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Hirsch JR, Afshar H. Recent Developments in Cardiac Contractility Modulation for Heart Failure. Tex Heart Inst J 2024; 51:e248464. [PMID: 39285672 PMCID: PMC11405886 DOI: 10.14503/thij-24-8464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2024]
Affiliation(s)
- Joshua R. Hirsch
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Hamid Afshar
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
- Department of Cardiology, Michael E. DeBakey Department of Veterans Affairs Medical Center, Houston, Texas
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2
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Bazoukis G, Saplaouras A, Efthymiou P, Yiannikourides A, Liu T, Letsas KP, Efremidis M, Lampropoulos K, Xydonas S, Tse G, Armoundas AA. Cardiac contractility modulation in patients with heart failure - A review of the literature. Heart Fail Rev 2024; 29:689-705. [PMID: 38393423 DOI: 10.1007/s10741-024-10390-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 02/25/2024]
Abstract
Experimental in vivo and in vitro studies showed that electric currents applied during the absolute refractory period can modulate cardiac contractility. In preclinical studies, cardiac contractility modulation (CCM) was found to improve calcium handling, reverse the foetal myocyte gene programming associated with heart failure (HF), and facilitate reverse remodeling. Randomized control trials and observational studies have provided evidence about the safety and efficacy of CCM in patients with HF. Clinically, CCM therapy is indicated to improve the 6-min hall walk, quality of life, and functional status of HF patients who remain symptomatic despite guideline-directed medical treatment without an indication for cardiac resynchronization therapy (CRT) and have a left ventricular ejection fraction (LVEF) ranging from 25 to 45%. Although there are promising results about the role of CCM in HF patients with preserved LVEF (HFpEF), further studies are needed to elucidate the role of CCM therapy in this population. Late gadolinium enhancement (LGE) assessment before CCM implantation has been proposed for guiding the lead placement. Furthermore, the optimal duration of CCM application needs further investigation. This review aims to present the existing evidence regarding the role of CCM therapy in HF patients and identify gaps and challenges that require further studies.
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Affiliation(s)
- George Bazoukis
- Department of Cardiology, Larnaca General Hospital, Inomenon Polition Amerikis, Larnaca, Cyprus.
- Medical School, European University Cyprus, Nicosia, Cyprus.
| | | | - Polyxeni Efthymiou
- Department of Cardiology, Larnaca General Hospital, Inomenon Polition Amerikis, Larnaca, Cyprus
| | | | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
| | | | - Michael Efremidis
- Department of Cardiology, Onassis Cardiac Surgery Center, Athens, Greece
| | | | - Sotirios Xydonas
- Second Department of Cardiology, Evangelismos General Hospital, Athens, Greece
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, China
- Kent and Medway Medical School, University of Kent, Canterbury, Kent, UK
- Canterbury Christ Church University, Canterbury, Kent, UK
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Hong Kong, China
| | - Antonis A Armoundas
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, Charlestown, Boston, MA, 02129, USA.
- Broad Institute, Massachusetts Institute of Technology, Cambridge, MA, USA.
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3
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Li Z, Liu Q, Zhou S, Xiao Y. Enhancing myocardial function with cardiac contractility modulation: potential and challenges. ESC Heart Fail 2024; 11:1-12. [PMID: 37947013 PMCID: PMC10804199 DOI: 10.1002/ehf2.14575] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 10/04/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023] Open
Abstract
Cardiac contractility modulation (CCM) offers a novel therapeutic avenue for heart failure patients, particularly those unresponsive to cardiac resynchronization therapy within specific QRS duration ranges. This review elucidates CCM's mechanistic underpinnings, its impact on myocardial function, and utility across patient demographics. However, CCM is limited by insufficient data on mortality and hospitalization rate reductions, as well as the need for specialized device implantation skills. While prevailing research has concentrated on left ventricular effects, a knowledge gap persists for other patient subsets. Future inquiries should address combinatory treatment strategies, extended usage and the impact of atrial fibrillation on device implantation. Such expanded studies could refine therapeutic outcomes and widen the scope of beneficiaries.
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Affiliation(s)
- Zihan Li
- Department of Cardiovascular Medicine, Second Xiangya HospitalCentral South UniversityChangshaChina
- Xiangya School of MedicineCentral South UniversityChangshaChina
| | - Qiming Liu
- Department of Cardiovascular Medicine, Second Xiangya HospitalCentral South UniversityChangshaChina
| | - Shenghua Zhou
- Department of Cardiovascular Medicine, Second Xiangya HospitalCentral South UniversityChangshaChina
| | - Yichao Xiao
- Department of Cardiovascular Medicine, Second Xiangya HospitalCentral South UniversityChangshaChina
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4
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Lyasnikova E, Sukhareva K, Vander M, Zaitsev K, Firulyova M, Sergushichev A, Sorokina M, Trukshina M, Galenko V, Lelyavina T, Mitrofanova L, Simonova K, Abramov M, Faggian G, Luciani GB, Lebedev DS, Mikhaylov EN, Sitnikova M, Kostareva A. Molecular effects of cardiac contractility modulation in patients with heart failure of ischemic aetiology uncovered by transcriptome analysis. Front Cardiovasc Med 2024; 11:1321005. [PMID: 38361583 PMCID: PMC10867213 DOI: 10.3389/fcvm.2024.1321005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 01/08/2024] [Indexed: 02/17/2024] Open
Abstract
Cardiac contractility modulation (CCM) is based on electrical stimulation of the heart without alteration of action potential and mechanical activation, the data on its fundamental molecular mechanisms are limited. Here we demonstrate clinical and physiological effect of 12 months CCM in 29 patients along with transcriptomic molecular data. Based on the CCM effect the patients were divided into two groups: responders (n = 13) and non-responders (n = 16). RNA-seq data were collected for 6 patients before and after CCM including 3 responders and 3 non-responders. The overall effect of CCM on gene expression was mainly provided by samples from the responder group and included the upregulation of the genes involved in the maintenance of proteostasis and mitochondrial structure and function. Using pathway enrichment analysis, we found that baseline myocardial tissue samples from responder group were characterized by upregulation of mitochondrial matrix-related genes, Z disc-protein encoding genes and muscle contraction-related genes. In summary, twelve months of ССM led to changes in signaling pathways associated with cellular respiration, apoptosis, and autophagy. The pattern of myocardial remodeling after CCM is associated with initial expression level of myocardial contractile proteins, adaptation reserves associated with mitochondria and low expression level of inflammatory molecules.
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Affiliation(s)
- E. Lyasnikova
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - K. Sukhareva
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
- Graduate School of Life and Health Science, University of Verona, Verona, Italy
| | - M. Vander
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - K. Zaitsev
- Computer Technologies Laboratory, ITMO University, Saint Petersburg
| | - M. Firulyova
- Computer Technologies Laboratory, ITMO University, Saint Petersburg
| | - A. Sergushichev
- Computer Technologies Laboratory, ITMO University, Saint Petersburg
| | - M. Sorokina
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - M. Trukshina
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - V. Galenko
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - T. Lelyavina
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - L. Mitrofanova
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - K. Simonova
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - M. Abramov
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - G. Faggian
- Graduate School of Life and Health Science, University of Verona, Verona, Italy
| | - G. B. Luciani
- Graduate School of Life and Health Science, University of Verona, Verona, Italy
| | - D. S. Lebedev
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - E. N. Mikhaylov
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - M. Sitnikova
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - A. Kostareva
- Institute of Molecular Biology and Genetics, Almazov National Medical Research Centre, Saint Petersburg, Russia
- Department of Women’s and Children’s Health and Center for Molecular Medicine, Karolinska Institute, Stockholm, Sweden
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5
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Masarone D, Kittleson MM, D'Onofrio A, Falco L, Fumarulo I, Massetti M, Crea F, Aspromonte N, Pacileo G. Basic science of cardiac contractility modulation therapy: Molecular and electrophysiological mechanisms. Heart Rhythm 2024; 21:82-88. [PMID: 37769793 DOI: 10.1016/j.hrthm.2023.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/21/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
In heart failure with reduced ejection fraction and heart failure with preserved ejection fraction, profound cellular and molecular changes have recently been documented in the failing myocardium. These changes include altered calcium handling and metabolic efficiency of the cardiac myocyte, reactivation of the fetal gene program, changes in the electrophysiological properties of the heart, and accumulation of collagen (fibrosis) at the interstitial level. Cardiac contractility modulation therapy is an innovative device-based therapy currently approved for heart failure with reduced ejection fraction in patients with narrow QRS complex and under investigation for the treatment of heart failure with preserved ejection fraction. This therapy is based on the delivery of high-voltage biphasic electrical signals to the septal wall of the right ventricle during the absolute refractory period of the myocardium. At the cellular level, in patients with heart failure with reduced ejection fraction, cardiac contractility modulation therapy has been shown to restore calcium handling and improve the metabolic status of cardiac myocytes, reverse the heart failure-associated fetal gene program, and reduce the extent of interstitial fibrosis. This review summarizes the preclinical literature on the use of cardiac contractility modulation therapy in heart failure with reduced and preserved ejection fraction, correlating the molecular and electrophysiological effects with the clinical benefits demonstrated by this therapy.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli/Monaldi Hospital, Naples, Italy.
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Antonio D'Onofrio
- Electrophysiology Unit, Department of Cardiology, AORN dei Colli/Monaldi Hospital, Naples, Italy
| | - Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli/Monaldi Hospital, Naples, Italy
| | | | - Massimo Massetti
- Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Crea
- Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Nadia Aspromonte
- Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli/Monaldi Hospital, Naples, Italy
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6
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Wallner AL, Savona S, Kahwash R. Cardiac Contractility Modulation: Implications in Heart Failure, a Current Review. Heart Fail Clin 2024; 20:51-60. [PMID: 37953021 DOI: 10.1016/j.hfc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Cardiac contractility modulation (CCM) is a novel therapeutic approach for heart failure patients, which utilizes nonexcitatory electrical myocardial stimulation in the absolute refractory period of the cardiac cycle. This stimulation has been shown to increase contractility, leading to improved heart failure symptoms, functional status, and quality of life. CCM is FDA approved for heart failure patients with an LVEF between 25% and 45% who remained symptomatic despite optimal medical therapy and not candidate of cardiac resynchronization therapy. CCM offers expanded treatment options for heart failure patients who have continued symptoms while on optimal medical therapy.
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Affiliation(s)
- Alexander L Wallner
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Salvatore Savona
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rami Kahwash
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
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7
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Haloot J, Chelu MG. Established and Emerging Device Therapy in Heart Failure: Cardiac Contractility Modulation. Tex Heart Inst J 2023; 50:e238184. [PMID: 37927070 PMCID: PMC10751469 DOI: 10.14503/thij-23-8184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Affiliation(s)
- Justin Haloot
- Division of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mihail G. Chelu
- Division of Cardiology, Baylor College of Medicine, Houston, Texas
- Department of Cardiology, The Texas Heart Institute, Houston, Texas
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8
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Pipilas DC, Hanley A, Singh JP, Mela T. Cardiac Contractility Modulation for Heart Failure: Current and Future Directions. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101176. [PMID: 39131075 PMCID: PMC11307863 DOI: 10.1016/j.jscai.2023.101176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 08/30/2023] [Accepted: 09/06/2023] [Indexed: 08/13/2024]
Abstract
Cardiac contractility modulation (CCM) is a Food and Drug Administration-approved device-based therapy for patients with heart failure. The system delivers biphasic electric stimulation to the ventricular myocardium during the absolute refractory period to augment left ventricular contraction. CCM therapy promotes acute and chronic changes at the cellular level, leading to favorable remodeling throughout the myocardium. CCM improves quality of life, New York Heart Association class, left ventricular ejection fraction, peak oxygen uptake, and the composite end point of cardiovascular death and heart failure hospitalizations. This review will focus on the biological basis, indications, and evidence for CCM, as well as the future applications of this technology.
