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Yaku H, Fudim M, Shah SJ. Role of splanchnic circulation in the pathogenesis of heart failure: State-of-the-art review. J Cardiol 2024; 83:330-337. [PMID: 38369183 DOI: 10.1016/j.jjcc.2024.02.004] [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: 11/07/2023] [Revised: 02/07/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
A hallmark of heart failure (HF), whether it presents itself during rest or periods of physical exertion, is the excessive elevation of intracardiac filling pressures at rest or with exercise. Many mechanisms contribute to the elevated intracardiac filling pressures, and notably, the concept of volume redistribution has gained attention as a cause of the elevated intracardiac filling pressures in patients with HF, particularly HF with preserved ejection fraction, who often present without symptoms at rest, with shortness of breath and fatigue appearing only during exertion. This phenomenon suggests cardiopulmonary system non-compliance and inappropriate volume distribution between the stressed and unstressed blood volume components. A substantial proportion of the intravascular blood volume is in the splanchnic vascular compartment in the abdomen. Preclinical and clinical investigations support the critical role of the sympathetic nervous system in modulating the capacitance and compliance of the splanchnic vascular bed via modulation of the greater splanchnic nerve (GSN). The GSN activation by stressors such as exercise causes excessive splanchnic vasoconstriction, which may contribute to the decompensation of chronic HF via volume redistribution from the splanchnic vascular bed to the central compartment. Accordingly, for example, GSN ablation for volume management has been proposed as a potential therapeutic intervention to increase unstressed blood volume. Here we provide a comprehensive review of the role of splanchnic circulation in the pathogenesis of HF and potential novel treatment options for redistributing blood volume to improve symptoms and prognosis in patients with HF.
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Affiliation(s)
- Hidenori Yaku
- Division of Cardiology, Department of Medicine, and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC, USA; Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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2
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Tung B, Frishman WH. Splanchnic Nerve Block: An Emerging Treatment for Heart Failure. Cardiol Rev 2024; 32:170-173. [PMID: 36409744 DOI: 10.1097/crd.0000000000000505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Heart failure (HF) is a disease syndrome whose management is increasingly challenging given the aging population and efficacious management of acute cardiac events. The current treatment options within our armamentarium incompletely address the unmet needs of HF. Splanchnic nerve block (SNB) is a novel technique that targets the greater splanchnic nerve, a potential therapeutic target in HF. However, the technique confers potential adverse side effects and complications that warrant further investigations. In this review paper, we aim to discuss the inextricable role of splanchnic nerve in HF by highlighting their physiological interplay, clinical studies that have exhibited favorable hemodynamic parameters in the context of acute and chronic HF, and common side effects and possible complications from SNB.
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Affiliation(s)
- Brian Tung
- From the School of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY
- Department of Medicine, Tufts University School of Medicine/Steward Carney Hospital, Boston, MA
| | - William H Frishman
- Department of Medicine, New York Medical College/Westchester Medical Center, Valhalla, NY
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3
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Khan MS, Paracha AA, Biegus J, Espriella RDL, Núñez J, Santos-Gallego CG, Yaranov D, Fudim M. Preload Reduction Therapies in Heart Failure. Heart Fail Clin 2024; 20:71-81. [PMID: 37953023 DOI: 10.1016/j.hfc.2023.05.004] [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
Preload reserve represents an important concept in the normal physiologic responses of the body to meet the changing metabolic demands. The recruitment of preload in healthy patients leads to an increase in effective circulating blood volume with a concomitant increase in cardiac output. However, in the setting of heart failure (HF), preload augmentation may precipitate HF decompensation. In this review, we focus on the role of splanchnic nerve modulation and pharmacological therapeutic interventions to prevent HF decompensation through preload reduction. Furthermore, we explore the emerging device-based approaches for cardiac preload reduction while reviewing the ongoing clinical trials.
