, sino-atrial and atrio-ventricular blockage, prolongation of the Q-T interval, use of anti-arrhytmic drugs of IA and IS classes, etc. As a rule, the more of these arrhythmias predictors are exposed, the more often sudden cardiac deaths develops. Hovewer, certain exceptions of this rule sometimes appear. Keywords: coronary heart disease combined with hypertension, diagnostic criteria, predictors of complications progression.

Nuances of Cardiac Resynchronization Therapy in Patients with Dilated Cardiomyopathy and Atrial Fibrillation (a Clinical Case)

Dilated cardiomyopathy (DCM) is a steadily developing disease characterized by progressive chronic heart failure (CHF) resistant to drug therapy. Cardiac resynchronization therapy (CRT) significantly improves the prognosis in these patients if they have indications for implantation of resynchronization devices. The article presents a clinical case of successful implantation of a cardioversion-defibrillation cardiac resynchronization device in a patient suffering from DCM in combination with permanent atrial fibrillation (AF). The nuances of ventricular rate control and the role of the catheter procedure for modifying the atrioventricular junction are discussed.

Clinical Classification of Arrhythmogenic Right Ventricular Cardiomyopathy

Introduction: Commonly accepted clinical classification of arrhythmogenic right ventricular cardiomyopathy (ARVC) is still not developed. Objective: To study the clinical forms of ARVC. Methods: Fifty-four patients (38.7 ± 14.1 years, 42.6% men) with ARVC. Follow-up period: 21 (6–60) months. All patients underwent electrocardiography, 24 h-Holter monitoring, echocardiography, and DNA diagnostic. Magnetic resonance imaging was performed in 49 patients. Results: According to the features of clinical course of ARVC, 4 clinical forms were identified. (I) Latent arrhythmic form (n = 27) – frequent premature ventricular contractions and/or nonsustained ventricular tachycardia (VT) in the absence of sustained VT and syncope; characterized by absence of fatal arrhythmic events. (II) Manifested arrhythmic form (n = 11) – sustained VT/ventricular fibrillation; the high incidence of appropriate implantation of cardioverter-defibrillator (ICD) interventions (75%) registered. (III) ARVC with progressive chronic heart failure (CHF, n = 8) as the main manifestation of the disease; incidence of appropriate ICD interventions was 50%, mortality rate due to CHF was 25%. (IV) Combination of ARVC with left ventricular noncompaction (n = 8); characterized by mutations in desmosomal or sarcomere genes, aggressive ventricular arrhythmias, appropriate ICD interventions in 100% patients. Described 4 clinical forms are stable in time, do not transform into each other, and they are genetically determined. Conclusions: The described clinical forms of ARVC are determined by a combination of genetic and environmental factors and do not transform into each other. The proposed classification could be used in clinical practice to determine the range of diagnostic and therapeutic measures and to assess the prognosis of the disease in a particular patient.

Physiological aspects of myocardial function improving during mechanical circulatory support

In recent years, the mechanical support of blood circulation has proved to be a vital therapy for a terminal heart failure, and is considered as a "bridge" to transplantation or is used on a permanent basis in a patient who can not be included in the waiting list for a donor organ. Recent studies of the critical heart failure treatment during an assist device in situ have shown the myocardial recovery at the molecular and cellular levels. However, the transition of these changes to a functionally stable recovery of the heart function, which would allow the long-term results to be achieved without a heart transplant or switching off the mechanical support, is now rather an exception to the rule. At this time, the cause of the discrepancy between the high rate of recovery at the cellular and molecular levels and the low rate of cardiac function recovery remains poorly understood. Patients with chronic progressive heart failure can demonstrate the normalization of many structural myocardial abnormalities after a mechanical support that is actually a reverse remodeling. However, the reverse remodeling is not always considered equivalent to clinical recovery. The aim of this research is to study a significant improvement in the structure and function of the myocardium during the mechanical support of blood circulation.

Tachycardia-Induced Cardiomyopathy As a Chronic Heart Failure Model in Swine.