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Affiliation(s)
- Daniel C. Pipilas
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Alan Hanley
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, Massachusetts
| | - Jagmeet P. Singh
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, Massachusetts
| | - Theofanie Mela
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, Massachusetts
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9
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Brener MI, Kapadia SR, Burkhoff D. Reverse Left Ventricular Remodeling With Transcatheter Interventions in Chronic Heart Failure Syndromes: An Updated Appraisal of the Device Landscape. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101196. [PMID: 39131059 PMCID: PMC11307650 DOI: 10.1016/j.jscai.2023.101196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 08/13/2024]
Abstract
Chronic heart failure (HF) is a clinical syndrome of myocardial dysfunction characterized by inadequate cardiac output or preserved output that can only be achieved by sustaining abnormal loading conditions. Morphologically, HF with reduced left ventricular function results in progressive chamber remodeling, meaning the ventricle dilates, operating at larger end-diastolic and end-systolic volumes, and takes on an abnormal, spherical shape that increases wall stress. Reverse remodeling is the goal of HF-directed therapies and can be achieved by biological means, ie, altering the loading conditions that, at a cellular level, promote myocardial dysfunction, or physical means, ie, directly altering myocardial mass or shape. In this review, we highlight the existing and emerging device-based mechanisms for biologically and physically reverse remodeling the left ventricle in chronic HF.
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Affiliation(s)
- Michael I. Brener
- Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Samir R. Kapadia
- Division of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University Medical Center, New York, New York
- Cardiovascular Research Foundation, New York, New York
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10
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Malaty MM, Sivagangabalan G, Qian PC. Beyond Conventional Cardiac Resynchronisation Therapy: A Review of Electrophysiological Options in the Management of Chronic Heart Failure. Heart Lung Circ 2023; 32:905-913. [PMID: 37286460 DOI: 10.1016/j.hlc.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/10/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023]
Abstract
The incidence of heart failure (HF) continues to grow and burden our health care system. Electrophysiological aberrations are common amongst patients with heart failure and can contribute to worsening symptoms and prognosis. Targeting these abnormalities with cardiac and extra-cardiac device therapies and catheter ablation procedures augments cardiac function. Newer technologies aimed to improvement procedural outcomes, address known procedural limitations and target newer anatomical sites have been trialled recently. We review the role and evidence base for conventional cardiac resynchronisation therapy (CRT) and its optimisation, catheter ablation therapies for atrial arrhythmias, cardiac contractility and autonomic modulation therapies.
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Affiliation(s)
- Michael M Malaty
- Department of Cardiology, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW, Australia
| | - Gopal Sivagangabalan
- Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia; School of Medicine, Sydney Campus, University of Notre Dame, Sydney, NSW, Australia
| | - Pierre C Qian
- Department of Cardiology, Blacktown Hospital, Western Sydney Local Health District, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Western Sydney Local Health District, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia.
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11
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Chugunov IA, Mareev YV, Fudim M, Mironova NA, Mareev VY, Davtyan RV. Cardiac contractility modulation in heart failure with reduced ejection fraction treatment. KARDIOLOGIIA 2022; 62:71-78. [DOI: 10.18087/cardio.2022.11.n2014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/23/2022] [Accepted: 04/22/2022] [Indexed: 12/23/2022]
Abstract
Heart failure with reduced left ventricular ejection fraction (LV EF) (HFrEF) is a significant issue of health care due to increasing indexes of morbidity and mortality. The emergence of a number of drugs and implantable devices for the treatment of HFrEF has allowed improvement of patients’ well-being and prognosis. However, high mortality and recurrent decompensated heart failure remain a substantial issue and stimulate the search for new methods of CHF treatment. Cardiac contractility modulation (CCM) is a method of managing patients with HFrEF. Available data from randomized clinical trials (RCT) indicate the efficacy of CCM in improvement of patients’ well-being and quality of life. The question remains open: what effect does CCM have on LV reverse remodeling? Experimental data and results of observational studies suggest a possibility of reverse remodeling by CCM; however, this has not been confirmed in RCT. Also, it remains unclear how CCM influences the frequency of hospitalizations for decompensated heart failure and the death rate of patients with HFrEF. Results of both RCTs and observational studies have shown a moderate improvement of quality of life associated with CCM. Furthermore, RCTs have not found any increase in LV EF due to the therapy, nor has a meta-analysis of RCTs revealed any improvement of the prognosis associated with CCM. Further RCTs are needed to evaluate the effect of CCM on reverse remodeling, survival rate, and to determine the place of CCM in the treatment of patients with CHF.
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Affiliation(s)
- I. A. Chugunov
- National Medical Research Center of Therapy and Preventive Medicine
| | - Yu. V. Mareev
- National Medical Research Center of Therapy and Preventive Medicine; Robertson Centre for Biostatistics, Glasgow University
| | - M. Fudim
- Duke University, Duke Clinical Research Institute
| | | | - V. Yu. Mareev
- Medical Research and Educational Center, Lomonosov Moscow State University; School of Fundamental Medicine, Lomonosov Moscow State University
| | - R. V. Davtyan
- National Medical Research Center of Therapy and Preventive Medicine
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12
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Lewis GD, Voors AA, Cohen-Solal A, Metra M, Whellan DJ, Ezekowitz JA, Böhm M, Teerlink JR, Docherty KF, Lopes RD, Divanji PH, Heitner SB, Kupfer S, Malik FI, Meng L, Wohltman A, Felker GM. Effect of Omecamtiv Mecarbil on Exercise Capacity in Chronic Heart Failure With Reduced Ejection Fraction: The METEORIC-HF Randomized Clinical Trial. JAMA 2022; 328:259-269. [PMID: 35852527 PMCID: PMC9297119 DOI: 10.1001/jama.2022.11016] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE Exercise limitation is a cardinal manifestation of heart failure with reduced ejection fraction (HFrEF) but is not consistently improved by any of the current guideline-directed medical therapies. OBJECTIVE To determine whether omecamtiv mecarbil, a novel direct myosin activator that improves cardiac performance and reduces the risk for cardiovascular death or first HF event in HFrEF, can improve peak exercise capacity in patients with chronic HFrEF. DESIGN, SETTING, AND PARTICIPANTS Phase 3, double-blind, placebo-controlled randomized trial of patients with HFrEF (left ventricular ejection fraction ≤35%), New York Heart Association class II-III symptoms, N-terminal pro-B-type natriuretic peptide level of 200 pg/mL or greater, and baseline peak oxygen uptake (V̇o2) of 75% or less of predicted. Patients were randomized in a 2:1 ratio (omecamtiv mecarbil to placebo) between March 2019 and May 2021 at 63 sites in North America and Europe, with the last patient visit occurring on November 29, 2021. INTERVENTIONS Omecamtiv mecarbil (n = 185) or matching placebo (n = 91), given orally twice daily at a dose of 25 mg, 37.5 mg, or 50 mg based on target plasma levels, for 20 weeks. MAIN OUTCOMES AND MEASURES The primary end point was a change in exercise capacity (peak V̇o2) from baseline to week 20. Secondary end points included total workload, ventilatory efficiency, and daily physical activity as determined by accelerometry. RESULTS Among 276 patients who were randomized (median age, 64 years; IQR, 55-70 years; 42 women [15%]), 249 (90%) completed the trial. The median left ventricular ejection fraction was 28% (IQR, 21-33) and the median baseline peak V̇o2 was 14.2 mL/kg/min (IQR, 11.6-17.4) in the omecamtiv mecarbil group and 15.0 mL/kg/min (IQR, 12.0-17.2) in the placebo group. Mean change in peak V̇o2 did not differ significantly between the omecamtiv mecarbil and placebo groups (mean, -0.24 mL/kg/min vs 0.21 mL/kg/min; least square mean difference, -0.45 mL/kg/min [95% CI, -1.02 to 0.13]; P = .13). Adverse events included dizziness (omecamtiv mecarbil: 4.9%, placebo: 5.5%), fatigue (omecamtiv mecarbil: 4.9%, placebo: 4.4%), heart failure events (omecamtiv mecarbil: 4.9%, placebo: 4.4%), death (omecamtiv mecarbil: 1.6%, placebo: 1.1%), stroke (omecamtiv mecarbil: 0.5%, placebo: 1.1%), and myocardial infarction (omecamtiv mecarbil: 0%, placebo: 1.1%). CONCLUSIONS AND RELEVANCE In patients with chronic HFrEF, omecamtiv mecarbil did not significantly improve exercise capacity over 20 weeks compared with placebo. These findings do not support the use of omecamtiv mecarbil for treatment of HFrEF for improvement of exercise capacity. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03759392.
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Affiliation(s)
| | - Adriaan A. Voors
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Alain Cohen-Solal
- Paris University, UMR-S 942, Department of Cardiology, Lariboisiere Hospital, Assistance Publique Hopitaux de Paris, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - David J. Whellan
- Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Michael Böhm
- Department of Internal Medicine, Saarland University, Homburg, Saarland, Germany
- Department of Cardiology, Saarland University, Homburg, Saarland, Germany
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and University of California, San Francisco
| | - Kieran F. Docherty
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Renato D. Lopes
- Division of Cardiology, School of Medicine, Duke University Medical Center, Durham, North Carolina
| | | | | | - Stuart Kupfer
- Cytokinetics, Incorporated, South San Francisco, California
| | - Fady I. Malik
- Cytokinetics, Incorporated, South San Francisco, California
| | - Lisa Meng
- Cytokinetics, Incorporated, South San Francisco, California
| | - Amy Wohltman
- Cytokinetics, Incorporated, South San Francisco, California
| | - G. Michael Felker
- Division of Cardiology, School of Medicine, Duke University Medical Center, Durham, North Carolina
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13
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Green PG, Herring N, Betts TR. What Have We Learned in the Last 20 Years About CRT Non-Responders? Card Electrophysiol Clin 2022; 14:283-296. [PMID: 35715086 DOI: 10.1016/j.ccep.2021.12.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Although cardiac resynchronization therapy (CRT) has become well established in the treatment of heart failure, the management of patients who do not respond after CRT remains a key challenge. This review will summarize what we have learned about non-responders over the last 20 years and discuss methods for optimizing response, including the introduction of novel therapies.
