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Kodur N, Tang WHW. Myocardial Recovery and Relapse in Heart Failure With Improved Ejection Fraction. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2024; 26:139-160. [PMID: 38993352 PMCID: PMC11238717 DOI: 10.1007/s11936-024-01038-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/13/2024]
Abstract
Purpose of review The purpose of this review is to discuss myocardial recovery in heart failure with reduced ejection fraction (HFrEF) and to summarize the contemporary insights regarding heart failure with improved ejection fraction (HFimpEF). Recent findings Improvement in left ventricular ejection fraction (LVEF ≥ 40%) with improved prognosis can be achieved in one out of three (10-40%) patients with HFrEF treated with guideline-directed medical therapy. Clinical predictors include non-ischemic etiology of HFrEF, less abnormal blood or imaging biomarkers, and lack of specific pathogenic genetic variants. However, a subset of patients may ultimately relapse, suggesting that many patients are merely in remission rather than having fully recovered. Summary Patients with HFimpEF have improved prognosis but nonetheless remain at risk of relapse and long-term adverse events. Future studies will hopefully chart the natural history of HFimpEF and identify clinical predictors such as blood or novel imaging biomarkers that distinguish subgroups of patients based on differential trajectory and prognosis.
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Affiliation(s)
- Nandan Kodur
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, US
| | - W. H. Wilson Tang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, US
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, US
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Hamad EA, Byku M, Larson SB, Billia F. LVAD therapy as a catalyst to heart failure remission and myocardial recovery. Clin Cardiol 2023; 46:1154-1162. [PMID: 37526373 PMCID: PMC10577530 DOI: 10.1002/clc.24094] [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: 04/14/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023] Open
Abstract
The management of chronic heart failure over the past decade has witnessed tremendous strides in medical optimization and device therapy including the use of left ventricular assist devices (LVAD). What we once thought of as irreversible damage to the myocardium is now demonstrating signs of reverse remodeling and recovery. Myocardial recovery on the structural, molecular, and hemodynamic level is necessary for sufficient recovery to withstand explant and achieve sustained recovery post-LVAD. Guideline-directed medical therapy and unloading have been shown to aid in recovery with the potential to successfully explant the LVAD. This review will summarize medical optimization, assessment for recovery, explant methodologies and outcomes post-recovery with explant of durable LVAD.
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Affiliation(s)
- Eman A. Hamad
- Lewis Katz School of MedicineTemple UniversityPhiladelphiaPennsylvaniaUSA
| | - Mirnela Byku
- Department of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Sharon B. Larson
- Baptist Heart Institute at Baptist Memorial HospitalMemphisTennesseeUSA
| | - Filio Billia
- Peter Munk Cardiac CenterUniversity Health NetworkTorontoOntarioCanada
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Boss LA, Lovell NH, Stevens MC. Evaluating Indices for Non-invasive Myocardial Recovery Assessment in LVAD-Supported Heart Failure Patients. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38082936 DOI: 10.1109/embc40787.2023.10339995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Accurate assessment of myocardial recovery (MR) under left ventricular assist device (LVAD) support is essential for clinicians to manage heart failure patients. However, current techniques for assessing MR are time-consuming, invasive, and infrequent. Measuring MR using indices derived from LVAD operating data instead provides a potential real-time alternative. Several of these indices for assessing the MR of LVAD-supported heart failure patients were collated from the literature and subject to a comprehensive comparative analysis. The objective of this analysis was to determine the most accurate index for assessing systolic cardiac function under LVAD-support, characterized by maximal end-systolic elastance (Emax), while remaining insensitive to preload & afterload. The indices were compared in computational simulation, utilizing an LVAD + cardiovascular system model to sweep through a large array of Emax and resistance conditions. Results demonstrated the index that correlated best with Emax, showing the highest accuracy, was the ratio between maximum flow acceleration and flow pulsatility (average R2 =0.9790). The same index also exhibited the lowest % variation (sensitivity) to preload & afterload (1.32% & 13.53% respectively). However, opportunities for improvement remain among current recovery assessment indices, with this study providing a baseline of performance for potential future indices to improve upon.Clinical relevance- This study presents a potential real-time measure of native cardiac function in LVAD-supported heart failure patients to support patient management and further recovery.