A stable and reliable model of chronic heart failure is required for many experiments to understand hemodynamics or to test effects of new treatment methods. Here, we present such a model by tachycardia-induced cardiomyopathy, which can be produced by rapid cardiac pacing in swine. A single pacing lead is introduced transvenously into fully anaesthetized healthy swine, to the apex of the right ventricle, and fixated. Its other end is then tunneled dorsally to the paravertebral region. There, it is connected to an in-house modified heart pacemaker unit that is then implanted in a subcutaneous pocket. After 4 - 8 weeks of rapid ventricular pacing at rates of 200 - 240 beats/min, physical examination revealed signs of severe heart failure - tachypnea, spontaneous sinus tachycardia, and fatigue. Echocardiography and X-ray showed dilation of all heart chambers, effusions, and severe systolic dysfunction. These findings correspond well to decompensated dilated cardiomyopathy and are also preserved after the cessation of pacing. This model of tachycardia-induced cardiomyopathy can be used for studying the pathophysiology of progressive chronic heart failure, especially hemodynamic changes caused by new treatment modalities like mechanical circulatory supports. This methodology is easy to perform and the results are robust and reproducible.

Heart functional and structural compendium of cardiosplenic and cardiorenal networks in acute and chronic heart failure pathology.

Heart failure (HF) secondary to myocardial infarction (MI) is linked to kidney complications that comprise cellular, structural, functional, and survival indicators. However, HF research is focused on left ventricular (LV) pathology. Here, we determined comprehensive functional analysis of the LV using echocardiography in transition from acute heart failure (AHF) to progressive chronic heart failure (CHF) pathology and developed a histological compendium of the cardiosplenic and cardiorenal networks in pathological remodeling. In surgically induced MI using permanent coronary ligation, the LV dysfunction is pronounced, with myocardium necrosis, wall thinning, and 20-30% LV rupture events that indicated AHF and CHF pathological remodeling in C57BL/6 male mice (2-4 mo old, n = 50). Temporal LV function analysis indicated that fractional shortening and strain are reduced from day 1 to day 5 in AHF and sustained to advance to CHF from day 28 to day 56 compared with naïve control mice ( n = 6). During the transition of AHF ( day 1 to day 5) to advanced CHF ( day 28 to day 56), histological and cellular changes in the spleen were definite, with bimodal inflammatory responses in kidney inflammatory biomarkers. Likewise, there was a unidirectional, progressive, and irreversible deposition of compact collagen in the LV along with dynamic changes in the cardiosplenic and cardiorenal networks post-MI. The renal histology and injury markers suggested that cardiac injury triggers irreversible dysregulation that actively alters the cardiosplenic and cardiorenal networks. In summary, the novel strategies or pathways that modulate comprehensive cardiosplenic and cardiorenal networks in AHF and CHF would be effective approaches to study either cardiac repair or cardiac pathology. NEW & NOTEWORTHY The present compendium shows irreversible ventricular dysfunction as assessed by temporal echocardiography while histological and structural measurements of the spleen and kidney added a novel direction to study cardiosplenic and cardiorenal networks in heart failure pathology. Therefore, the consideration of systems biology and integrative approach is essential to develop novel treatments.

Possibilities of Echocardiography at the Stages of Surgical Treatment of the Patient with the Mitral Valve Posterior Leaflet Prolapse Resulted in Mitral Insufficiency and Atrial Fibrillation (A Case Report)

The mitral valve prolapse is characterized by the degeneration of the valve leaflets, accompanied by their thickening, increasing surface area and flexibility. The mitral valves leaflets bulge (prolapse) beyond the plane of the atrioventricular ring into the left atrium during ventricular systole and lose the ability to close tightly, leading to the mitral regurgitation. Acute chord rupture of the mitral valve posterior leaflet is a rare but important cause of severe mitral regurgitation and the development of acute or progressive chronic heart failure. Acute mitral insufficiency, accompanied by hemodynamic disorders, requires an urgent valve plastic surgery or valve prosthetics. The mitral valve plastic surgery gives a number of undeniable advantages over prosthetics, providing the best hemodynamic parameters, saving the patient from lifelong receiving of anticoagulant drugs. Detailed qualified echocardiographic evaluation of all structures of the mitral valve (fibrous ring, MV leaflets by segments, overlapping structures, structure of the chordal apparatus, papillary muscles) provides the necessary information for the mitral valve reconstructive plastic surgery with the choice of the method that is most optimal for a certain patient at the preoperative stage. We report herein a clinical observation of the patient with a diagnosis: acquired heart disease, the mitral valve posterior leaflet prolapse with mitral insufficiency Grade 3. Chronic heart failure IIA. II FC. Atrial fibrillation. The patient underwent multicomponent mitral valve reconstruction with the creation of a neochord and the fibrous ring plastic on the duplicate of a PTFE strip (soft support ring), pairwise isolation of the pulmonary vein entrance and right cavotricuspid isthmus.