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Affiliation(s)
- Peregrine G Green
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Centre for Clinical Magnetic Resonance Research (OCMR), University of Oxford, Level 0 John Radcliffe Hospital, Oxford, OX3 9DU, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Neil Herring
- Department of Physiology, Anatomy and Genetics, University of Oxford, Sherrington Building, Parks Road, Oxford, OX1 3PT, UK; Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK
| | - Timothy R Betts
- Oxford Heart Centre, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, OX3 9DU, UK; Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
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14
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 756] [Impact Index Per Article: 378.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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15
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 891] [Impact Index Per Article: 445.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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16
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Lewis GD, Docherty KF, Voors AA, Cohen-Solal A, Metra M, Whellan DJ, Ezekowitz JA, Ponikowski P, Böhm M, Teerlink JR, Heitner SB, Kupfer S, Malik FI, Meng L, Felker GM. Developments in Exercise Capacity Assessment in Heart Failure Clinical Trials and the Rationale for the Design of METEORIC-HF. Circ Heart Fail 2022; 15:e008970. [PMID: 35236099 DOI: 10.1161/circheartfailure.121.008970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is a highly morbid condition for which exercise intolerance is a major manifestation. However, methods to assess exercise capacity in HFrEF vary widely in clinical practice and in trials. We describe advances in exercise capacity assessment in HFrEF and a comparative analysis of how various therapies available for HFrEF impact exercise capacity. Current guideline-directed medical therapy has indirect effects on cardiac performance with minimal impact on measured functional capacity. Omecamtiv mecarbil is a novel selective cardiac myosin activator that directly increases cardiac contractility and in a phase 3 cardiovascular outcomes study significantly reduced the primary composite end point of time to first heart failure event or cardiovascular death in patients with HFrEF. The objective of the METEORIC-HF trial (Multicenter Exercise Tolerance Evaluation of Omecamtiv Mecarbil Related to Increased Contractility in Heart Failure) is to assess the effect of omecamtiv mecarbil versus placebo on multiple components of functional capacity in HFrEF. The primary end point is to test the effect of omecamtiv mecarbil compared with placebo on peak oxygen uptake as measured by cardiopulmonary exercise testing after 20 weeks of treatment. METEORIC-HF will provide state-of-the-art assessment of functional capacity by measuring ventilatory efficiency, circulatory power, ventilatory anaerobic threshold, oxygen uptake recovery kinetics, daily activity, and quality-of-life assessment. Thus, the METEORIC-HF trial will evaluate the potential impact of increased myocardial contractility with omecamtiv mecarbil on multiple important measures of functional capacity in ambulatory patients with symptomatic HFrEF. Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT03759392.
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Affiliation(s)
- Gregory D Lewis
- Division of Cardiology, Massachusetts General Hospital, Boston (G.D.L.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (K.F.D.)
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, the Netherlands (A.A.V.)
| | - Alain Cohen-Solal
- Paris University, UMR-S 942, Department of Cardiology, Lariboisiere Hospital, Assistance Publique Hopitaux de Paris, France (A.C.-S.)
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M.M.)
| | - David J Whellan
- Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA (D.J.W.)
| | | | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Poland (P.P.)
| | - Michael Böhm
- Department of Internal Medicine, Saarland University, Homburg, Germany. (M.B.).,Department of Cardiology, Saarland University, Homburg, Germany. (M.B.)
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and University of California San Francisco (J.R.T.)
| | - Stephen B Heitner
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Stuart Kupfer
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Fady I Malik
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Lisa Meng
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - G Michael Felker
- Division of Cardiology, School of Medicine, Duke University Medical Center, Durham, NC (G.M.F.)
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17
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Safiullina AA, Uskach TM, Dobrovolskaya. SV, Saidova MA, Zhirov IV, Tereshchenko SN. Myocardial remodeling in patients with chronic heart failure and implanted cardiac contractility modulators. TERAPEVT ARKH 2022; 93:1443-1450. [DOI: 10.26442/00403660.2021.12.201218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 01/14/2022] [Indexed: 11/22/2022]
Abstract
Aim. To study the effect of cardiac contractility modulation on reverse remodeling and myocardial function in patients with chronic heart failure (HF) according to echocardiography (EchoCG).
Materials and methods. In a group of 40 patients with a combination of chronic HF and atrial fibrillation (AF), the dynamics of standard EchoCG parameters and the effectiveness of myocardial work of the left ventricle (LV) against the background of 12-month therapy of cardiac contractility modulation (CCM) were analyzed.
Results. The results obtained indicate a statistically significant positive effect of CCM on LV remodeling parameters and the effectiveness of myocardial work according to EchoCG.
Conclusion. Transthoracic echocardiography is the main imaging method and provides great opportunities for evaluating the effectiveness of HF treatment, including non-drug methods such as CCM. Evaluation of LV myocardial function in patients with HF and implanted CCM devices is a promising scientific and practical research method.
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18
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Kuck KH, Ujeyl A, Vogler J, Tilz RR. [Cardiac contractility modulation]. Herz 2021; 46:533-540. [PMID: 34797397 DOI: 10.1007/s00059-021-05071-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2021] [Indexed: 11/28/2022]
Abstract
Heart failure (HF) will be one of the biggest medical challenges in the coming years, with increasing prevalence in an aging society. It is associated with a poor prognosis and impaired quality of life-despite steadily improving medical therapy which has resulted in a steady decrease in mortality and an increase in quality of life. In medically refractory patients with impaired left ventricular (LV) function, left bundle branch block and wide QRS complex (≥130 ms) cardiac resynchronization therapy (CRT) in addition to medical therapy has become the gold standard. Additionally, other therapeutic modalities such as vagal stimulation are being clinically tested but as yet have no general therapeutic recommendation. Overall, CRT patients represent only one-third of all HF patients and about 25% are "non-responders" who do not benefit from CRT.In HF patients with an LVEF between 25 and 45% and a QRS duration <130 ms who are not suitable for CRT, cardiac contractility modulation (CCM) is currently a therapeutic option that has been shown in several randomized trials to be efficacious and safe. It reduces the frequency of HF hospitalizations and improves HF symptoms, functional capacity, and quality of life. The goal of this article is to present mechanisms of action, major clinical studies, current indications, and recent developments of CCM for the treatment of patients with chronic HF.
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Affiliation(s)
- Karl-Heinz Kuck
- Medizinische Klinik II, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Deutschland. .,LANS Cardio, Hamburg, Deutschland.
| | | | - Julia Vogler
- Medizinische Klinik II, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Deutschland
| | - Roland Richard Tilz
- Medizinische Klinik II, Universitätsklinikum Schleswig-Holstein - Campus Lübeck, Ratzeburger Allee 160, 23562, Lübeck, Deutschland
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19
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Safiullina AA, Uskach TM, Dobrovolskaya SV, Saidova MA, Makeev MI, Tereshchenko SN. Reverse remodeling against the background of cardiac contractility modulation therapy in patients with heart failure and atrial fibrillation. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2022-2948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aim. To study myocardial remodeling in patients with heart failure (HF) with reduced ejection fraction (HFrEF) and atrial fibrillation (AF) against the background of cardiac contractility modulation (CCM) therapy.Material and methods. In a group of 100 patients with HFrEF and AF, transthoracic echocardiography was performed before CCM device implantation and after 2, 6 and 12 months. All patients received longterm optimal medical therapy for HF before surgery.Results. Against the background of CCM therapy, there was a significant increase in left ventricular (LV) ejection fraction, a decrease in LV volume and linear dimensions, a decrease in left atrial volume in patients with coronary and non-coronary HFrEF, with an initial LVEF < and >35%, and also regardless of AF type.Conclusion. CCM therapy in patients with HFrEF and AF led to favorable myocardial remodeling changes. Further study of CCM effect on echocardiographic parameters in randomized clinical trials is needed.
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Affiliation(s)
| | - T. M. Uskach
- National Medical Research Center of Cardiology;
Russian Medical Academy of Continuous Professional Education
| | | | | | | | - S. N. Tereshchenko
- National Medical Research Center of Cardiology;
Russian Medical Academy of Continuous Professional Education
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20
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Li P, Zhao H, Zhang J, Ning Y, Tu Y, Xu D, Zeng Q. Similarities and Differences Between HFmrEF and HFpEF. Front Cardiovasc Med 2021; 8:678614. [PMID: 34616777 PMCID: PMC8488158 DOI: 10.3389/fcvm.2021.678614] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/23/2021] [Indexed: 12/11/2022] Open
Abstract
The new guidelines classify heart failure (HF) into three subgroups based on the ejection fraction (EF): HF with reduced EF (HFrEF), HF with mid-range EF (HFmrEF), and HF with preserved EF (HFpEF). The new guidelines regarding the declaration of HFmrEF as a unique phenotype have achieved the goal of stimulating research on the basic characteristics, pathophysiology, and treatment of HF patients with a left ventricular EF of 40-49%. Patients with HFmrEF have more often been described as an intermediate population between HFrEF and HFpEF patients; however, with regard to etiology and clinical indicators, they are more similar to the HFrEF population. Concerning clinical prognosis, they are closer to HFpEF because both populations have a good prognosis and quality of life. Meanwhile, growing evidence indicates that HFmrEF and HFpEF show heterogeneity in presentation and pathophysiology, and the emergence of this heterogeneity often plays a crucial role in the prognosis and treatment of the disease. To date, the exact mechanisms and effective treatment strategies of HFmrEF and HFpEF are still poorly understood, but some of the current evidence, from observational studies and post-hoc analyses of randomized controlled trials, have shown that patients with HFmrEF may benefit more from HFrEF treatment strategies, such as beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, mineralocorticoid receptor antagonists, and sacubitril/valsartan. This review summarizes available data from current clinical practice and mechanistic studies in terms of epidemiology, etiology, clinical indicators, mechanisms, and treatments to discuss the potential association between HFmrEF and HFpEF patients.
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Affiliation(s)
- Peixin Li
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China
- Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
| | - Hengli Zhao
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China
- Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, China
| | - Jianyu Zhang
- Department of Cardiology, Foshan First People's Hospital, Foshan, Guangdong, China
| | - Yunshan Ning
- School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, China
| | - Yan Tu
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Dingli Xu
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China
- Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
| | - Qingchun Zeng
- State Key Laboratory of Organ Failure Research, Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Shock and Microcirculation, Southern Medical University, Guangzhou, China
- Bioland Laboratory (Guangzhou Regenerative Medicine and Health Guangdong Laboratory), Guangzhou, China
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21
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Chera HH, Al-Sadawi M, Michelakis N, Spinelli M. Optimizer Smart System for the treatment of chronic heart failure: Overview of its safety and efficacy. Expert Rev Med Devices 2021; 18:505-512. [PMID: 34323128 DOI: 10.1080/17434440.2021.1923478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Heart failure (HF) is a major cause of morbidity and mortality throughout the world. Despite the significant progress in the prevention and treatment of HF, mortality rates still remain high. Device therapy for HF includes cardiac resynchronization therapy (CRT) and the use of an implantable cardioverter-defibrillator (ICD). Recently, a new device therapy for the treatment of HF became available, called cardiac contractility modulation (CCM). CCM is a new device therapy for patients with HF who do not qualify for CRT. It is implanted in a minimally invasive manner to improve the patient's morbidity. Optimizer Smart System is a new device that delivers CCM therapy.Areas covered: We review the function of the Optimizer Smart System, the data from the recent clinical trials, and discuss its efficacy and future projections in the treatment for HF.Expert opinion: CCM therapy provided with the Optimizer® Smart System is safe, feasible, and applicable to a wide range of patients with HF. To demonstrate the effectiveness of the Optimizer Smart System's use merits further large multicenter randomized controlled trials.