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Ruge M, Marek-Iannucci S, Massey HT, Ruggiero NJ, Lawrence J, Mehrotra P, Rame JE, Alvarez R, Rajapreyar I, Brailovsky Y. Percutaneous Decommissioning 11 Years After Initial CF-LVAD Placement. JACC: CASE REPORTS 2022; 4:101682. [PMID: 36438893 PMCID: PMC9685357 DOI: 10.1016/j.jaccas.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/27/2022] [Accepted: 10/14/2022] [Indexed: 11/24/2022]
Abstract
An 80-year-old man with severe nonischemic cardiomyopathy status post left ventricular assist device (LVAD) placement 11 years prior presented for recurrent LVAD alarms from internal driveline fracture. Given his partial myocardial recovery and his preference to avoid surgical procedures, percutaneous LVAD decommissioning was performed by occlusion of the outflow graft and subsequently driveline removal. (Level of Difficulty: Advanced.)
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Tseliou E, Lavine KJ, Wever-Pinzon O, Topkara VK, Meyns B, Adachi I, Zimpfer D, Birks EJ, Burkhoff D, Drakos SG. Biology of myocardial recovery in advanced heart failure with long-term mechanical support. J Heart Lung Transplant 2022; 41:1309-1323. [PMID: 35965183 DOI: 10.1016/j.healun.2022.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022] Open
Abstract
Cardiac remodeling is an adaptive, compensatory biological process following an initial insult to the myocardium that gradually becomes maladaptive and causes clinical deterioration and chronic heart failure (HF). This biological process involves several pathophysiological adaptations at the genetic, molecular, cellular, and tissue levels. A growing body of clinical and translational investigations demonstrated that cardiac remodeling and chronic HF does not invariably result in a static, end-stage phenotype but can be at least partially reversed. One of the paradigms which shed some additional light on the breadth and limits of myocardial elasticity and plasticity is long term mechanical circulatory support (MCS) in advanced HF pediatric and adult patients. MCS by providing (a) ventricular mechanical unloading and (b) effective hemodynamic support to the periphery results in functional, structural, cellular and molecular changes, known as cardiac reverse remodeling. Herein, we analyze and synthesize the advances in our understanding of the biology of MCS-mediated reverse remodeling and myocardial recovery. The MCS investigational setting offers access to human tissue, providing an unparalleled opportunity in cardiovascular medicine to perform in-depth characterizations of myocardial biology and the associated molecular, cellular, and structural recovery signatures. These human tissue findings have triggered and effectively fueled a "bedside to bench and back" approach through a variety of knockout, inhibition or overexpression mechanistic investigations in vitro and in vivo using small animal models. These follow-up translational and basic science studies leveraging human tissue findings have unveiled mechanistic myocardial recovery pathways which are currently undergoing further testing for potential therapeutic drug development. Essentially, the field is advancing by extending the lessons learned from the MCS cardiac recovery investigational setting to develop therapies applicable to the greater, not end-stage, HF population. This review article focuses on the biological aspects of the MCS-mediated myocardial recovery and together with its companion review article, focused on the clinical aspects, they aim to provide a useful framework for clinicians and investigators.
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Affiliation(s)
- Eleni Tseliou
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Kory J Lavine
- Division of Cardiology, Washington University School of Medicine, St Louis, MO
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Bart Meyns
- Department of Cardiology and Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Iki Adachi
- Division of Cardiac Surgery, Texas Children's Hospital, Houston, TX
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Daniel Burkhoff
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY; Cardiovascular Research Foundation (CRF), New York, NY
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT.