Клинические варианты течения и исходы прогрессирования хронической сердечной недостаточности у пациентов с гипертрофической кардиомиопатией

Клинические варианты течения и исходы прогрессирования хронической сердечной недостаточности у пациентов с гипертрофической кардиомиопатией

The role of inflammation in the pathogenesis of chronic heart failure

The review considers the main points of the concept of progressive chronic heart failure (CHF). The neurohumoral model of CHF pathogenesis could create novel approaches to treating these patients. However, recent studies have shown that the ways of activating the neurohumoral systems in CHF are much more complex. The increased local synthesis of hormones causes the activation of proinflammatory cytokines and proto-oncogenes, which have a number of negative effects. Multiple studies have formulated the immunoinflammatory concept of CHF pathogenesis, according to which the increased concentration of interleukin-6 is a marker of poor prognosis in CHF, and the level of tumor necrosis factor-α directly correlates with the severity of its clinical manifestations and the activity of the neurohumoral background in decompensation. The review gives a classification of cytokines and describes the reasons for their elevated plasma concentration, their possible role in the occurrence and progression of CHF, and their prognostic significance. The pathogenesis of CHF, which includes cytokine aggression, requires further studies of the effect of the inflammatory component on the course of heart failure.

B-type natriuretic peptide: powerful predictor of end-stage chronic heart failure in individuals with systolic dysfunction of the systemic right ventricle.

AimTo assess whether B-type natriuretic peptide (BNP) can serve as a predictor of end-stage chronic heart failure (CHF) in patients with severe systolic dysfunction of the systemic right ventricle (SRV).MethodsWe performed a retrospective analysis in 28 patients with severe systolic dysfunction of the SRV (ejection fraction 23 ± 6%) who were evaluated as heart transplant (HTx) candidates between May 2007 and October 2014. The primary endpoints of the study (end-stage CHF) were progressive CHF, urgent HTx, and ventricular assist device (VAD) implantation. Plasma BNP levels were measured using a chemiluminescent immunoassay.ResultsDuring median follow-up of 29 months (interquartile range, 9-50), 3 patients died of progressive CHF, 5 patients required an urgent HTx, and 6 patients underwent VAD implantation. BNP was a strong predictor of end-stage CHF (hazard ratio per 100 ng/L: 1.079, 95% confidence interval, 1.042-1.117, P˂0.001). The following variables with corresponding areas under the curve (AUC) were identified as the most significant predictors of end-stage CHF: BNP (AUC 1.00), New York Heart Association functional class class III or IV (AUC 0.98), decompensated CHF in the last year (AUC 0.96), and systolic dysfunction of the subpulmonal ventricle (AUC 0.96).ConclusionBNP is a powerful predictor of end-stage CHF in individuals with systolic dysfunction of the SRV.

Abstract 14822: Impact of Proportional Assist Ventilation on Skeletal Muscle Reoxygenation and Central Hemodynamic During Constant Work Rate Exercise in Chronic Heart Failure

Introduction: Progressive chronic heart failure slows the recovery of microvascular oxygen delivery and utilization, which produce deleterious implications to exercise capacity. Respiratory muscle unloading can enhance the responses to exercise thereby allowing a closer matching between skeletal muscle oxygen delivery and utilization in patients with chronic heart failure (CHF). Hypothesis: We reasoned that noninvasive ventilation administered by proportional assisted ventilation (PAV) could accelerate skeletal muscle reoxygenation after high intensity exercise in CHF humans. To test this hypothesis, we conducted a study with 12 patients with stable CHF who were randomized to receive PAV or sham ventilation during high-intensity constant work exercise and compared the effects of these interventions on oxygen pulmonary (O2p), cardiac output and [[Unable to Display Character: ∆]][deoxi-Hb+Mb] off kinetics. Methods: Twelve patients with CHF (NYHA class II and III and left ventricle ejection fraction= 26±9%) underwent two high-intensity, constant-work rate (80% peak) cycle ergometer tests receiving PAV or sham ventilation. Off-exercise kinetics of the primary component of oxygen uptake, an index of fractional oxygen extraction by near infrared spectroscopy (~[[Unable to Display Character: ∆]][deoxy-Hb+Mb]) in the vastus lateralis) and cardiac output (QT) by impedance cardiography were assessed. Results: PAV significantly accelerated the recovery of O2p when compared with sham τ = 56±22 vs. 77±42s, respectively, p<0.05). Interestingly, PAV was associated with faster fractional O2 extraction (~[[Unable to Display Character: ∆]][deoxy-Hb+Mb] by near-infrared spectroscopy) (τ= 31±19 vs. 42±22s, respectively, p<0.05) . In addition, kinetics of QT were significantly faster with PAV than sham (τ = 39±22 vs. 78±46s, respectively, p<0.05). Conclusions: These data indicate that PAV has beneficial effects on recovery of muscle metabolism and central hemodynamics after high-intensity exercise in CHF patients. Financial Support: FAPESP 2009-01842-0