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22
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Ning B, Zhang F, Song X, Hao Q, Li Y, Li R, Dang Y. Cardiac contractility modulation attenuates structural and electrical remodeling in a chronic heart failure rabbit model. J Int Med Res 2021; 48:300060520962910. [PMID: 33044118 PMCID: PMC7556184 DOI: 10.1177/0300060520962910] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background Cardiac contractility modulation (CCM) is non-excitatory electrical stimulation for improving cardiac function. This study aimed to evaluate the effects of CCM on structural and electrical remodeling in a rabbit model of chronic heart failure (CHF). Methods Thirty rabbits were randomly divided into the sham, CHF, and CCM groups. The CHF model was induced 12 weeks after trans-aortic constriction by pressure unloading and CCM was delivered to the myocardium for 4 weeks. Corrected QT intervals, the ventricular effective refractory period, and inducibility of ventricular tachycardia were measured by an electrophysiological examination. Connective tissue growth factor, galectin-3, Kv4.3, KCNQ1, KCNH2, and connexin 43 protein levels were measured by western blotting. Results The CHF group had a significantly prolonged corrected QT interval and ventricular effective refractory period, and increased inducibility of ventricular tachycardia. Prominent myocardial fibrosis and increased hydroxyproline content were observed in the CHF group, but these were suppressed in the CCM group. Kv4.3, KCNQ1, KCNH2, and connexin 43 protein levels were significantly lower in the CHF group, but treatment with CCM partially restored their levels. Conclusions CCM attenuates myocardial structural and electrical remodeling during CHF. These findings provide evidence for clinical use of CCM in treating CHF.
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Affiliation(s)
- Bin Ning
- Department of Cardiology, The People's Hospital of Fuyang, Fuyang, Anhui Province, People's Republic of China
| | - Feifei Zhang
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei Province, People's Republic of China
| | - Xuelian Song
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei Province, People's Republic of China
| | - Qingqing Hao
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei Province, People's Republic of China
| | - Yingxiao Li
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei Province, People's Republic of China
| | - Rong Li
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei Province, People's Republic of China
| | - Yi Dang
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, Hebei Province, People's Republic of China
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23
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Cardiac Contractility Modulation in Patients with Heart Failure with Reduced Left Ventricular Ejection Fraction. HEARTS 2021. [DOI: 10.3390/hearts2010013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Cardiac contractility modulation is an innovative therapy conceived for the treatment of heart failure. It is a device-based therapy, employing multiple electrodes to deliver relatively high-voltage (~7.5 V) biphasic signals to the endocardium of the right ventricular septum, in order to improve heart failure symptoms, exercise capacity and quality of life. Multiple clinical and mechanistic studies have been conducted to investigate the potential usefulness of this technology and, as of now, they suggest that it could have a place in therapy and meet a relevant medical need for a specific sub-category of underserved heart failure patients with reduced left ventricular ejection fraction. More studies are needed to further investigate its effect on outcomes such as mortality and rate of hospitalizations.
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24
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Pilecky D, Muk B, Majoros Z, Vágány D, Kósa K, Szabó M, Szögi E, Dékány M, Kiss RG, Nyolczas N. Proportion of Patients Eligible for Cardiac Contractility Modulation: Real-Life Data from a Single-Center Heart Failure Clinic. Cardiology 2021; 146:195-200. [PMID: 33582674 DOI: 10.1159/000512946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/15/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Based on recently published randomized controlled trials, cardiac contractility modulation (CCM) seems to be an effective device-based therapeutic option in symptomatic chronic heart failure (HF) (CHF). The aim of the current study was to estimate what proportion of patients with CHF and left ventricular ejection fraction (LVEF) <50% could be eligible for CCM based on the inclusion criteria of the FIX-HF-5C trial. METHODS Consecutive patients referred and followed up at our HF clinic due to HF with reduced or mid-range LVEF were retrospectively assessed. After a treatment optimization period of 3-6 months, the inclusion criteria of the FIX-HF-5C trial (New York Heart Association (NYHA) class III/IV, 25% ≤ LVEF ≤45%, QRS <130 ms, and sinus rhythm) were applied to determine the number of patients eligible for CCM. RESULTS Of the 640 patients who were involved, the proportion of highly symptomatic patients in NYHA class III/IV decreased from 77.0% (n = 493) at baseline to 18.6% (n = 119) after the treatment optimization period (p < 0.001). Mean LVEF increased significantly from 29.0 ± 7.9% to 36.3 ± 9.9% (p < 0.001), while the proportion of patients with 25% ≤ LVEF ≤45% increased from 69.7% (n = 446) to 73.3% (n = 469) (p < 0.001). QRS duration was below 130 ms in 63.1% of patients, while 30.0% of patients had persistent or permanent atrial fibrillation. We found that the eligibility criteria for CCM therapy based on the FIX-HF-5C study were fulfilled for 23.0% (n = 147) of patients at baseline and 5.2% (n = 33) after treatment optimization. CONCLUSION This single-center cohort study showed that 5% of patients with CHF and impaired LVEF immediately after treatment optimization fulfilled the inclusion criteria of the FIX-HF-5C study and would be candidates for CCM.
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Affiliation(s)
- Dávid Pilecky
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary, .,Department of Internal Medicine III, Klinikum Passau, Passau, Germany,
| | - Balázs Muk
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary
| | - Zsuzsanna Majoros
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary
| | - Dénes Vágány
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary
| | - Krisztina Kósa
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary
| | - Márta Szabó
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary
| | - Emese Szögi
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary
| | - Miklós Dékány
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary
| | - Róbert Gábor Kiss
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary
| | - Noémi Nyolczas
- Department of Cardiology, Medical Centre - Hungarian Defence Forces, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
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25
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Rao IV, Burkhoff D. Cardiac contractility modulation for the treatment of moderate to severe HF. Expert Rev Med Devices 2020; 18:15-21. [PMID: 33287592 DOI: 10.1080/17434440.2020.1853525] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Heart failure (HF) affects over 6 million Americans and approximately 650,000 new cases are diagnosed annually, with patients evenly split between HFrEF and HFpEF. Recent advances in therapy for these patients have been limited to pharmaceutical agents, with CRT remaining the most reliable device therapy option since its advent almost twenty years ago. In 2019, after almost two decades without the introduction of a new device therapy for the treatment of moderate HF, the FDA approved CCM® therapy, delivered by the Optimizer Smart device, for patients with NYHA Class III HF who are on guideline-directed medical therapy (GDMT), in normal sinus rhythm (NSR), and with EF ranging from 25% to 45%, and who are ineligible for CRT.Areas covered: Multiple clinical trials support the use of CCM to improve quality of life, functional class, and 6-min hall walk distance. This article will discuss the science behind CCM therapy, the presumed mechanisms of action, the pre-clinical studies that shaped subsequent endeavors, and the clinical trials that support its use.Expert opinion: The introduction of CCM therapy bridges a therapeutic gap for patients with few or no other therapeutic options for NYHA III heart failure.
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Affiliation(s)
- Ishu V Rao
- Medical Director and Vice President of Clinical Affairs, Impulse Dynamics, Marlton, NJ, USA
| | - Daniel Burkhoff
- Heart Failure, Hemodynamics and MCS Research, Cardiovascular Research Foundation, New York, NY, USA
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26
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Cardiac contractility modulation for patient with refractory heart failure: an updated evidence-based review. Heart Fail Rev 2020; 26:227-235. [PMID: 32974722 DOI: 10.1007/s10741-020-10030-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
Heart failure is the cardiovascular epidemic of the twenty-first century, with poor prognosis and quality of life despite optimized medical treatment. Despite over the last decade significant improvements, with a major impact on morbidity and mortality, have been made in therapy for heart failure with reduced ejection fraction, little progress was made in the development of devices, with the implantable defibrillator indicated for patients with left ventricle ejection fraction ≤ 35% and cardiac resynchronization therapy for those with QRS ≥ 130 ms and evidence of left bundle branch block. Nevertheless, only a third of patients meet these criteria and a high percentage of patients are non-responders in terms of improving symptoms. Nowadays, in patients with symptomatic heart failure with ejection fraction between 25% and 45% and QRS < 130 ms, not eligible for cardiac resynchronization, the cardiac contractility modulation (CCM) represents a concrete therapeutic option, having proved to be safe and effective in reducing hospitalizations for heart failure and improving symptoms, functional capacity, and quality of life. The aim of this review is therefore to summarize the pathophysiological mechanisms, the current indications, and the recent developments regarding the new applications of the CCM for patients with chronic heart failure.
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Edelson JB, Genuardi MV, Santangeli P, Birati EY. Cardiac Contractility Monitoring: an Important Therapy in the Treatment of Advanced Heart Failure. Curr Cardiol Rep 2020; 22:81. [DOI: 10.1007/s11886-020-01330-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Giallauria F, Cuomo G, Parlato A, Raval NY, Kuschyk J, Stewart Coats AJ. A comprehensive individual patient data meta-analysis of the effects of cardiac contractility modulation on functional capacity and heart failure-related quality of life. ESC Heart Fail 2020; 7:2922-2932. [PMID: 32700809 PMCID: PMC7524137 DOI: 10.1002/ehf2.12902] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/24/2020] [Accepted: 06/29/2020] [Indexed: 12/20/2022] Open
Abstract
Aims Cardiac contractility modulation, also referred to as CCM™, has emerged as a promising device treatment for heart failure (HF) in patients not indicated for cardiac resynchronization therapy. We performed a comprehensive individual patient data meta‐analysis of all non‐confounded prospective randomized controlled trials of CCM vs. control that have measured functional capacity and/or quality of life questionnaires in patients with HF. Methods and results The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched in January 2020 to identify eligible randomized controlled trials. We also asked the sole manufacturer of the device for their list of known trials. Primary outcomes of interest were peak oxygen consumption (peak VO2), 6 min walk test distance, and quality of life measured by Minnesota Living with Heart Failure Questionnaire (MLWHFQ), and all data were received as individual patient and individual time point data‐points. Mean differences and 95% confidence intervals (CIs) were calculated for continuous data using a fixed‐effects model. Five trials were identified, four randomized studies enrolling 801 participants for all endpoints of interest, and for peak VO2 alone (n = 60), there was an additional single arm non‐randomized trial (FIX‐HF‐5C2) with a prospective comparison of its 24 week peak VO2 data compared with the control group of the FIX‐HF‐5C control patients. Pooled analysis showed that, compared with control, CCM significantly improved peak VO2 (mean difference +0.93, 95% CI 0.56 to 1.30 mL/kg/min, P < 0.00001), 6 min walk test distance (mean difference +17.97, 95% CI 5.48 to 30.46 m, P = 0.005), and quality of life measured by MLWHFQ (mean difference −7.85, 95% CI −10.76 to −4.94, P < 0.00001). As a sensitivity analysis, we excluded the FIX‐HF‐5C2 trial (only relevant for peak VO2), and the result was similar, mean difference +0.65, 95% CI 0.21 to 1.08 mL/kg/min, P = 0.004. Conclusions This comprehensive meta‐analysis of individual patient data from all known randomized trials has shown that CCM provides statistically significant and clinically meaningful benefits in measures of functional capacity and HF‐related quality of life.