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LVAD as a Bridge to Remission from Advanced Heart Failure: Current Data and Opportunities for Improvement. J Clin Med 2022; 11:jcm11123542. [PMID: 35743611 PMCID: PMC9225013 DOI: 10.3390/jcm11123542] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/16/2022] [Accepted: 06/16/2022] [Indexed: 02/04/2023] Open
Abstract
Left ventricular assist devices (LVADs) are an established treatment modality for advanced heart failure (HF). It has been shown that through volume and pressure unloading they can lead to significant functional and structural cardiac improvement, allowing LVAD support withdrawal in a subset of patients. In the first part of this review, we discuss the historical background, current evidence on the incidence and assessment of LVAD-mediated cardiac recovery, and out-comes including quality of life after LVAD support withdrawal. In the second part, we discuss current and future opportunities to promote LVAD-mediated reverse remodeling and improve our pathophysiological understanding of HF and recovery for the benefit of the greater HF population.
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A Mechanistic Lumped Parameter Model of the Berlin Heart EXCOR to Analyze Device Performance and Physiologic Interactions. Cardiovasc Eng Technol 2022; 13:603-623. [PMID: 34997556 DOI: 10.1007/s13239-021-00603-1] [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: 04/20/2021] [Accepted: 12/09/2021] [Indexed: 11/02/2022]
Abstract
PURPOSE The Berlin Heart EXCOR (BH) is the only FDA-approved, extracorporeal pulsatile ventricular assist device (VAD) for infants and children with heart failure. Clinicians control four settings on the device-systolic and diastolic drive pressures, device pump rate, and systolic time as a percentage of the pump cycle. However, interactions between BH pneumatics and the native circulation remain poorly understood. Thus, establishing appropriate device size and settings can be challenging on a patient-to-patient basis. METHODS In this study we develop a novel lumped parameter network based on simplified device mechanics. We perform parametric studies to characterize device behavior, study interactions between the left ventricle (LV) and BH across different device settings, and develop patient-specific simulations. We then simulate the impact of changing device parameters for each of three patients. RESULTS Increasing systolic pressure and systolic time increased device output. We identified previously unobserved cycle-to-cycle variations in LV-BH interactions that may impact patient health. Patient-specific simulations demonstrated the model's ability to replicate BH performance, captured trends in LV behavior after device implantation, and emphasized the importance of device rate and volume in optimizing BH efficiency. CONCLUSION We present a novel, mechanistic model that can be readily adjusted to study a wide range of device settings and clinical scenarios. Physiologic interactions between the BH and the native LV produced large variability in cardiac loading. Our findings showed that operating the BH at a device rate greater than the patient's native heart decreases variability in physiological interactions between the BH and LV, increasing cardiac offloading while maintaining cardiac output. Device rates that are close to the resting heart rate may result in unfavorable cardiac loading conditions. Our work demonstrates the utility of our model to investigate BH performance for patient-specific physiologies.
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8
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Cheng CJ, Mandour A, Yoshida T, Watari T, Tanaka R, Matsuura K. Changes in renin-angiotensin-aldosterone system during cardiac remodeling after mitral valvuloplasty in dogs. J Vet Intern Med 2022; 36:397-405. [PMID: 34994485 PMCID: PMC8965262 DOI: 10.1111/jvim.16346] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 12/07/2021] [Accepted: 12/13/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Information regarding changes in renin-angiotensin-aldosterone system (RAAS) during cardiac remodeling after mitral valvuloplasty (MVP) in dogs remains lacking. HYPOTHESIS/OBJECTIVES To assess the longitudinal effects of MVP on circulating RAAS activity. ANIMALS Eight client-owned dogs receiving MVP for myxomatous mitral valve disease (MMVD). METHODS This is a cohort study. Plasma renin activity (PRA), angiotensin II (AT2), aldosterone (PAC), blood urea nitrogen (BUN), and creatinine concentrations, were measured in these dogs before (baseline) and at 3 consecutive monthly follow-ups (Post-1M, Post-2M, Post-3M). Echocardiography was concomitantly used to assess the process of cardiac recovery after MVP. RESULTS The echocardiography revealed a significant decrease in LVIDDN, LA/Ao, FS, E velocity, E/A, E' sep, S' lat, E' lat, and A' lat after MVP compared with baseline (P < .05). There was a significant reduction in the PRA (2.45, 3.05, 2.74 vs 8.8 ng/mL/h; P = .002), AT2 (466, 315, 235 vs 1200 pg/mL; P = .009), and PAC (39.88, 47, 54.62 vs 179.5 pg/mL; P = .01), respectively at Post-1M, Post-2M, Post-3M compared to the baseline. Additionally, BUN and creatinine concentrations decreased from Post-1M. The RAAS variables showed significant, weak to moderate, relationship with selected echocardiographic variables. CONCLUSIONS AND CLINICAL IMPORTANCE Mitral valvuloplasty contributes to decreased RAAS activity in MMVD dogs, which paralleled the process of cardiac reverse remodeling up to Post-3M. This information facilitates formulating strategies to optimize clinical outcomes for dogs after MVP.