The Syncardia™ total artificial heart: in vivo, in vitro, and computational modeling studies

The SynCardia™ total artificial heart (TAH) is the only FDA-approved TAH in the world. The SynCardia™ TAH is a pneumatically driven, pulsatile system capable of flows of >9L/min. The TAH is indicated for use as a bridge to transplantation (BTT) in patients at imminent risk of death from non-reversible bi-ventricular failure. In the Pivotal US approval trial the TAH achieved a BTT rate of >79%. Recently a multi-center, post-market approval study similarly demonstrated a comparable BTT rate. A major milestone was recently achieved for the TAH, with over 1100 TAHs having been implanted to date, with the bulk of implantation occurring at an ever increasing rate in the past few years.The TAH is most commonly utilized to save the lives of patients dying from end-stage bi-ventricular heart failure associated with ischemic or non-ischemic dilated cardiomyopathy. Beyond progressive chronic heart failure, the TAH has demonstrated great efficacy in supporting patients with acute irreversible heart failure associated with massive acute myocardial infarction. In recent years several diverse clinical scenarios have also proven to be well served by the TAH including severe heart failure associated with advanced congenital heart disease. failed or burned-out transplants, infiltrative and restrictive cardiomyopathies and failed ventricular assist devices.Looking to the future a major unmet need remains in providing total heart support for children and small adults. As such, the present TAH design must be scaled to fit the smaller patient, while providing equivalent, if not superior flow characteristics, shear profiles and overall device thrombogenicity. To aid in the development of a new “pediatric,” TAH an engineering methodology known as “Device Thrombogenicity Emulation (DTE)”, that we have recently developed and described, is being employed.Recently, to further our engineering understanding of the TAH, as steps towards next generation designs we have: (1) assessed of the degree of platelet reactivity induced by the present clinical 70cc TAH using a closed loop platelet activity state assay, (2) modeled the motion of the TAH pulsatile mobile diaphragm, and (3) performed fluid-structure interactions and assessment of the flow behavior through inflow and outflow regions of the TAH fitted with modern bi-leaflet heart valves. Developing a range of TAH devices will afford biventricular replacement therapy to a wide range of patients, for both short and long-term therapy.

Integrated proteomic and metabolomic analysis reveals the NADH-mediated TCA cycle and energy metabolism disorders based on a new model of chronic progressive heart failure

Despite major advances in the treatment of heart failure (HF), it remains the major cause of mortality and morbidity worldwide. Experimental models of HF typically utilize acute myocardial infarction. However, the majority of clinical HFs occur gradually by a chronic progressive mechanism. Thus, more relevant models are required to aid identification, quantification, and characterization of HF, and its underlying mechanisms. We developed a model of progressive chronic heart failure (CHF) in the mini-swine by placement of an ameroid constrictor on the left anterior descending coronary artery (LAD). This model demonstrated a steady decline in the cardiac function from 8 to 12 weeks, with a 50% reduction in the ejection fraction. Further, the proteomic, metabolomic and bioinformatic analyses of ischemic tissue and plasma revealed a significant alteration of the mitochondrial respiratory chain mediated by nicotinamide adenine dinucleotide (NADH), which resulted in down-regulation of malate dehydrogenase (MDH) and insufficient energy supply to support cardiac contractility and relaxation. Furthermore, significant changes in apolipoprotein A-I, low density lipoprotein (LDL), and very LDL (VLDL) in plasma indicated that lipid metabolism disorders occurred in mini-swines with myocardial ischemia via glycerolipid metabolism. We describe a stable and easily reproducible CHF model using an ameroid constrictor placed on the LAD. We found that the NADH-mediated tricarboxylic acid cycle and energy metabolism disorders are key pathophysiological mechanisms underlying CHF. These data will provide potential biomarkers for monitoring the therapeutic intervention of CHF.