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Affiliation(s)
- Francesco Giallauria
- Department of Translational Medical Sciences, "Federico II" University of Naples, Via S. Pansini 5, Naples, 80131, Italy
| | - Gianluigi Cuomo
- Department of Translational Medical Sciences, "Federico II" University of Naples, Via S. Pansini 5, Naples, 80131, Italy
| | - Alessandro Parlato
- Department of Translational Medical Sciences, "Federico II" University of Naples, Via S. Pansini 5, Naples, 80131, Italy
| | - Nirav Y Raval
- Advent Health Transplant Institute, Orlando, FL, USA
| | - Jürgen Kuschyk
- I. Medical Department, University Medical Centre, Mannheim, Germany
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Matta M, Devecchi C, DE Vecchi F, Barbonaglia L, Gravellone M, Occhetta E, Rametta F. Cardiac contractility modulation in left ventricular systolic dysfunction: one-year experience in a pilot study and design of a prospective registry. Minerva Cardiol Angiol 2020; 69:15-24. [PMID: 32657553 DOI: 10.23736/s2724-5683.20.05219-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cardiac contractility modulation (CCM) is a treatment option for patients suffering symptomatic chronic heart failure (CHF) with reduced left ventricular ejection fraction (LVEF) who are not eligible for cardiac resynchronization. Data on mid-term follow-up are limited to small observational studies. The aim of this study was to assess the impact of CCM on quality of life, symptoms, exercise tolerance and left ventricular function in patients with CHF and moderate-to-severe left ventricular systolic dysfunction. METHODS Patients suffering CHF with LVEF <45% and NYHA class >II despite optimal medical therapy, underwent CCM implantation. Enrolled patients underwent baseline and 3, 6 and 12-months evaluation with ECG, echocardiogram, clinical assessment, 6-minute walking test and Minnesota Living with Heart Failure Questionnaire (MLWHFQ). RESULTS Ten patients underwent CCM implantation. All patients were actively treated with the optimal pharmacological therapy as tolerated and had at least one hospitalization for worsening heart failure during the previous year. After a mean follow-up of 15 months, 9 patients were alive, while one patient died for worsening heart failure precipitated by pneumonia. Among the remaining 9 patients, LVEF improved non-significantly from 29.4±8% to 32.2±10% (P=0.092), 6-minute walking test distance improved from 179±73 m to 304±99 m (P<0.001), NYHA class reduced from 3.0±0.4 to 1.6±0.5 (P=0.003) and MLWHFQ score improved from 59.6±49 to 34.2±32 (P=0.037). Only 2 patients have been hospitalized during the 12 months. Overall, a net clinical benefit was detected in 6 out of 9 patients. CONCLUSIONS CCM could be effective in improving quality of life, symptoms and exercise tolerance, and reduces hospitalizations in patients with symptomatic CHF on top of optimal medical and electrical therapy. A prospective registry has been designed to identify the subsets of patients gaining more benefit, and to assess the long-term effect of CCM on those clinical endpoints.
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Affiliation(s)
- Mario Matta
- Division of Cardiology, Sant'Andrea Hospital, Vercelli, Italy -
| | - Chiara Devecchi
- Division of Cardiology, Sant'Andrea Hospital, Vercelli, Italy
| | | | | | | | - Eraldo Occhetta
- Division of Cardiology, Sant'Andrea Hospital, Vercelli, Italy
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Wiegn P, Chan R, Jost C, Saville BR, Parise H, Prutchi D, Carson PE, Stagg A, Goldsmith RL, Burkhoff D. Safety, Performance, and Efficacy of Cardiac Contractility Modulation Delivered by the 2-Lead Optimizer Smart System. Circ Heart Fail 2020; 13:e006512. [DOI: 10.1161/circheartfailure.119.006512] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background:
Prior studies of cardiac contractility modulation (CCM) employed a 3-lead Optimizer system. A new 2-lead system eliminated the need for an atrial lead. This study tested the safety and effectiveness of this 2-lead system compared with the 3-lead system.
Methods:
Patients with New York Heart Association III/IVa symptoms despite medical therapy, left ventricular ejection fraction 25% to 45%, and not eligible for cardiac resynchronization therapy could participate. All subjects received an Optimizer 2-lead implant. The primary end point was the estimated difference in the change of peak VO
2
from baseline to 24 weeks between FIX-HF-5C2 (2-lead system) subjects relative to control subjects from the prior FIX-HF-5C (3-lead system) study. Changes in New York Heart Association were a secondary end point. The primary safety end point was a comparison of device-related adverse events between FIX-HF-5C2 and FIX-HF-5C subjects.
Results:
Sixty subjects, 88% male, 66±9 years old with left ventricular ejection fraction 34±6% were included. Baseline characteristics were similar between FIX-HF-5C and FIX-HF-5C2 subjects except that 15% of FIX-HF-5C2 subjects had permanent atrial fibrillation versus 0% in FIX-HF-5C. CCM delivery did not differ significantly between 2- and 3-lead systems (19 892±3472 versus 19 583±4998 CCM signals/day, CI of difference [−1228 to 1847]). The change of peak VO
2
from baseline to 24 weeks was 1.72 (95% Bayesian credible interval, 1.02–2.42) mL/kg per minute greater in the 2-lead device group versus controls. 83.1% of 2-lead subjects compared with 42.7% of controls experienced ≥1 class New York Heart Association improvement (
P
<0.001). There were decreased Optimizer-related adverse events with the 2-lead system compared with the 3-lead system (0% versus 8%;
P
=0.03).
Conclusions:
The 2-lead system effectively delivers comparable amount of CCM signals (including in subjects with atrial fibrillation) as the 3-lead system, is equally safe and improves peak VO
2
and New York Heart Association. Device-related adverse effects are less with the 2-lead system.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT03339310
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Affiliation(s)
- Phi Wiegn
- Department of Clinical Cardiac Electrophysiology, Dallas VA Medical Center, TX (P.W.)
| | | | - Charles Jost
- Southwest Cardiovascular Associates, Mesa, AZ (C.J.)
| | | | | | | | - Peter E. Carson
- Department of Medicine, Washington VA Medical Center, DC (P.E.C.)
| | | | - Rochelle L. Goldsmith
- Exercise Physiology Laboratory, Columbia University Medical Center, New York (R.L.G.)
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Witte K, Hasenfuss G, Kloppe A, Burkhoff D, Green M, Moss J, Peel A, Mealing S, Durand Zaleski I, Cowie MR. Cost-effectiveness of a cardiac contractility modulation device in heart failure with normal QRS duration. ESC Heart Fail 2019; 6:1178-1187. [PMID: 31997539 PMCID: PMC6989288 DOI: 10.1002/ehf2.12526] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 06/28/2019] [Accepted: 09/04/2019] [Indexed: 12/28/2022] Open
Abstract
AIMS The objective of this paper is to assess whether cardiac contractility modulation (via the Optimizer System) plus standard of care (SoC) is a cost-effective treatment for people with heart failure [New York Heart Association (NYHA) III, left ventricular ejection fraction of 25-45%, and narrow QRS] compared against SoC alone from the perspective of the English National Health Service. METHODS AND RESULTS We developed a regression equation-based cost-effectiveness model, using individual patient data from three randomized control trials (FIX-HF-5 Phases 1 and 2, and FIX-HF-5C) to populate the majority of parameters. A series of regression equations predicted NYHA class over time, mortality, all-cause hospitalization rates, and health-related quality of life. We conducted the analysis in line with the National Institute for Health and Care Excellence reference case, modelling costs from an English National Health Service perspective, and considering outcomes in quality-adjusted life years (QALYs) over a patient lifetime perspective. Our base case analysis produced an incremental cost per additional QALY of GBP22 988 (€25 750) when comparing Optimizer + SoC to SoC alone. This result was not sensitive to parameter uncertainty but was sensitive to the time horizon over which costs and QALYs were captured and the duration over which a survival benefit with Optimizer + SoC can be assumed to apply. CONCLUSIONS Cardiac contractility modulation is likely to be cost-effective in people with heart failure with reduced ejection fraction, NYHA III, and narrow QRS, provided that the treatment benefit can be maintained beyond the duration of the existing clinical trial follow-up. This analysis supports the current recommendations of the European Society of Cardiology that this therapy may be considered for such patients.
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Affiliation(s)
- Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUK
| | - Gerd Hasenfuss
- Heart Center of GöttingenUniversity Medical Center GöttingenGöttingenGermany
| | - Axel Kloppe
- Department of CardiologyRuhr‐Universität‐BochumBochumGermany
| | - Daniel Burkhoff
- Division of Cardiology, Department of MedicineColumbia University Medical Center ‐ New York PresbyterianNew YorkNYUSA
| | - Michelle Green
- York Health Economics Consortium, Enterprise House, Innovation WayUniversity of YorkYorkYO10 5NQUK
| | - Joe Moss
- York Health Economics Consortium, Enterprise House, Innovation WayUniversity of YorkYorkYO10 5NQUK
| | - Alison Peel
- York Health Economics Consortium, Enterprise House, Innovation WayUniversity of YorkYorkYO10 5NQUK
| | - Stuart Mealing
- York Health Economics Consortium, Enterprise House, Innovation WayUniversity of YorkYorkYO10 5NQUK
| | | | - Martin R. Cowie
- Department of CardiologyImperial College London, Royal Brompton HospitalLondonUK
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Outcomes of Cardiac Contractility Modulation: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Cardiovasc Ther 2019; 2019:9769724. [PMID: 31772622 PMCID: PMC6739758 DOI: 10.1155/2019/9769724] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/19/2019] [Indexed: 11/24/2022] Open
Abstract
Background Cardiac contractility modulation (CCM) is a device therapy for systolic heart failure (HF) in patients with narrow QRS. We aimed to perform an updated meta-analysis of the randomized clinical trials (RCTs) to assess the efficacy and safety of CCM therapy. Methods We conducted a systematic review and meta-analysis of randomized clinical trials (RCTs) between January 2001 and June 2018. Outcomes of interest were peak oxygen consumption (peak VO2), 6-Minute Walk Distance (6MWD), Minnesota Living with Heart Failure Questionnaire (MLHFQ), HF hospitalizations, cardiac arrhythmias, pacemaker/ICD malfunctioning, all-cause hospitalizations, and mortality. Data were expressed as standardized mean difference (SMD) or odds ratio (OR). Results Four RCTs including 801 patients (CCM n = 394) were available for analysis. The mean age was 59.63 ± 0.84 years, mean ejection fraction was 29.14 ± 1.22%, and mean QRS duration was 106.23 ± 1.65 msec. Mean follow-up duration was six months. CCM was associated with improved MLWHFQ (SMD -0.69, p = 0.0008). There were no differences in HF hospitalizations (OR 0.76, p = 0.12), 6MWD (SMD 0.67, p = 0.10), arrhythmias (OR 1.40, p = 0.14), pacemaker/ICD malfunction/sensing defect (OR 2.23, p = 0.06), all-cause hospitalizations (OR 0.73, p = 0.33), or all-cause mortality (OR 1.04, p = 0.92) between the CCM and non-CCM groups. Conclusions Short-term treatment with CCM may improve MLFHQ without significant difference in 6MWD, arrhythmic events, HF hospitalizations, all-cause hospitalizations, and all-cause mortality. There is a trend towards increased pacemaker/ICD device malfunction. Larger RCTs might be needed to determine if the CCM therapy will be beneficial with longer follow-up.
