Severe Advanced Heart Failure Research Articles

Transcatheter mitral valve repair (TMVR) using MitraClip in patients younger than 65 years: a multicenter analysis of 2-years outcomes

Abstract Background TMVR using MitraClip became a well-established interventional therapy for severe MR. However, TMVR has been almost only applied to old aged patients rejected from surgical therapy. Objective To present 2-years outcomes of 36 patients younger than 65 years with no surgical options treated by TMVR. Methods A retrospective clinical and TEE study was conducted to evaluate 36 patients younger than 65 years treated by TMVR in 3 heart centers. Results Mean age of the 36 study patients was 56.3±6.6 years, male gender was 72.2%. High operative risk was estimated by STS score (mean = 8.73±2.97) and EuroSCORE (mean = 24.71±12.79). All patients were refused for surgery by heart team decision, therefore admitted to TMVR. Baseline severity of MR was assessed by 3D-TEE based biplane vena contracta width (mean = 8.35±1.87 mm). Baseline transmitral mean pressure gradient was 1.81±0.78 mmHg. 21 patients showed mitral annular dilatation as the main cause of MR, 8 patients had leaflet prolapse, 4 patients exhibited papillary muscle displacement leading to leaflet tethering and 3 patients showed mitral leaflet thickening and/or retraction due to fibrosis. Procedural success was achieved in all patients with 1/2/3 clips implanted in 52.8%/44.4%/2.8% of cases with a mean of 1.5 clip per case. Two grades or more reduction in severity of MR (MR grade ≤ II/IV) was accomplished in 88.9% of patients. Mean postprocedural MPG was 3.78±1.96 mmHg. Average follow-up (FU) period was 25,8 months and the median was 20 months (25th–75th percentile: 12–36 months). During 2-years FU, statistically significant difference (p value <0.002) was detected for NT-proBNP levels compared to baseline (mean = 9870±10819, median = 7748, 25th–75th percentile: 2702–14237 pg/ml) and at follow up visits (mean = 7645±11292, median = 3263, 25th-75th percentile: 883–8078 pg/ml). Furthermore, persistent symptomatic improvement during FU, defined as NYHA functional class improvement by 2 or more Grades, was achieved in 69% of patient in parallel with efficient reduction of MR in 34 patients so that a second intervention by reclipping was required in 2 patients to correct recurrent significant MR. Only two patients experienced procedure-related complications by large puncture site hematoma. No procedure-related mortality during the first 30 days was detected. However, mortality was recorded in 2 patients during the first month and was attributed to severe advanced heart failure in one case and septicemia after exclusion of infective endocarditis in another case. Over 2 years FU, other 5 patients passed away, 3 cases owing to advanced heart failure, one case due to multi-organ failure and one because of tumor disease. Conclusion TMVR in patients younger than 65 years refused from surgical repair provides satisfactory clinical and echocardiography outcomes at 2 years. Future studies should evaluate the outcomes of MitraClip in this population in a larger cohort. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Hassan M.H. Mohammed received a scholarship grant from the Egyptian ministry of higher education and Minia University, Egypt.

Heart Transplant and Ventricular Assist: Cardiac Surgery and Heart Failure Perspective

For nearly 60 years, there have been two surgical treatment options for individuals with severe advanced heart failure: heart transplantation or implantation of a left ventricular assist device. As these fields have advanced in parallel, improvements in surgical technique, device development, and patient selection have improved outcomes for both therapies. Development of a comprehensive approach to the management of the most severe forms of advanced heart failure requires a deep understanding of both heart transplantation and durable ventricular assistance, including recent advancements in both fields. This article will review the substantial progress in the fields of heart transplantation and mechanical left ventricular assistance, including recent changes to organ allocation prioritization and left ventricular assist device evaluation, both of which have dramatically influenced practice in these fields.

Use of ECMO for Cardiogenic Shock in Pediatric Population.

In children with severe advanced heart failure where medical management has failed, mechanical circulatory support in the form of veno-arterial extracorporeal membrane oxygenation (VA ECMO) or ventricular assist device represents life-sustaining therapy. This review provides an overview of VA ECMO used for cardiovascular support including medical and surgical heart disease. Indications, contraindications, and outcomes of VA ECMO in the pediatric population are discussed.VA ECMO provides biventricular and respiratory support and can be deployed in rapid fashion to rescue patient with failing physiology. There have been advances in conduct and technologic aspects of VA ECMO, but survival outcomes have not improved. Stringent selection and optimal timing of deployment are critical to improve mortality and morbidity of the patients supported with VA ECMO.

Transplantation and Mechanical Circulatory Support in Congenital Heart Disease: A Scientific Statement From the American Heart Association.