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Affiliation(s)
- Chieh-Jen Cheng
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, Fujisawa, Kanagawa, Japan.,Laboratory of Veterinary Surgery, Tokyo University of Agriculture and Technology, Fuchu, Tokyo, Japan.,VCA Japan Shiraishi Animal Hospital, Sayama, Saitama, Japan
| | - Ahmed Mandour
- Laboratory of Veterinary Surgery, Tokyo University of Agriculture and Technology, Fuchu, Tokyo, Japan.,Department of Animal Medicine (Internal Medicine), Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt
| | - Tomohiko Yoshida
- Laboratory of Veterinary Surgery, Tokyo University of Agriculture and Technology, Fuchu, Tokyo, Japan.,VCA Japan Shiraishi Animal Hospital, Sayama, Saitama, Japan
| | - Toshihiro Watari
- Laboratory of Veterinary Internal Medicine, Department of Veterinary Medicine, College of Bioresource Sciences, Nihon University, Fujisawa, Kanagawa, Japan
| | - Ryou Tanaka
- Laboratory of Veterinary Surgery, Tokyo University of Agriculture and Technology, Fuchu, Tokyo, Japan
| | - Katsuhiro Matsuura
- Laboratory of Veterinary Surgery, Tokyo University of Agriculture and Technology, Fuchu, Tokyo, Japan.,VCA Japan Shiraishi Animal Hospital, Sayama, Saitama, Japan
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Izumida T, Imamura T, Ueno Y, Tanaka S, Kataoka N, Nakamura M, Kinugawa K. Impact of optimal heart rate on left ventricular reverse remodeling and functional improvement in patients with systolic heart failure. Heart Vessels 2021; 36:1688-1693. [PMID: 33956182 DOI: 10.1007/s00380-021-01864-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/30/2021] [Indexed: 11/25/2022]
Abstract
Heart rate modulation therapy using ivabradine reduces mortality and morbidity in patients with systolic heart failure, whereas too reduced heart rate seems to worsen the clinical outcome. The optimal heart rate during heart rate modulation therapy remains unknown. Consecutive patients with left ventricular ejection fraction < 50% who received echocardiographic assessments and simultaneous heart rate measurements were retrospectively investigated. Theoretically ideal heart rate was calculated using a previously proposed formula: 93 - 0.13 × (deceleration time [msec]). Impacts of heart rate on the 1-year echocardiographic left ventricular reverse remodeling were compared among the three groups stratified by the heart rate status: optimal heart rate group (within 10 bpm of ideal heart rate), below-optimal heart rate group (< 10 bpm of ideal heart rate), and above-optimal heart rate group (> 10 bpm of ideal heart rate). A total of 75 patients (70 years old, 60 men) were included. There were no significant differences in the baseline characteristics among the three groups, except for the higher prevalence of tolvaptan use and higher plasma B-type natriuretic peptide level in the below-optimal heart rate group. Left ventricular end-diastolic diameter (from 55 to 54) and left ventricular ejection fraction (from 39 to 46) improved significantly only in the optimal heart rate group at 1-year follow-up (p < 0.05 for both). Optimal heart rate, which was calculated using a formula consisting of deceleration time, was associated with cardiac reverse remodeling in patients with systolic heart failure. Prospective study to investigate the implication of deceleration time-guided aggressive heart rate optimization is the next concern.