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Affiliation(s)
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Poland
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Fundación de Investigación INCLIVA, Valencia, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Fundación de Investigación INCLIVA, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Carlos G Santos-Gallego
- Cardiology Department, Mount Sinai Hospital, NYC; Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NYC
| | | | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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4
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Khadka N, Bikson M. Neurocapillary-Modulation. Neuromodulation 2022; 25:1299-1311. [PMID: 33340187 PMCID: PMC8213863 DOI: 10.1111/ner.13338] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/05/2020] [Accepted: 11/23/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVES We consider two consequences of brain capillary ultrastructure in neuromodulation. First, blood-brain barrier (BBB) polarization as a consequence of current crossing between interstitial space and the blood. Second, interstitial current flow distortion around capillaries impacting neuronal stimulation. MATERIALS AND METHODS We developed computational models of BBB ultrastructure morphologies to first assess electric field amplification at the BBB (principle 1) and neuron polarization amplification by the presence of capillaries (principle 2). We adapt neuron cable theory to develop an analytical solution for maximum BBB polarization sensitivity. RESULTS Electrical current crosses between the brain parenchyma (interstitial space) and capillaries, producing BBB electric fields (EBBB) that are >400x of the average parenchyma electric field (ĒBRAIN), which in turn modulates transport across the BBB. Specifically, for a BBB space constant (λBBB) and wall thickness (dth-BBB), the analytical solution for maximal BBB electric field (EABBB) is given as: (ĒBRAIN × λBBB)/dth-BBB. Electrical current in the brain parenchyma is distorted around brain capillaries, amplifying neuronal polarization. Specifically, capillary ultrastructure produces ∼50% modulation of the ĒBRAIN over the ∼40 μm inter-capillary distance. The divergence of EBRAIN (Activating function) is thus ∼100 kV/m2 per unit ĒBRAIN. CONCLUSIONS BBB stimulation by principle 1 suggests novel therapeutic strategies such as boosting metabolic capacity or interstitial fluid clearance. Whereas the spatial profile of EBRAIN is traditionally assumed to depend only on macroscopic anatomy, principle 2 suggests a central role for local capillary ultrastructure-which impact forms of neuromodulation including deep brain stimulation (DBS), spinal cord stimulation (SCS), transcranial magnetic stimulation (TMS), electroconvulsive therapy (ECT), and transcranial electrical stimulation (tES)/transcranial direct current stimulation (tDCS).
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Affiliation(s)
- Niranjan Khadka
- Department of Psychiatry, Laboratory for Neuropsychiatry and Neuromodulation, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Marom Bikson
- Department of Biomedical Engineering, The City College of New York, CUNY, New York, NY, USA.
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5
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Device Therapy for Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:507-515. [DOI: 10.1016/j.ccl.2022.06.005] [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: 11/20/2022]
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6
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Fudim M, Fail PS, Litwin SE, Shaburishvili T, Goyal P, Hummel S, Borlaug BA, Mohan RC, Patel RB, Mitter SS, Klein L, Rocha-Singh K, Patel MR, Reddy VY, Burkhoff D, Shah SJ. Endovascular Ablation of the Right Greater Splanchnic Nerve in Heart Failure with Preserved Ejection Fraction: Early Results of the REBALANCE-HF Trial Roll-in Cohort. Eur J Heart Fail 2022; 24:1410-1414. [PMID: 35598154 PMCID: PMC9388552 DOI: 10.1002/ejhf.2559] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/12/2022] [Accepted: 05/15/2022] [Indexed: 11/25/2022] Open
Abstract