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Contrasting Effects of Pharmacological, Procedural, and Surgical Interventions on Proportionate and Disproportionate Functional Mitral Regurgitation in Chronic Heart Failure. Circulation 2019; 140:779-789. [DOI: 10.1161/circulationaha.119.039612] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Two distinct pathways can lead to functional mitral regurgitation (MR) in patients with chronic heart failure and a reduced ejection fraction. When remodeling and enlargement of the left ventricle (LV) cause annular dilatation and tethering of the mitral valve leaflets, there is a linear relationship between LV end-diastolic volume and the effective regurgitant orifice area of the mitral valve. These patients, designated as having proportionate MR, respond favorably to treatments that lead to reversal of LV remodeling and a decrease in LV volumes (eg, neurohormonal antagonists and LV assist devices), but they may not benefit from interventions that are directed only at the mitral valve leaflets (eg, transcatheter mitral valve repair). In contrast, when ventricular dyssynchrony causes functional MR attributable to unequal contraction of the papillary muscles, the magnitude of regurgitation is greater than that predicted by LV volumes. These patients, designated as having severe but disproportionate MR, respond favorably to treatments that are directed to the mitral valve leaflets or their supporting structures (eg, cardiac resynchronization or transcatheter mitral valve repair), but they may derive little benefit from interventions that act only to reduce LV cavity size (eg, pharmacological treatments). This novel conceptual framework reflects the important interplay between LV geometry and mitral valve function in determining the clinical presentation of patients, and it allows characterization of the determinants of functional MR to guide the most appropriate therapy in the clinical setting.
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Anker SD, Borggrefe M, Neuser H, Ohlow MA, Röger S, Goette A, Remppis BA, Kuck KH, Najarian KB, Gutterman DD, Rousso B, Burkhoff D, Hasenfuss G. Cardiac contractility modulation improves long-term survival and hospitalizations in heart failure with reduced ejection fraction. Eur J Heart Fail 2019; 21:1103-1113. [PMID: 30652394 DOI: 10.1002/ejhf.1374] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/23/2018] [Accepted: 11/04/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS Cardiac contractility modulation (CCM) improves symptoms and exercise tolerance and reduces heart failure (HF) hospitalizations over 6-month follow-up in patients with New York Heart Association (NYHA) class III or IV symptoms, QRS < 130 ms and 25% ≤ left ventricular ejection fraction (LVEF) ≤ 45% (FIX-HF-5C study). The current prospective registry study (CCM-REG) aimed to assess the longer-term impact of CCM on hospitalizations and mortality in real-world experience in this same population. METHODS AND RESULTS A total of 140 patients with 25% ≤ LVEF ≤ 45% receiving CCM therapy (CCM-REG25-45 ) for clinical indications were included. Cardiovascular and HF hospitalizations, Minnesota Living with Heart Failure Questionnaire (MLHFQ) and NYHA class were assessed over 2 years. Mortality was tracked through 3 years and compared with predictions by the Seattle Heart Failure Model (SHFM). A separate analysis was performed on patients with 35% ≤ LVEF ≤ 45% (CCM-REG35-45 ) and 25% ≤ LVEF < 35% (CCM-REG25-34 ). Hospitalizations decreased by 75% (from 1.2/patient-year the year before, to 0.35/patient-year during the 2 years following CCM, P < 0.0001) in CCM-REG25-45 and by a similar amount in CCM-REG35-45 (P < 0.0001) and CCM-REG25-34 . MLHFQ and NYHA class improved in all three cohorts, with progressive improvements over time (P < 0.002). Three-year survival in CCM-REG25-45 (82.8%) and CCM-REG24-34 (79.4%) were similar to those predicted by SHFM (76.7%, P = 0.16; 78.0%, P = 0.81, respectively) and was better than predicted in CCM-REG35-45 (88.0% vs. 74.7%, P = 0.046). CONCLUSION In real-world experience, CCM produces results similar to those of previous studies in subjects with 25% ≤ LVEF ≤ 45% and QRS < 130 ms; cardiovascular and HF hospitalizations are reduced and MLHFQ and NYHA class are improved. Overall mortality was comparable to that predicted by the SHFM but was lower than predicted in patients with 35% ≤ LVEF ≤ 45%.
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Affiliation(s)
- Stefan D Anker
- Division of Cardiology and Metabolism; Department of Cardiology (CVK; and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology and Pneumology and The German Center for Cardiovascular Research (DZHK), University Medicine Göttingen (UMG), Göttingen, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim (UMM), Mannheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany.,DZHK (German Centre for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Hans Neuser
- HELIOS Vogtland-Klinikum Plauen, Klinik für Innere Medizin II/Kardiologie, Pneumologie und Angiologie, Plauen, Germany
| | | | - Susanne Röger
- First Department of Medicine, University Medical Centre Mannheim (UMM), Mannheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany.,DZHK (German Centre for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Andreas Goette
- St. Vincenz Krankenhaus Paderborn, Paderborn, Germany.,Working Group of Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany
| | | | | | | | | | | | | | - Gerd Hasenfuss
- Department of Cardiology and Pneumology and The German Center for Cardiovascular Research (DZHK), University Medicine Göttingen (UMG), Göttingen, Germany
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Tschöpe C, Kherad B, Klein O, Lipp A, Blaschke F, Gutterman D, Burkhoff D, Hamdani N, Spillmann F, Van Linthout S. Cardiac contractility modulation: mechanisms of action in heart failure with reduced ejection fraction and beyond. Eur J Heart Fail 2019; 21:14-22. [PMID: 30485591 PMCID: PMC6607484 DOI: 10.1002/ejhf.1349] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/04/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is responsible for substantial morbidity and mortality and is increasing in prevalence. Although there has been remarkable progress in the treatment of HF with reduced ejection fraction (HFrEF), morbidity and mortality are still substantial. Cardiac contractility modulation (CCM) signals, consisting of biphasic high-voltage bipolar signals delivered to the right ventricular septum during the absolute refractory period, have been shown to improve symptoms, exercise tolerance and quality of life and reduce the rate of HF hospitalizations in patients with ejection fractions (EF) between 25% and 45%. CCM therapy is currently approved in the European Union, China, India, Australia and Brazil for use in symptomatic HFrEF patients with normal or slightly prolonged QRS duration. CCM is particularly beneficial in patients with baseline EF between 35% and 45%, which includes half the range of HF patients with mid-range EFs (HFmrEF). At the cellular level, CCM has been shown in HFrEF patients to improve calcium handling, to reverse the foetal myocyte gene programme associated with HF, and to facilitate reverse remodelling. This review highlights the preclinical and clinical literature related to CCM in HFrEF and HFmrEF and outlines the potential of CCM for HF with preserved EF, concluding that CCM may fill an important unmet need in the therapeutic approach to HF across the range of EFs.
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Affiliation(s)
- Carsten Tschöpe
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
- Berlin Center for Regenerative Therapies (BCRT), Campus Virchow Klinikum (CVK)Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site BerlinBerlinGermany
| | - Behrouz Kherad
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
| | - Oliver Klein
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
- Berlin Center for Regenerative Therapies (BCRT), Campus Virchow Klinikum (CVK)Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site BerlinBerlinGermany
| | - Axel Lipp
- Department of NeurologyUniversitätsmedizin Berlin, CVKBerlinGermany
| | - Florian Blaschke
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
| | | | | | - Nazha Hamdani
- Department of Cardiovascular PhysiologyRuhr University BochumBochumGermany
| | - Frank Spillmann
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
| | - Sophie Van Linthout
- Department of CardiologyUniversitätsmedizin Berlin, Campus Virchow Klinikum (CVK)BerlinGermany
- Berlin Center for Regenerative Therapies (BCRT), Campus Virchow Klinikum (CVK)Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site BerlinBerlinGermany
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36
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Kuschyk J, Rudic B, Liebe V, Tülümen E, Borggrefe M, Akin I. [Cardiac contractility modulation for treatment of chronic heart failure]. Herzschrittmacherther Elektrophysiol 2018; 29:369-376. [PMID: 30361862 DOI: 10.1007/s00399-018-0600-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 10/08/2018] [Indexed: 06/08/2023]
Abstract
The worldwide prevalence of heart failure is 1-2% with a portion of >10% in patients older than 70 years. In addition to treatment of causal determined factors and lifestyle modification, basic treatment consists of guideline-directed medical therapy with angiotensin-converting enzyme inhibitors (ACE), β‑blockers (BB), mineralocorticoid receptor antagonists (MRA), diuretics, digitalis (class IIb recommendation), angiotensin receptor blockers (ARB), Iƒ-channel blockers plus recently recommended in the guidelines angiotensin receptor neprilysin inhibitor (ARNI) to substitute the ACE inhibitor (class I b). Cardiac contractility modulation (CCM) is a device-based electrical therapy for the treatment of refractory heart failure symptoms. CCM signals are relatively high intensity, nonexcitatory signals applied during the absolute refractory period that have been shown to enhance the strength of left ventricular (LV) contraction and improve exercise tolerance and quality of life. The mechanisms of action appear to involve effects on myocardial gene expression and normalization of myocardial key-proteins. So far, more than 3500 CCM devices have been implanted worldwide. For patients with symptomatic heart failure and narrow QRS complex, CCM is together with baroreceptor activation the only additive electrical therapy which had been approved in Germany. Actually, for the first time, CCM has been referenced in the current Heart Failure Guidelines. Prognostic data with regard to mortality are currently being evaluated in case series; some of which have since been published. Approval by the US Food and Drug Administration (FDA) is expected within the next months.