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Affiliation(s)
- Toshihide Izumida
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani Toyama, Toyama, 930-0194, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani Toyama, Toyama, 930-0194, Japan.
| | - Yohei Ueno
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani Toyama, Toyama, 930-0194, Japan
| | - Shuhei Tanaka
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani Toyama, Toyama, 930-0194, Japan
| | - Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani Toyama, Toyama, 930-0194, Japan
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani Toyama, Toyama, 930-0194, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani Toyama, Toyama, 930-0194, Japan
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Ventricular assist device-promoted recovery and technical aspects of explant. JTCVS Tech 2021; 7:182-188. [PMID: 34318239 PMCID: PMC8311694 DOI: 10.1016/j.xjtc.2021.02.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 02/11/2021] [Indexed: 01/09/2023] Open
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Dandel M, Javier MFDM, Javier Delmo EM, Loebe M, Hetzer R. Weaning from ventricular assist device support after recovery from left ventricular failure with or without secondary right ventricular failure. Cardiovasc Diagn Ther 2021; 11:226-242. [PMID: 33708495 DOI: 10.21037/cdt-20-288] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although complete myocardial recovery after ventricular assist device (VAD) implantation is rather seldom, systematic search for recovery is worthwhile because for recovered patients weaning from VADs is feasible and can provide survival benefits with long-term freedom from heart failure (HF) recurrence, even if a chronic cardiomyopathy was the primary cause for the drug-refractory HF necessitating left ventricular (LVAD) or biventricular support (as bridge-to-transplantation or definitive therapy) and even if recovery remains incomplete. LVAD patients explanted for myoacardial recovery compared to those transplanted from LVAD support showed similar survival rates and a significant proportion of explanted patients can achieve cardiac and physical functional capacities that are within the normal range of healthy controls. In apparently sufficiently recovered patients, a major challenge remains still the pre-explant prediction of the weaning success which is meanwhile reliably possible for experienced clinicians. In weaning candidates, the combined use of certain echocardiography and right heart catheterization parameters recorded before VAD explantation can predict post-weaning cardiac stability with good accuracy. However, in the absence of standardization or binding recommendations, the protocols for assessment of native cardiac improvement and also the weaning criteria differ widely among centers. Currently there are still only few larger studies on myocardial recovery assessment after VAD implantation. Therefore, the weaning practice relies mostly on small case series, local practice patterns, and case reports, and the existing knowledge, as well as the partially differing recommendations which are based mainly on expert opinions, need to be periodically systematised. Addressing these shortcomings, our review aims to summarize the evidence and expert opinion on the evaluation of cardiac recovery during mechanical ventricular support by paying special attention to the reliability of the methods and parameters used for assessment of myocardial recovery and the challenges met in both evaluation of recovery and weaning decision making.