Aims In heart failure (HF) with preserved ejection fraction (HFpEF), excessive redistribution of blood volume into the central circulation leads to elevations of intracardiac pressures with exercise limitations. Splanchnic ablation for volume management (SAVM) has been proposed as a therapeutic intervention. Here we present preliminary safety and efficacy data from the initial roll‐in cohort of the REBALANCE‐HF trial. Methods and results The open‐label (roll‐in) arm of REBALANCE‐HF will enrol up to 30 patients, followed by the randomized, sham‐controlled portion of the trial (up to 80 additional patients). Patients with HF, left ventricular ejection fraction (LVEF) ≥50%, and invasive peak exercise pulmonary capillary wedge pressure (PCWP) ≥25 mmHg underwent SAVM. Baseline and follow‐up assessments included resting and exercise PCWP, New York Heart Association (NYHA) class, Kansas City Cardiomyopathy Questionnaire (KCCQ), 6‐min walk test, and N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP). Efficacy and safety were assessed at 1 and 3 months. Here we report on the first 18 patients with HFpEF that have been enrolled into the roll‐in, open‐label arm of the study across nine centres; 14 (78%) female; 16 (89%) in NYHA class III; and median (interquartile range) age 75.2 (68.4–81) years, LVEF 61.0 (56.0–63.2)%, and average (standard deviation) 20 W exercise PCWP 36.4 (±8.6) mmHg. All 18 patients were successfully treated. Three non‐serious moderate device/procedure‐related adverse events were reported. At 1‐month, the mean PCWP at 20 W exercise decreased from 36.4 (±8.6) to 28.9 (±7.8) mmHg (p < 0.01), NYHA class improved by at least one class in 33% of patients (p = 0.02) and KCCQ score improved by 22.1 points (95% confidence interval 9.4–34.2) (p < 0.01). Conclusion The preliminary open‐label results from the multicentre REBALANCE‐HF roll‐in cohort support the safety and efficacy of SAVM in HFpEF. The findings require confirmation in the ongoing randomized, sham‐controlled portion of the trial.
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Affiliation(s)
| | - Peter S Fail
- Cardiovascular Institute of the South, Houma, LA
| | | | | | | | - Scott Hummel
- Michigan School of Medicine, University of Michigan, Ann Arbor, MI
| | | | | | - Ravi B Patel
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sumeet S Mitter
- Mount Sinai Hospital - Icahn School of Medicine at Mount Sinai, New York, NY
| | - Liviu Klein
- University of California San Francisco, San Francisco, CA
| | | | | | - Vivek Y Reddy
- Mount Sinai Hospital - Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL
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7
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Fudim M, Khan MS, Paracha AA, Sunagawa K, Burkhoff D. Targeting Preload in Heart Failure: Splanchnic Nerve Blockade and Beyond. Circ Heart Fail 2022; 15:e009340. [PMID: 35290092 PMCID: PMC8931843 DOI: 10.1161/circheartfailure.121.009340] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Preload augmentation represents a critical mechanism for the cardiovascular system to increase effective circulating blood volume to increase cardiac filling pressures and, subsequently, for the heart to increase cardiac output. The splanchnic vascular compartment is the primary source of vascular capacity and thus the primary target for preload recruitment in humans. Under normal conditions, sympathetic stimulation of these primary venous vessels promotes the shift of blood from the splanchnic to the thoracic compartment and elevates preload and cardiac output. However, in heart failure, since filling pressures may be elevated at rest due to decreased venous capacitance, incremental recruitment of preload to enhance cardiac output may exacerbate congestion and limit exercise capacity. Accordingly, recent attention has focused on therapies designed to regulate splanchnic vascular redistribution to improve cardiac filling pressures and patient-centered outcomes such as quality of life and exercise capacity in patients with heart failure. In this review, we discuss the relevance of splanchnic circulation as a venous reservoir, the contribution of stressed blood volume to heart failure pathogenesis, and the implications for pharmacological therapeutic interventions to prevent heart failure decompensation. Further, we review emerging device-based approaches for cardiac preload reduction such as partial/complete occlusion of the superior vena cava or the inferior vena cava.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (M.F., M.S.K.).,Duke Clinical Research Institute, Durham, NC (M.F.)
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC (M.F., M.S.K.)
| | | | - Kenji Sunagawa
- Circulatory System Research Foundation, Hongo, Tokyo, Japan (K.S.)