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Affiliation(s)
- J Kuschyk
- I. Medizinische Klinik, Universitätsmedizin Mannheim, DZHK, Deutsches Zentrum für Herz-Kreislauf-Forschung, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - B Rudic
- I. Medizinische Klinik, Universitätsmedizin Mannheim, DZHK, Deutsches Zentrum für Herz-Kreislauf-Forschung, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - V Liebe
- I. Medizinische Klinik, Universitätsmedizin Mannheim, DZHK, Deutsches Zentrum für Herz-Kreislauf-Forschung, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - E Tülümen
- I. Medizinische Klinik, Universitätsmedizin Mannheim, DZHK, Deutsches Zentrum für Herz-Kreislauf-Forschung, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - M Borggrefe
- I. Medizinische Klinik, Universitätsmedizin Mannheim, DZHK, Deutsches Zentrum für Herz-Kreislauf-Forschung, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - I Akin
- I. Medizinische Klinik, Universitätsmedizin Mannheim, DZHK, Deutsches Zentrum für Herz-Kreislauf-Forschung, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Kuschyk J, Rudic B, Borggrefe M, Akin I. [Cardiac contractility modulation]. Internist (Berl) 2018; 59:1021-1027. [PMID: 30209514 DOI: 10.1007/s00108-018-0493-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cardiac contractility modulation (CCM) is a device-based electrical therapy for the additive treatment of chronic drug-refractory heart insufficiency. High-amplitude signals are applied during the absolute refractory period and have been shown to enhance the strength of left ventricular (LV) contraction and improve exercise tolerance and quality of life. The mechanisms of action appear to involve effects on myocardial gene expression and on normalization of key myocardial proteins. So far, more than 3500 CCM devices have been implanted worldwide. For patients with therapy refractory heart insufficiency and narrow QRS complex, CCM is together with baroreceptor activation the only additive electrical therapy which had been approved in Germany. For the first time CCM has been referenced in the current guidelines on cardiac insufficiency. Prognostic data with respect to mortality have been evaluated in case series. Ongoing randomized trials and registries will address these specific endpoints and have to a significant extent already been recently published. A Food and Drug Administration (FDA) approval is expected within the next few months.
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Affiliation(s)
- J Kuschyk
- I. Medizinische Klinik, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - B Rudic
- I. Medizinische Klinik, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - M Borggrefe
- I. Medizinische Klinik, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - I Akin
- I. Medizinische Klinik, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
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Röger S, Rudic B, Akin I, Shchetynska‐Marinova T, Fastenrath F, Tülümen E, Liebe V, El‐Battrawy I, Baumann S, Kuschyk J, Borggrefe M. Long-term results of combined cardiac contractility modulation and subcutaneous defibrillator therapy in patients with heart failure and reduced ejection fraction. Clin Cardiol 2018; 41:518-524. [PMID: 29697870 PMCID: PMC5947638 DOI: 10.1002/clc.22919] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/28/2018] [Accepted: 02/04/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Cardiac contractility modulation (CCM) is an electrical-device therapy for patients with heart failure with reduced ejection fraction (HFrEF). Patients with left ventricular ejection fraction (LVEF) ≤35% also have indication for an implantable cardioverter-defibrillator (ICD), and in some cases subcutaneous ICD (S-ICD) is selected. HYPOTHESIS CCM and S-ICD can be combined to work efficaciously and safely. METHODS We report on 20 patients with HFrEF and LVEF ≤35% who received CCM and S-ICD. To exclude device interference, patients received intraoperative crosstalk testing, S-ICD testing, and bicycle exercise testing while CCM was activated. Clinical and QOL measures before CCM activation and at last follow-up were analyzed. S-ICD performance was evaluated while both CCM and S-ICD were active. RESULTS Mean follow-up was 34.3 months. NYHA class improved from 2.9 ± 0.4 to 2.1 ± 0.7 (P < 0.0001), Minnesota Living With Heart Failure Questionnaire score improved from 50.2 ± 23.7 to 29.6 ± 22.8 points (P < 0.0001), and LVEF improved from 24.4% ± 8.1% to 30.9% ± 9.6% (P = 0.002). Mean follow-up time with both devices active was 22 months. Three patients experienced a total of 6 episodes of sustained ventricular tachycardia, all successfully treated with first ICD shock. One case received an inappropriate shock unrelated to the concomitant CCM. One patient received an LVAD, so CCM and S-ICD were discontinued. CONCLUSIONS CCM and S-ICD can be successfully combined in patients with HFrEF. S-ICD and CCM remain efficacious when used together, with no interference affecting their function.
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Affiliation(s)
- Susanne Röger
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Boris Rudic
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Tetyana Shchetynska‐Marinova
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Fabian Fastenrath
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Erol Tülümen
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Volker Liebe
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Ibrahim El‐Battrawy
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Stefan Baumann
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Jürgen Kuschyk
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
| | - Martin Borggrefe
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM)University of HeidelbergMannheimGermany
- DZHK (German Centre for Cardiovascular Research) Partner Site MannheimGermany
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Kuschyk J, Rudic B, Borggrefe M, Akin I. [Current impact of cardiac implantable electronic devices]. Herz 2017; 42:151-161. [PMID: 28229200 DOI: 10.1007/s00059-017-4548-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Sudden cardiac death and chronic heart failure are among the main contributors to persisting high mortality rates in Germany. In addition to removal of causal factors and guideline-conform pharmacological therapy, therapy with cardiac implantable electronic devices (CIED) is of undisputed importance. Subcutaneous defibrillators have the advantage that they do not have intracardiac electrodes but still have the same efficacy and safety. For patients with a wide QRS complex and reduced ejection fraction, cardiac resynchronization has led to a reduction of morbidity and mortality. For patients with a normal QRS complex, cardiac contractility modulation had been shown to improve the quality of life, exercise capacity and left ventricular function. As a procedure for autonomic modulation in patients with reduced cardiac strength, the data for baroreceptor stimulation are the most convincing.
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Affiliation(s)
- J Kuschyk
- I. Medizinische Klinik, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland. .,Deutsches Zentrum für Herz-Kreislauf-Erkrankungen (DZHK), Mannheim, Deutschland.
| | - B Rudic
- I. Medizinische Klinik, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.,Deutsches Zentrum für Herz-Kreislauf-Erkrankungen (DZHK), Mannheim, Deutschland
| | - M Borggrefe
- I. Medizinische Klinik, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.,Deutsches Zentrum für Herz-Kreislauf-Erkrankungen (DZHK), Mannheim, Deutschland
| | - I Akin
- I. Medizinische Klinik, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.,Deutsches Zentrum für Herz-Kreislauf-Erkrankungen (DZHK), Mannheim, Deutschland
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Al-Ghamdi B, Shafquat A, Mallawi Y. Cardiac contractility modulation therapy: Are there superresponders? HeartRhythm Case Rep 2017; 3:229-232. [PMID: 28491808 PMCID: PMC5419822 DOI: 10.1016/j.hrcr.2017.02.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 01/28/2017] [Accepted: 02/03/2017] [Indexed: 12/02/2022] Open
Affiliation(s)
- Bandar Al-Ghamdi
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
- Address reprint requests and correspondence: Dr Bandar Al-Ghamdi, Heart Centre, King Faisal Specialist Hospital and Research Centre, MBC-16, PO Box 3354, Riyadh 11211, Saudi Arabia.Heart Centre, King Faisal Specialist Hospital and Research CentreMBC-16, PO Box 3354Riyadh11211Saudi Arabia
| | - Azam Shafquat
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | - Yaseen Mallawi
- Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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Röger S, Said S, Kloppe A, Lawo T, Emig U, Rousso B, Gutterman D, Borggrefe M, Kuschyk J. Cardiac contractility modulation in heart failure patients: Randomized comparison of signal delivery through one vs. two ventricular leads. J Cardiol 2016; 69:326-332. [PMID: 27590412 DOI: 10.1016/j.jjcc.2016.06.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/11/2016] [Accepted: 06/16/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cardiac contractility modulation (CCM) is an electrical stimulation treatment for symptomatic heart failure (HF) patients. The procedure involves implantation of two ventricular leads for delivery of CCM impulses. The purpose of this study is to compare the efficacy and safety of CCM when the signal is delivered through one vs. two ventricular leads. METHODS This prospective blinded randomized trial enrolled 48 patients. Eligible subjects had symptoms despite optimal HF medications, left ventricular ejection fraction <40% and peakVO2≥9ml O2/kg/min. All patients received a CCM system with two ventricular leads, and were randomized to CCM active through both or just one ventricular lead; 25 patients were randomized to receive signal delivery through two leads (Group A) and 23 patients to signal delivery through one lead (Group B). The study compared the mean changes from baseline to 6 months follow-up in peakVO2, New York Heart Association (NYHA) classification, and quality of life (by MLWHFQ). RESULTS Following 6 months, similar and significant (p<0.05) improvements from baseline in NYHA (-0.7±0.5 vs. -0.9±0.7) and MLWHFQ (-14±20 vs. -16±22) were observed in Group A and in Group B. PeakVO2 showed improvement trends in both groups (0.34±1.52 vs. 0.10±2.21ml/kg/min; p=ns). No patient died. Serious adverse event rates (20 events in 10 subjects) were not different between groups. No statistically significant difference was found in any of the study endpoints. CONCLUSIONS The efficacy and safety of CCM in this study were similar when the signal was delivered through either one or two ventricular leads. These results support the potential use of a single ventricular lead for delivery of CCM.
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Affiliation(s)
- Susanne Röger
- Mannheim University Hospital, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research) partner site, Mannheim, Germany.
| | - Samir Said
- Magdeburg University Hospital, Magdeburg, Germany
| | - Axel Kloppe
- University Hospital of the Ruhr-University Bochum, Bochum, Germany
| | | | - Ulf Emig
- Helios Klinikum Meiningen Medical Clinic, Meiningen, Germany
| | | | | | - Martin Borggrefe
- Mannheim University Hospital, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research) partner site, Mannheim, Germany
| | - Jürgen Kuschyk
- Mannheim University Hospital, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research) partner site, Mannheim, Germany
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Cardiac Contractility Modulation in a Model of Repaired Tetralogy of Fallot: A Sheep Model. Pediatr Cardiol 2016; 37:826-33. [PMID: 27126593 DOI: 10.1007/s00246-016-1356-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Accepted: 02/09/2016] [Indexed: 10/21/2022]
Abstract
The onset of right ventricular dysfunction in patients presenting with congenital heart disease is associated with a dismal long-term outcome and often represents a therapeutic dead end. Our study had several objectives: (1) to analyse the anatomical, functional, histological and cellular characteristics of an animal model of repaired tetralogy of Fallot with right ventricular dysfunction (2) to test the new electrical treatment known as cardiac contractility modulation in this animal model. Seven sheep underwent a first surgery at the age of three weeks aiming to mimic the characteristics of a repaired tetralogy of Fallot. Five controls were sham-operated. Experimental studies were performed 12 months after the initial operation. The hemodynamic, echocardiographic, and mitochondrial function studies were carried out before and after cardiac contractility modulation in closed- and open-chest conditions. In this animal model of right ventricular dysfunction, short-term cardiac contractility modulation was associated with a significant improvement in (a) right ventricular function, as evidenced by a significant increase in right ventricular dP/dt (p < 0.05) (b) left ventricular function evidenced by the increase in left ventricular dP/dt max (p < 0.05) (c) in mitochondrial function (p < 0.05). In this animal model of chronic right ventricular dysfunction, cardiac contractility modulation significantly improved acute cardiac hemodynamic and mitochondrial functions of both ventricles and may represent a promising option in patients with right heart failure.