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Affiliation(s)
- Michael Dandel
- Department of Cardiology, Cardio Centrum Berlin, Berlin, Germany
| | | | | | - Matthias Loebe
- Thoracic Transplant and Mechanical Support, Miami Transplant Institute, Memorial Jackson Health System, University of Miami, Miami, Florida, USA
| | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
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Szlapka M, Hetzer R, Ennker J, Hausmann H. Conventional cardiac surgery in patients with end-stage coronary artery disease: yesterday and today. Cardiovasc Diagn Ther 2021; 11:202-212. [PMID: 33708493 PMCID: PMC7944224 DOI: 10.21037/cdt-20-284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 04/22/2020] [Indexed: 12/28/2022]
Abstract
Surgical therapy of combined coronary artery disease (CAD) and heart failure, also referred to as end-stage CAD, has evolved throughout the years and patients are currently being offered traditional coronary artery bypass grafting (CABG), with or without surgical ventricle restoration (SVR), interventions for ischemic mitral valve regurgitation, heart transplantation or implantation of mechanical cardiovascular support systems. Among surgical methods, operative myocardial revascularization (with or without ventricle restoration) is still playing an important role, aiming at restoration of proper myocardial perfusion, especially if heart muscle viability is present. Facing the donor shortage, CABG may constitute a valuable alternative to transplantation in selected patients. In individuals considered not suitable for surgical revascularization, implantation of mechanical circulatory support (MCS) not only appears as a salvage procedure, but also allows for reevaluation of future therapy directions. This article aims at providing an overview of evolving and current surgical practices in patients with end-stage CAD.
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Affiliation(s)
- Michal Szlapka
- Department of Cardiac and Vascular Surgery, MediClin Heart Center Coswig, Coswig, Germany
| | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Immanuel Cardio Centrum Berlin, Berlin, Germany
| | - Jürgen Ennker
- Department of Cardiac and Vascular Surgery, Heart Center Niederrhein, Krefeld, Germany
| | - Harald Hausmann
- Department of Cardiac and Vascular Surgery, MediClin Heart Center Coswig, Coswig, Germany
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Ventricular systolic dysfunction with and without altered myocardial contractility: Clinical value of echocardiography for diagnosis and therapeutic decision-making. Int J Cardiol 2020; 327:236-250. [PMID: 33285193 DOI: 10.1016/j.ijcard.2020.11.068] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 02/06/2023]
Abstract
The inability of one of the two or both ventricles to contract normally and expel sufficient blood to meet the functional demands of the body results from a complex interplay between intrinsic abnormalities and extracardiac factors that limit ventricular pump function and is a major cause for heart failure (HF). Even if impaired myocardial contractile function was the primary cause for ventricular dysfunction, with the progression of systolic dysfunction, additionally developed diastolic dysfunction can also contribute to the severity of HF. Although at the first sight, the diagnosis of systolic HF appears quite easy because it is usually defined by reduction of the ejection fraction (EF), in reality this issue is far more complex because ventricular pumping performance depends not only on myocardial contractility, but also largely on loading conditions (preload and afterload), being also influenced by valvular function, ventricular interdependence, pericardial constraint, synchrony of ventricular contrac-tion and heart rhythm. Conventional echocardiography (ECHO) combined with new imaging techniques such as tissue Doppler and tissue tracking can detect early subclinical alteration of ventricular systolic function. However, no single ECHO parameter reveals alone the whole picture of systolic dysfunction. Multiparametric ECHO evaluation and the use of integrative approaches using ECHO-parameter combinations which include also the ventricular loading conditions appeared particularly useful especially for differentiation between primary (myocardial damage-induced) and secondary (hemodynamic overload-induced) systolic dysfunction. This review summarizes the available evidence on the usefulness and limitations of comprehensive evaluation of LV and RV systolic function by using all the currently available ECHO techniques.