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8
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9
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Fudim M, Abraham WT, von Bardeleben RS, Lindenfeld J, Ponikowski PP, Salah HM, Khan MS, Sievert H, Stone GW, Anker SD, Butler J. Device Therapy in Chronic Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:931-956. [PMID: 34446165 PMCID: PMC9941752 DOI: 10.1016/j.jacc.2021.06.040] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022]
Abstract
The regulatory landscape for device-based heart failure (HF) therapies has seen a major shift in the last 7 years. In 2013, the U.S. Food and Drug Administration released guidance for early feasibility and first-in-human studies, thereby encouraging device innovation, and in 2016 the U.S. Congress authorized the Breakthrough Devices Program to expedite access for Americans to innovative devices indicated for diagnosis and treatment of serious illnesses, such as HF. Since December 2016, there has been an increase in the number of HF devices for which manufacturers are seeking approval through the breakthrough designation pathway. This has led to a rapid uptake in the development and evaluation of device-based HF therapies. This article reviews the current and future landscape of device therapies for chronic HF and associated comorbidities and the regulatory environment that is driving current and future innovation.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - William T. Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Ralph Stephan von Bardeleben
- Medizinische Klinik - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsmedizin Mainz, Mainz, Germany
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Piotr P. Ponikowski
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland,Department of Heart Diseases, Medical University, Wroclaw, Poland
| | - Husam M. Salah
- Department of Medicine, University of Arkansas for Medical Sciences, AR, USA
| | - Muhammad Shahzeb Khan
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Horst Sievert
- CardioVascular Center Frankfurt, Frankfurt, Germany,Anglia Ruskin University, Chelmsford, United Kingdom
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, and the Cardiovascular Research Foundation, New York, NY, USA
| | - Stefan D. Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA.
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10
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Fudim M, Ponikowski PP, Burkhoff D, Dunlap ME, Sobotka PA, Molinger J, Patel MR, Felker GM, Hernandez AF, Litwin SE, Borlaug BA, Bapna A, Sievert H, Reddy VY, Engelman ZJ, Shah SJ. Splanchnic nerve modulation in heart failure: mechanistic overview, initial clinical experience, and safety considerations. Eur J Heart Fail 2021; 23:1076-1084. [PMID: 33886137 PMCID: PMC8298285 DOI: 10.1002/ejhf.2196] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 12/20/2022] Open
Abstract
Volume recruitment from the splanchnic compartment is an important physiological response to stressors such as physical activity and blood loss. In the setting of heart failure (HF), excess fluid redistribution from this compartment leads to increased cardiac filling pressures with limitation in exercise capacity. Recent evidence suggests that blocking neural activity of the greater splanchnic nerve (GSN) could have significant benefits in some patients with HF by reducing cardiac filling pressures and improving exercise capacity. However, to date the long-term safety of splanchnic nerve modulation (SNM) in the setting of HF is unknown. SNM is currently used in clinical practice to alleviate some forms of chronic abdominal pain. A systematic review of the series where permanent SNM was used as a treatment for chronic abdominal pain indicates that permanent SNM is well tolerated, with side-effects limited to transient diarrhoea or abdominal colic and transient hypotension. The pathophysiological role of the GSN in volume redistribution, the encouraging findings of acute and chronic pilot SNM studies and the safety profile from permanent SNM for pain provides a strong basis for continued efforts to study this therapeutic target in HF.
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11
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Jorbenadze A, Fudim M, Mahfoud F, Adamson PB, Bekfani T, Wachter R, Sievert H, Ponikowski PP, Cleland JGF, Anker SD. Extra-cardiac targets in the management of cardiometabolic disease: Device-based therapies. ESC Heart Fail 2021; 8:3327-3338. [PMID: 34002946 PMCID: PMC8318435 DOI: 10.1002/ehf2.13361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/14/2021] [Accepted: 03/29/2021] [Indexed: 12/14/2022] Open
Abstract
Heart failure (HF) does not occur in a vacuum and is commonly defined and exacerbated by its co‐morbid conditions. Neurohormonal imbalance and systemic inflammation are some of the key pathomechanisms of HF but also commonly encountered co‐morbidities such as arterial hypertension, diabetes mellitus, cachexia, obesity and sleep‐disordered breathing. A cornerstone of HF management is neurohormonal blockade, which in HF with reduced ejection fraction has been tied to a reduction in morbidity and mortality. Pharmacological treatment effective in patients with HF with reduced ejection fraction did not show substantial effects in HF with preserved ejection fraction. Here, we review novel device‐based therapies using neuromodulation of extra‐cardiac targets to treat cardiometabolic disease.