Dramatic evolution in the medical and surgical care of children with congenital heart disease (CHD) has led to a growing number of adults with late-onset complications, including heart failure (HF).1 In parallel with an overall increase in hospital admissions for adults with CHD (ACHD) and HF,2 CHD complexity has increased substantially in survivors over the past 2 decades.3 Heart transplant (HTx) specialists face the challenge of determining eligibility for advanced HF treatments among an increasingly complex population of CHD patients in whom guidelines for HTx and mechanical circulatory support (MCS) are scant. The purpose of this review is to provide a state-of-the-art update on HTx and MCS in CHD. HTx remains the surgical procedure of choice for eligible patients with severe advanced HF,4,5 with little change in the number of transplants performed yearly over the past decade. The body of information related to transplantation for CHD is derived almost entirely from registry and single-center–based outcome data; no randomized clinical trial or meta-analysis data are available. CHD presents additional challenges to successful HTx compared with HTx in patients with acquired HF. Many CHD patients require complex vascular reconstruction at the time of transplantation. The presence of antibodies to human leukocyte antigen (HLA) and ABO blood group sensitization are also impediments to timely transplantation. The ability of patients with single-ventricle physiology to survive during the waiting period is also limited by the additional burden of “outgrowing” their pulmonary blood flow and the resultant cyanosis. It is not surprising that CHD remains a risk factor during the waiting period and after transplantation. Therefore, although the management of the CHD patient with end-stage HF must include the option of HTx, its indication and timing are very different from that for acquired HF. Patients with ACHD represent an increasing …

The patients with severe heart failure: central role of echocardiography in indication of optimal treatment — two cases

Cardiologia CROATICA In our poster presentation we present two cases of patients with severe advanced heart failure. The patients were sent to echocardiography assessment with a history of several week’s of progressive dyspnoea and left bundle block on ECG. Patient 1: Man, born 1958, smoker, negative family history. 5/2009 two month progressive dyspnoea; NYHA III/IV; on ECG: LBBB; echocardiography: EF 25%, diffuse hypokinesis. 6/2009 CABG (RIA LIMA, RMS); NYHA III. 11/2009 Implantation BIV ICD; NYHA II/III. Th: furosemid 40 mg, atoravastatin 20 mg, aspirin 100 mg, carvediol 2x12,5 mg, ramipril 5 mg, spironolactone 25 mg daily. 11/2010 start with ivabradine therapy 2x5 mg daily. 03/2011 echocardiography: improvement diameter of LA, LV, EF 40%, NYHA II. Patient 2: Man, born 1954, smoker, businessman. Two month worsening of dyspnoea, NYHA IV at the time of addmission. Echocardiography: EF 20%; ECG: LBBB; BP 160/110, P 98. SCG: nonsignificant changes of coronary arteries. Th: furosemid 40mg, perindopril 5mg, atorvastatin 20 mg, aspirin 100 mg, carvediol 2x6,25 mg (fatigue after higher doses of carvediol). 6/2011 echocardiography: EF 35%; NYHA III. 8/2011 adding ivabradine 2x5 mg daily. Last control echocardiography: EF 40-45%; NYHA II. Conclusion: The central role of careful echocardiography follow up of heart failure patients is essential for optimal pharmacology therapy managment, including ivabradine addition to the therapy. Our case results correlate with ECHO substudy conclusion of SHIFT study. We show schematically in diagrams the significant improvement of echocardiography parameters after ivabradine addition. The good clinical status correlates with lowering of level NT pro BNP too.

The feasibility of left ventricular mechanical support as a bridge to cardiac recovery

To study the achievability of device weaning in patients receiving left ventricular assist devices (LVADs) as a bridge to transplantation. Eighteen consecutive patients receiving a LVAD between September 1997 and June 2002 were included in the study. During a four-month follow-up, patients were repeatedly evaluated with right heart catheterization and echocardiography and, if functional improvement was observed, studied with the device turned off. Cardiac recovery was defined as off-pump LVEF>or=40% together with a significant improvement in invasive haemodynamic measurements (CI>or=2.5 and PCWP<or=10-12 mm Hg). Patients fulfilling these criteria were considered for weaning. Three patients fulfilled the predefined criteria for cardiac recovery and were subjected to device explantation. In one patient, a young female with acute myocarditis, the following course was uneventful. In the second patient, a male with dilated cardiomyopathy, heart failure reoccurred only a few days later. The third patient had a relapse of giant cell myocarditis and was transplanted. One patient underwent transplantation before follow-up evaluation could be performed. In our experience, patients with severe advanced heart failure are unlikely to show significant cardiac recovery following treatment with LVAD, in contrast to previous suggestions.