INTEGRATED PROTEOMIC AND METABOLOMIC ANALYSIS REVEALS NADH-MEDIATED TCA ENERGY METABOLISM DISORDER IN CHRONIC PROGRESSIVE HEART FAILURE

ObjectivesAlthough great progress has been made in heart failure (HF), it is still the major cause of mortality and morbidity worldwide. Typically, research associated with heart failure has focused on...

The Prognostic Value of Estimated Glomerular Filtration Rate, Amino-Terminal Portion of the Pro-Hormone B-Type Natriuretic Peptide and Parameters of Cardiopulmonary Exercise Testing in Patients with Chronic Heart Failure

The aim of this study was to evaluate the prognostic value of renal function in relation to amino-terminal portion of the pro-hormone B-type natriuretic peptide (NT-proBNP) and parameters of cardiopulmonary exercise testing in predicting mortality and morbidity in patients with moderate chronic heart failure (CHF). Sixty-one CHF patients were included in the study. Patients' characteristics were: age 64.3±11.6 years; New York Heart Association class I/II/III: 14/37/10; left ventricular ejection fraction: 0.30±0.13 (%); NT-proBNP: 252.2±348.0 (ng/L); estimated creatinine clearance (e-CC): 73.6±31.4 (mL/min); estimated glomerular filtration rate (e-GFR): 66.1±24.6 (mL/min/1.73 m2); the highest O2 uptake during exercise (VO2-peak): 1.24±0.12 mL/kg/min; VO2/workload: 8.52±1.81 (mL/min/W)]. During follow up (59.5±4.0 months) there were 15 cardiac deaths and 16 patients were hospitalized due to progression of heart failure. NT-proBNP and VO2/workload were independently associated with cardiac death (P=0.007 and P=0.006, respectively). Hospitalization for progressive CHF was only associated with NT-proBNP (P=0.002). The combined cardiac events (cardiac death and hospitalization) were associated with NT-proBNP and VO2/ workload (P=0.007 and P=0.005, respectively). The addition of estimates of renal function (neither serum creatinine nor e-GFR) did not improve the prognostic value for any of the models.In conclusion, in patients with moderate CHF, increased NT-proBNP and reduced VO2/ work-load identify those with increased mortality and morbidity, irrespective of estimates of renal function.

Progressive chronic heart failure slows the recovery of microvascular O2pressures after contractions in the rat spinotrapezius muscle

Chronic heart failure (CHF) induces muscle fiber-type specific alterations in skeletal muscle O(2) delivery and utilization during metabolic transitions. As a result, the recovery of microvascular Po(2) (Pmv(O(2))) is prolonged in slow-twitch skeletal muscle but not fast-twitch skeletal muscle in rats with CHF. We tested the hypothesis that CHF slows Pmv(O(2)) recovery in rat skeletal muscle of a mixed fiber-type analogous to human locomotory muscles and that the degree of slowing correlates with central indexes of heart failure. Healthy control [n = 6, left ventricular end-diastolic pressure (LVEDP): 10 ± 1 mmHg], moderate CHF (n = 6, LVEDP: 18 ± 2 mmHg), and severe CHF (n = 4, LVEDP: 34 ± 2 mmHg) female Sprague-Dawley rats had their right spinotrapezius muscles (41% type I, 7% type IIa, and 52% type IIb and d/x) exposed, and Pmv(O(2)) was measured via phosphorescence quenching during 180 s of recovery from 180 s of electrically induced twitch contractions (1 Hz, 4-6 V). CHF progressively slowed the mean response time (MRT; the time to reach 63% of the overall dynamic response) of Pmv(O(2)) recovery (MRT(off); control: 60.2 ± 6.9, moderate CHF: 72.8 ± 6.6, and severe CHF: 109.8 ± 6.6 s, P < 0.05 for all). MRT(off) correlated positively with central hemodynamic (LVEDP: r = 0.76, P < 0.01) and morphological (right ventricle-to-body weight ratio: r = 0.74, P < 0.01; and lung weight-to-body weight ratio: r = 0.79, P < 0.01) indexes of heart failure. The present investigation suggests that slowed Pmv(O(2)) kinetics during recovery in CHF constitutes a mechanistic link between impaired circulatory and metabolic recovery after contractions in CHF.