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Affiliation(s)
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology, and Intensive Care Medicine, Saarland University, Saarbrücken, Germany
| | | | - Tarek Bekfani
- Department of Internal Medicine I, Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Magdeburg, Otto von Guericke University, Magdeburg, Germany
| | - Rolf Wachter
- Clinic and Polyclinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
| | | | | | - John G F Cleland
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Stefan D Anker
- Division of Cardiology and Metabolism - Heart Failure, Cachexia & Sarcopenia, Department of Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin-Brandenburg Centre for Regenerative Therapies (BCRT), Charité - Universitätsmedizin Berlin, Berlin, Germany
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12
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Fudim M, Neuzil P, Malek F, Engelman ZJ, Reddy VY. Greater Splanchnic Nerve Stimulation in Heart Failure With Preserved Ejection Fraction. J Am Coll Cardiol 2021; 77:1952-1953. [PMID: 33858631 DOI: 10.1016/j.jacc.2021.02.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 02/11/2021] [Accepted: 02/22/2021] [Indexed: 10/21/2022]
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13
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Fudim M, Patel MR, Boortz-Marx R, Borlaug BA, DeVore AD, Ganesh A, Green CL, Lopes RD, Mentz RJ, Patel CB, Rogers JG, Felker GM, Hernandez AF, Sunagawa K, Burkhoff D. Splanchnic Nerve Block Mediated Changes in Stressed Blood Volume in Heart Failure. JACC. HEART FAILURE 2021; 9:293-300. [PMID: 33714749 PMCID: PMC9990498 DOI: 10.1016/j.jchf.2020.12.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/30/2020] [Accepted: 12/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The authors estimated changes of stressed blood volume (SBV) induced by splanchnic nerve block (SNB) in patients with either decompensated or ambulatory heart failure with reduced ejection fraction (HFrEF). BACKGROUND The splanchnic vascular capacity is a major determinant of the SBV, which in turn determines cardiac filling pressures and may be modifiable through SNB. METHODS We analyzed data from 2 prospective, single-arm clinical studies in decompensated HFrEF (splanchnic HF-1; resting hemodynamics) and ambulatory heart failure (splanchnic HF-2; exercise hemodynamics). Patients underwent invasive hemodynamics and short-term SNB with local anesthetics. SBV was simulated using heart rate, cardiac output, central venous pressure, pulmonary capillary wedge pressure, systolic and diastolic systemic arterial and pulmonary artery pressures, and left ventricular ejection fraction. SBV is presented as ml/70 kg body weight. RESULTS Mean left ventricular ejection fraction was 21 ± 11%. In patients with decompensated HFrEF (n = 11), the mean estimated SBV was 3,073 ± 251 ml/70 kg. At 30 min post-SNB, the estimated SBV decreased by 10% to 2,754 ± 386 ml/70 kg (p = 0.003). In ambulatory HFrEF (n = 14) patients, the mean estimated SBV was 2,664 ± 488 ml/70 kg and increased to 3,243 ± 444 ml/70 kg (p < 0.001) at peak exercise. The resting estimated SBV was lower in ambulatory patients with HFrEF than in decompensated HFrEF (p = 0.019). In ambulatory patients with HFrEF, post-SNB, the resting estimated SBV decreased by 532 ± 264 ml/70 kg (p < 0.001). Post-SNB, with exercise, there was no decrease of estimated SBV out of proportion to baseline effects (p = 0.661). CONCLUSIONS The estimated SBV is higher in decompensated than in ambulatory heart failure. SNB reduced the estimated SBV in decompensated and ambulatory heart failure. The reduction in estimated SBV was maintained throughout exercise. (Splanchnic Nerve Anesthesia in Heart Failure, NCT02669407; Abdominal Nerve Blockade in Chronic Heart Failure, NCT03453151).