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Liu M, Fang F, Luo XX, Shlomo BH, Burkhoff D, Chan JYS, Chan CP, Cheung L, Rousso B, Gutterman D, Yu CM. Improvement of long-term survival by cardiac contractility modulation in heart failure patients: A case-control study. Int J Cardiol 2016; 206:122-6. [PMID: 26788686 DOI: 10.1016/j.ijcard.2016.01.071] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 12/23/2015] [Accepted: 01/01/2016] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cardiac contractility modulation (CCM) has been shown to be effective in improving symptoms and cardiac function in heart failure (HF). However, there is limited data on the role of CCM on long-term survival, which was explored in the present study. METHODOLOGY Forty-one consecutive HF patients with left ventricular ejection fraction (EF) <40% received CCM and were followed for approximately 6 years. They were compared with another 41 HF patients who were enrolled into the HF registry in the same period, and had similar age, gender, EF and etiology of HF. The primary end-point was all cause-mortality. This was stratified by EF. Secondary end-points included HF hospitalization, cardiovascular death, and the composite outcome of death or heart failure hospitalization. RESULTS The CCM and control groups were well balanced for demographic data, medications and baseline left ventricular EF (27 ± 6 vs 27 ± 7%, p=NS). The mean follow-up duration was 75 ± 19 months in the CCM group and 69 ± 17 months in the control group. All-cause mortality was lower in the CCM group than the control group (39% vs. 71%, respectively; Log-rank χ(2)=11.23, p=0.001). Of note, the improvement of all-cause mortality is more dramatic in patients with EF ≥ 25-40% (36% vs. 80%, Log-rank χ(2)=15.8, p<0.001) than those with EF<25% (50% vs. 56%, p=NS), CCM vs. control respectively. Similar results were shown for the benefit of CCM in the secondary endpoints of cardiovascular death, and the composite outcome of death or heart failure hospitalization. The occurrence of HF hospitalization showed no significant difference between CCM and control groups in the whole cohort (41% vs. 49%, p=NS), but was significantly lower with CCM in subjects with EF ≥ 25-40% at baseline (36% vs. 64%, Log-rank χ(2)=7.79, p=0.005). CONCLUSION CCM resulted in significant improvement of long-term survival, in particular in those with EF ≥ 25-40%. A reduction in heart failure hospitalizations was also seen in this group of patients with less severely reduced EF.
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Affiliation(s)
- Ming Liu
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Fang Fang
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Xiu Xia Luo
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Ben-Haim Shlomo
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Daniel Burkhoff
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Joseph Y S Chan
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Chin-Pang Chan
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Lili Cheung
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Benny Rousso
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - David Gutterman
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong
| | - Cheuk-Man Yu
- Division of Cardiology and HEART Centre, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Institute of Vascular Medicine, The Chinese University of Hong Kong, Hong Kong; LCW Institute of Innovative Medicine, The Chinese University of Hong Kong, Hong Kong; Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong.
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Cardiac contractility modulation signals improve exercise intolerance and maladaptive regulation of cardiac key proteins for systolic and diastolic function in HFpEF. Int J Cardiol 2016; 203:1061-6. [DOI: 10.1016/j.ijcard.2015.10.208] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 10/26/2015] [Indexed: 01/09/2023]
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Röger S, Borggrefe M, Kuschyk J. Heart Failure With Reduced Ejection Fraction And A Narrow QRS Complex: Combination Of A Subcutaneous Defibrillator With Cardiac Contractility Modulation. J Atr Fibrillation 2015; 8:1081. [PMID: 27957197 DOI: 10.4022/jafib.1081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 09/09/2015] [Accepted: 08/26/2015] [Indexed: 11/10/2022]
Abstract
Cardiac contractility modulation (CCM) is a relatively new electrical therapy for heart failure patients with reduced ejection fraction. The majority of patients eligible for CCM will also need an implantable cardioverter-defibrillator (ICD). To-date, three pacing electrodes are mandatory for CCM therapy because the current CCM signal delivery algorithm requires sequential intracardiac sensing of a p-wave, followed by appropriately timed ventricular activation by the two ventricular septal leads. As there is no device combining CCM with ICD functions, most CCM patients will need multiple intracardiac electrodes, which increase the cumulative risk for complications such as systemic infections, thrombosis of central venous lines, insulation failures or lead fractures. The long-term complications associated with trans-venous ICD leads have led to the development of a totally subcutaneous implantable cardioverter-defibrillator (S-ICD). In this essay the two technologies CCM and S-ICD are reviewed. Additionally, we present their successful combination on the basis of a case report on the first patient receiving both devices.
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Affiliation(s)
- Susanne Röger
- Medical Faculty Mannheim of the University of Heidelberg, 1st Department of Medicine, Mannheim, Germany; Medical Faculty Mannheim of the University of Heidelberg, 1st Department of Medicine, Mannheim, Germany
| | - Martin Borggrefe
- Medical Faculty Mannheim of the University of Heidelberg, 1st Department of Medicine, Mannheim, Germany; DZHK (German Centre for Cardiovascular Research) partner site Mannheim, Germany
| | - Jürgen Kuschyk
- DZHK (German Centre for Cardiovascular Research) partner site Mannheim, Germany; DZHK (German Centre for Cardiovascular Research) partner site Mannheim, Germany
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Kuschyk J, Roeger S, Schneider R, Streitner F, Stach K, Rudic B, Weiß C, Schimpf R, Papavasilliu T, Rousso B, Burkhoff D, Borggrefe M. Efficacy and survival in patients with cardiac contractility modulation: long-term single center experience in 81 patients. Int J Cardiol 2015; 183:76-81. [PMID: 25662055 DOI: 10.1016/j.ijcard.2014.12.178] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 11/27/2014] [Accepted: 12/23/2014] [Indexed: 11/29/2022]
Abstract
AIMS To analyze long-term efficacy and survival in patients with chronic heart failure treated with cardiac contractility modulation. METHODS 81 patients implanted with a CCM device between 2004 and 2012 were included in this retrospective analysis. Changes in NYHA class, ejection fraction (EF), Minnesota Living with Heart Failure Questionnaire, NT-proBNP and peak VO₂ were analyzed during a mean follow up of 34.2 ± 28 months (6-123 months). Observed mortality rate was compared with that predicted by the MAGGIC Score. RESULTS Patients were 61 ± 12 years old with EF 23 ± 7%. Heart failure was due to ischemic (n=48, 59.3%) or idiopathic dilated (n=33, 40.7%) cardiomyopathy. EF increased from 23.1 ± 7.9 to 29.4 ± 8.6% (p<0.05), mean NT-proBNP decreased from 4395 ± 3818 to 2762 ± 3490 ng/l (p<0.05) and mean peak VO2 increased from 13.9 ± 3.3 to 14.6 ± 3.5 ml/kg/min (p=0.1). The overall clinical responder rate (at least 1 class improvement of NYHA within 6 months or last follow-up) was 74.1%. 21 (25.9%) patients died during follow up, 11 (52.4%) due to cardiac conditions and 10 (47.6%) due to non-cardiac conditions. Mortality rates at 1 and 3 years were 5.2% and 29.5% compared to mortality rates estimated from the MAGGIC risk score of 18.4% (p<0.001) and 40% (p=ns), respectively. Log-Rank analysis of all events through 3 years of follow-up, however, was significantly less than predicted (p=0.022). CONCLUSIONS CCM therapy improved quality of life, exercise capacity, NYHA class, EF and NT-proBNP levels during long-term follow up. Mortality rates appeared to be lower than estimated from the MAGGIC score.
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Affiliation(s)
- Jürgen Kuschyk
- University Medical Centre, I. Medical Department, Mannheim, Germany.
| | - Susanne Roeger
- University Medical Centre, I. Medical Department, Mannheim, Germany
| | | | | | - Ksenija Stach
- University Medical Centre, I. Medical Department, Mannheim, Germany
| | - Boris Rudic
- University Medical Centre, I. Medical Department, Mannheim, Germany
| | - Christel Weiß
- University Medical Centre, Institute for Medical Statistics, Mannheim, Germany
| | - Rainer Schimpf
- University Medical Centre, I. Medical Department, Mannheim, Germany
| | | | | | | | - Martin Borggrefe
- University Medical Centre, I. Medical Department, Mannheim, Germany
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Blinova K, Stohlman J, Krauthamer V, Knapton A, Bloomquist E, Gray RA. Acute effects of nonexcitatory electrical stimulation during systole in isolated cardiac myocytes and perfused heart. Physiol Rep 2014; 2:2/8/e12106. [PMID: 25096553 PMCID: PMC4246583 DOI: 10.14814/phy2.12106] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Application of electrical field to the heart during the refractory period of the beat has been shown to increase the force of contraction both in animal models and in heart failure patients (cardiac contractility modulation, or CCM). A direct increase in intracellular calcium during CCM has been suggested to be the mechanism behind the positive inotropic effect of CCM. We studied the effect of CCM on isolated rabbit cardiomyocytes and perfused whole rat hearts. The effect of CCM was observed in single cells via fluorescent measurements of intracellular calcium concentration ([Ca2+]i) and cell length (L). Cells were paced once per second throughout these recordings, and CCM stimulation was delivered via biphasic electric fields of 20 ms duration applied during the refractory period. CCM increased the peak amplitude of both [Ca2+]i and L for the first beat during CCM compared to control, but then [Ca2+]i and L decayed to levels lower than the control. During CCM, all contractions had a faster time to peak for both [Ca2+]i and L; after stopping CCM the rise times returned to control levels. In the whole rat heart, the positive inotropic effect of CCM stimulation on left ventricular pressure was completely abolished in the presence of metoprolol, a beta‐1 adrenergic blocker. In summary, the CCM‐induced changes in intracellular calcium handling by cardiomyocytes did not explain the sustained positive inotropic effect in the whole heart and the β‐adrenergic pathway may be involved in the CCM mechanism of action. Cardiac contractility modulation (CCM) is a heart failure therapy which delivers electrical pulses to the heart during refractory period. While there are some promising reports on the therapy's safety and effectiveness in humans, the underlining mechanism remains unknown. We studied the effect of CCM pulses in isolated rabbit cardiomyocytes and isolated rat heart in the presence of beta adrenergic blocker and recorded intracellular calcium transients and contractions. We concluded that the CCM‐induced changes in intracellular calcium handling by cardiomyocytes did not explain the sustained positive iotropic efect in the whole heart and beta‐adrenergic pathway may be involved in the CCM mechanism of action.
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Affiliation(s)
- Ksenia Blinova
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jayna Stohlman
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Victor Krauthamer
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Alan Knapton
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Eric Bloomquist
- Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Richard A Gray
- Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
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Giallauria F, Vigorito C, Piepoli MF, Stewart Coats AJ. Effects of cardiac contractility modulation by non-excitatory electrical stimulation on exercise capacity and quality of life: An individual patient's data meta-analysis of randomized controlled trials. Int J Cardiol 2014; 175:352-7. [DOI: 10.1016/j.ijcard.2014.06.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 05/14/2014] [Accepted: 06/08/2014] [Indexed: 10/25/2022]
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Roger S, Schneider R, Rudic B, Liebe V, Stach K, Schimpf R, Borggrefe M, Kuschyk J. Cardiac contractility modulation: first experience in heart failure patients with reduced ejection fraction and permanent atrial fibrillation. Europace 2014; 16:1205-9. [DOI: 10.1093/europace/euu050] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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