Cardiac rehabilitation and artificial heart devices

Recently, cardiac rehabilitation has gained popularity in Japan because beneficial effects on patients' prognosis have been reported. Another reason is that cardiac rehabilitation has been covered by health insurance since 1988 in Japan. Currently, cardiac rehabilitation is covered for the diseases of angina pectoris, acute myocardial infarction, chronic heart failure (CHF), peripheral arterial disease, and diseases of the aorta and after open-heart surgery. Left ventricular assist devices (LVADs) are sometimes used in patients with progressive CHF symptoms to provide circulatory support, because in most of these patients heart failure does not improve with application of medical therapy, intra-aortic balloon pumping, or a percutaneous cardiopulmonary system. Modern VAD control systems are compact, allowing patients to carry them around without difficulty. Since patient management at the outpatient clinic has become possible, patients are able to expand the scope of their activities. Early active rehabilitation in patients implanted with a LVAD improves their condition, favorably impacts the clinical course while they await heart transplantation, and also improves posttransplant recovery. Exercise therapy is one of the important components in comprehensive cardiac rehabilitation. Exercise therapy is important to improve the quality of life of patients with LVADs. Appropriate exercise therapy is effective for patients with various cardiac conditions who undergo diverse treatments and is practiced actively by many patients. In order to facilitate cardiac rehabilitation safely and effectively for patients with serious conditions, education for health care professionals is essential. In this review, we describe the concept of rehabilitation followed by cardiac rehabilitation for patients with heart failure, patients after open-heart surgery, and patients with implanted LVADs.

Development of Right Ventricular Dysfunction in Acute Myocardial Infarction and Chronic Heart Failure

Objective: to evaluate the structural and functional state of the right cardiac cavities in acute left ventricular myocardial infarction and in progressive chronic heart failure (CHF) in patients with coronary heart disease. Materials and methods. 20 patients with acute myocardial infarction and 48 with postinfarct cardiosclerosis with NYHA functional classes I to IV CHF were examined. The structural and functional state of the right heart was evaluated in progressive left ventricular systolic and diastolic dysfunction by echocardiography. Results. In the acute period of infarction, remodeling processes occur in the left ventricle, with normal postload values, volumetric indices and right ventricular contractility are in the normal range. There is right cardiac dilatation at the early stage of left ventricular systolic and diastolic dysfunction in postinfarct remodeling and evolving CHF, normal pulmonary arterial and right atrial pressures. With a significant reduction in left ventricular contractility and its pronounced filling impairment, increases in post- and preload for the right ventricle occur with a just considerable change in its structural and functional state. Conclusion. In impaired myocardial relaxation in the presence of CHF, remodeling of the right cardiac cavities takes place without the influence of a hemodynamic factor. There is a close relationship of remodeling of both ventricles from the very early CHF stages, which suggests that there are common pathogenetic mechanisms responsible for the development of myocardial dysfunction.

A new concept of ventricular restoration for nonischemic dilated cardiomyopathy

Left ventricular restoration is used to treat patients with chronic progressive heart failure caused by nonischemic dilated cardiomyopathy. This study addresses the use of site selection to determine either lateral wall or septal exclusion. Evolution of intraoperative echocardiography to define the site of poorest contraction and use of multiple biopsies to show the nonhomogeneous nature of damage are reviewed. To address the heterogeneity of extent of fibrosis in nonischemic cardiomyopathy, target selection was used to determine the mode of left ventriculoplasty. Either the lateral wall was excluded by partial left ventriculectomy (PLV) or septal anterior ventricular exclusion (SAVE or Pacopexy) was employed if the septum was primarily diseased. Surgical results in 107 high-risk (43% NYHA (New York Heart Association) class III and 57% class IV) patients with idiopathic dilated cardiomyopathy over the past 9 years are reviewed. Overall hospital mortality was 7.1% in 84 elective operations and 60.9% in 23 emergency operations, and fell from 42.8% (6 of 14) to 15.0% (14 of 93), when site selection for the area of left ventricular excision or exclusion was determined by the intraoperative echocardiography test. The SAVE/Pacopexy procedure was performed in 36 patients with 62.2% 5-year survival rate. For the entire cohort of PLV and SAVE/Pacopexy population, overall ejection fraction increased from 20 to 31%, and NYHA class improved from 3.6 to 1.8. The 1-, 5-, and 7-year survival rates were 66.9, 46.0, and 36.2%, respectively. In patients having the operation before inotropic dependent, the survival rate was 78.1, 58.0, and 50.2%, respectively. Left ventriculoplasty is effective for patients with idiopathic dilated cardiomyopathy with heart failure by proper patient selection, appropriate timing of the operation, and choice of the surgical procedure (exclusion site selection).