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Manesh R Patel
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Richard Boortz-Marx
- Division of Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | | | - Adam D DeVore
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Arun Ganesh
- Division of Pain Medicine, Department of Anesthesiology, Duke University, Durham, North Carolina, USA
| | - Cynthia L Green
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Renato D Lopes
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Joseph G Rogers
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - G Michael Felker
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adrian F Hernandez
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kenji Sunagawa
- Center for Disruptive Cardiovascular Medicine, Kyushu University, Fukuoka, Japan
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14
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Fudim M, Sobotka PA, Dunlap ME. Extracardiac Abnormalities of Preload Reserve: Mechanisms Underlying Exercise Limitation in Heart Failure with Preserved Ejection Fraction, Autonomic Dysfunction, and Liver Disease. Circ Heart Fail 2021; 14:e007308. [PMID: 33464948 DOI: 10.1161/circheartfailure.120.007308] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
While many of the cardiac limitations to exercise performance are now well-characterized, extracardiac limitations to exercise performance have been less well recognized but are nevertheless important. We propose that abnormalities of cardiac preload reserve represents an under-recognized but common cause of exercise limitations. We further propose that mechanistic links exist between conditions as seemingly disparate as heart failure with preserved ejection fraction, nonalcoholic fatty liver disease, and pelvic venous compression/obstruction syndromes (eg, May-Thurner). We conclude that extracardiac abnormalities of preload reserve serve as a major pathophysiologic mechanism underlying these and other disease states.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (M.F.). Duke Clinical Research Institute, Durham, NC (M.F.)
| | - Paul A Sobotka
- Affiliated Faculty, Department of Medicine, Division of Cardiology, The Ohio State University, Columbus (P.A.S.)
| | - Mark E Dunlap
- Heart and Vascular Center, MetroHealth Campus of Case Western Reserve University, Cleveland, OH (M.E.D.)
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15
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Soloveva A, Fedorova D, Villevalde S, Zvartau N, Mareev Y, Sitnikova M, Shlyakhto E, Fudim M. Addressing Orthostatic Hypotension in Heart Failure: Pathophysiology, Clinical Implications and Perspectives. J Cardiovasc Transl Res 2020; 13:549-569. [PMID: 32748206 DOI: 10.1007/s12265-020-10044-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 06/03/2020] [Indexed: 12/21/2022]
Abstract
Heart failure (HF)is a condition at high risk for orthostatic hypotension (OH)given the large proportion of patients at an advanced age and high burden of comorbidities contributing to OH, as well as a high prevalence of medications with neurovascular and volume modulating properties. Early identification of OH in HF seems to be crucial as OH can have an impact on patient symptoms, activity level and independence, be a marker of specific pathophysiological changes or be an indicator of need for personalized treatment. OH might contribute significantly to bad enough prognosis in HF, as, besides a risk of falls and cognitive decline, it was found to be associated with cardiovascular morbidity and mortality. In this review, we aimed to incentivize the routine use of orthostatic testing in HF, as well as stimulate future research in this field, which could lead to significant advances in the treatment and outcomes.
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Affiliation(s)
- Anzhela Soloveva
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation.
| | - Darya Fedorova
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Svetlana Villevalde
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Nadezhda Zvartau
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Yury Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russian Federation
| | - Mariya Sitnikova
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Evgeny Shlyakhto
- Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
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Soloveva A, Fudim M. A Contemporary Picture of Congestion in Heart Failure: from Dropsy Impression to Multifaceted Reality. J Cardiovasc Transl Res 2020; 13:507-508. [PMID: 32367342 DOI: 10.1007/s12265-020-10012-9] [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: 10/24/2022]
Affiliation(s)
- Anzhela Soloveva
- Division of Cardiology, Almazov National Medical Research Centre, Saint Petersburg, Russia
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27715, USA.
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