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14
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Ge Z, Li A, McNamara J, Dos Remedios C, Lal S. Pathogenesis and pathophysiology of heart failure with reduced ejection fraction: translation to human studies. Heart Fail Rev 2020; 24:743-758. [PMID: 31209771 DOI: 10.1007/s10741-019-09806-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Heart failure represents the end result of different pathophysiologic processes, which culminate in functional impairment. Regardless of its aetiology, the presentation of heart failure usually involves symptoms of pump failure and congestion, which forms the basis for clinical diagnosis. Pathophysiologic descriptions of heart failure with reduced ejection fraction (HFrEF) are being established. Most commonly, HFrEF is centred on a reactive model where a significant initial insult leads to reduced cardiac output, further triggering a cascade of maladaptive processes. Predisposing factors include myocardial injury of any cause, chronically abnormal loading due to hypertension, valvular disease, or tachyarrhythmias. The pathophysiologic processes behind remodelling in heart failure are complex and reflect systemic neurohormonal activation, peripheral vascular effects and localised changes affecting the cardiac substrate. These abnormalities have been the subject of intense research. Much of the translational successes in HFrEF have come from targeting neurohormonal responses to reduced cardiac output, with blockade of the renin-angiotensin-aldosterone system (RAAS) and beta-adrenergic blockade being particularly fruitful. However, mortality and morbidity associated with heart failure remains high. Although systemic neurohormonal blockade slows disease progression, localised ventricular remodelling still adversely affects contractile function. Novel therapy targeted at improving cardiac contractile mechanics in HFrEF hold the promise of alleviating heart failure at its source, yet so far none has found success. Nevertheless, there are increasing calls for a proximal, 'cardiocentric' approach to therapy. In this review, we examine HFrEF therapy aimed at improving cardiac function with a focus on recent trials and emerging targets.
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Affiliation(s)
- Zijun Ge
- Sydney Medical School, University of Sydney, Camperdown, Australia
- Bosch Institute, School of Medical Sciences, University of Sydney, Camperdown, Australia
| | - Amy Li
- Bosch Institute, School of Medical Sciences, University of Sydney, Camperdown, Australia
- Department of Pharmacy and Biomedical Science, La Trobe University, Melbourne, Australia
| | - James McNamara
- Bosch Institute, School of Medical Sciences, University of Sydney, Camperdown, Australia
| | - Cris Dos Remedios
- Bosch Institute, School of Medical Sciences, University of Sydney, Camperdown, Australia
| | - Sean Lal
- Sydney Medical School, University of Sydney, Camperdown, Australia.
- Bosch Institute, School of Medical Sciences, University of Sydney, Camperdown, Australia.
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia.
- Cardiac Research Laboratory, Discipline of Anatomy and Histology, University of Sydney, Anderson Stuart Building (F13), Camperdown, NSW, 2006, Australia.
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15
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Granegger M, Choi Y, Locher B, Aigner P, Hubmann EJ, Lemme F, Cesarovic N, Hübler M, Schweiger M. Comparative analysis of cardiac mechano-energetics in isolated hearts supported by pulsatile or rotary blood pumps. Sci Rep 2019; 9:20058. [PMID: 31882656 PMCID: PMC6934785 DOI: 10.1038/s41598-019-56344-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 12/10/2019] [Indexed: 12/02/2022] Open
Abstract
The previously more frequently implanted pulsatile blood pumps (PBPs) showed higher recovery rates than the currently preferred rotary blood pumps (RBPs), with unclear causality. The aim of this study was to comparatively assess the capability of PBPs and RPBs to unload the left ventricle and maintain cardiac energetics as a possible implication for recovery. An RBP and a heartbeat synchronized PBP were alternately connected to isolated porcine hearts. Rotational speed of RBPs was set to different support levels. For PBP support, the start of ejection was phased to different points during the cardiac cycle, prescribed as percentage delays from 0% to 90%. Cardiac efficiency, quantified by the ratio of external work over myocardial oxygen consumption, was determined. For RBP support, higher degrees of RBP support correlated with lower left atrial pressures (LAP) and lower cardiac efficiency (r = 0.91 ± 0.12). In contrast, depending on the phase delay of a PBP, LAP and cardiac efficiency exhibited a sinusoidal relationship with the LAP minimum at 90% and efficiency maximum at 60%. Phasing of a PBP offers the possibility to maintain a high cardiac efficiency and simultaneously unload the ventricle. These results warrant future studies investigating whether optimized cardiac energetics promotes functional recovery with LVAD therapy.
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Affiliation(s)
- Marcus Granegger
- Pediatric Cardiovascular Surgery, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland. .,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland. .,Biofluid Mechanics Laboratory, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Young Choi
- Pediatric Cardiovascular Surgery, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Benedikt Locher
- Pediatric Cardiovascular Surgery, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Philipp Aigner
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria
| | - Emanuel J Hubmann
- Pediatric Cardiovascular Surgery, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Frithjof Lemme
- Pediatric Cardiovascular Surgery, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Nikola Cesarovic
- Division of Surgical Research, Department of Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael Hübler
- Pediatric Cardiovascular Surgery, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Schweiger
- Pediatric Cardiovascular Surgery, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
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16
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Belletti A, Landoni G, Lomivorotov VV, Oriani A, Ajello S. Adrenergic Downregulation in Critical Care: Molecular Mechanisms and Therapeutic Evidence. J Cardiothorac Vasc Anesth 2019; 34:1023-1041. [PMID: 31839459 DOI: 10.1053/j.jvca.2019.10.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/09/2019] [Accepted: 10/10/2019] [Indexed: 02/08/2023]
Abstract
Catecholamines remain the mainstay of therapy for acute cardiovascular dysfunction. However, adrenergic receptors quickly undergo desensitization and downregulation after prolonged stimulation. Moreover, prolonged exposure to high circulating catecholamines levels is associated with several adverse effects on different organ systems. Unfortunately, in critically ill patients, adrenergic downregulation translates into progressive reduction of cardiovascular response to exogenous catecholamine administration, leading to refractory shock. Accordingly, there has been a growing interest in recent years toward use of noncatecholaminergic inotropes and vasopressors. Several studies investigating a wide variety of catecholamine-sparing strategies (eg, levosimendan, vasopressin, β-blockers, steroids, and use of mechanical circulatory support) have been published recently. Use of these agents was associated with improvement in hemodynamics and decreased catecholamine use but without a clear beneficial effect on major clinical outcomes. Accordingly, additional research is needed to define the optimal management of catecholamine-resistant shock.
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Affiliation(s)
- Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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17
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See Hoe LE, Bartnikowski N, Wells MA, Suen JY, Fraser JF. Hurdles to Cardioprotection in the Critically Ill. Int J Mol Sci 2019; 20:E3823. [PMID: 31387264 PMCID: PMC6695809 DOI: 10.3390/ijms20153823] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 07/26/2019] [Accepted: 08/03/2019] [Indexed: 02/07/2023] Open
Abstract
Cardiovascular disease is the largest contributor to worldwide mortality, and the deleterious impact of heart failure (HF) is projected to grow exponentially in the future. As heart transplantation (HTx) is the only effective treatment for end-stage HF, development of mechanical circulatory support (MCS) technology has unveiled additional therapeutic options for refractory cardiac disease. Unfortunately, despite both MCS and HTx being quintessential treatments for significant cardiac impairment, associated morbidity and mortality remain high. MCS technology continues to evolve, but is associated with numerous disturbances to cardiac function (e.g., oxidative damage, arrhythmias). Following MCS intervention, HTx is frequently the destination option for survival of critically ill cardiac patients. While effective, donor hearts are scarce, thus limiting HTx to few qualifying patients, and HTx remains correlated with substantial post-HTx complications. While MCS and HTx are vital to survival of critically ill cardiac patients, cardioprotective strategies to improve outcomes from these treatments are highly desirable. Accordingly, this review summarizes the current status of MCS and HTx in the clinic, and the associated cardiac complications inherent to these treatments. Furthermore, we detail current research being undertaken to improve cardiac outcomes following MCS/HTx, and important considerations for reducing the significant morbidity and mortality associated with these necessary treatment strategies.
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Affiliation(s)
- Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia.
- Faculty of Medicine, University of Queensland, Chermside 4032, Australia.
| | - Nicole Bartnikowski
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- Science and Engineering Faculty, Queensland University of Technology, Chermside 4032, Australia
| | - Matthew A Wells
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- School of Medical Science, Griffith University, Southport 4222, Australia
| | - Jacky Y Suen
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- Faculty of Medicine, University of Queensland, Chermside 4032, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Chermside 4032, Australia
- Faculty of Medicine, University of Queensland, Chermside 4032, Australia
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