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Yuecel G, Gaasch L, Kodeih A, Hetjens S, Yazdani B, Pfleger S, Duerschmied D, Abraham WT, Akin I, Kuschyk J. Device-therapy in chronic heart failure: Cardiac contractility modulation versus cardiac resynchronization therapy. ESC Heart Fail 2024. [PMID: 39344273 DOI: 10.1002/ehf2.15067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 05/26/2024] [Accepted: 08/21/2024] [Indexed: 10/01/2024] Open
Abstract
AIMS Cardiac implantable electrical devices such as cardiac resynchronization therapy with defibrillator (CRT-Ds) or cardiac contractility modulation (CCMs) are therapy options for patients with symptomatic heart failure (HF) and reduced left ventricular ejection fraction (LVEF) despite optimal medical treatment. As yet, a comparison between both devices has not been performed. METHODS AND RESULTS The Mannheim Cardiac Resynchronization Therapy Registry (MARACANA) and the Mannheim Cardiac Contractility Modulation Observational Study (MAINTAINED) included all patients who received CRTs or CCMs in our medical centre between 2012 and 2021. For the present analysis, we retrospectively compared patients provided with either CRT-Ds (n = 220) or CCMs with additional defibrillators (n = 105) regarding New York Heart Association classification (NYHA), LVEF, tricuspid annular plane systolic excursion (TAPSE), QRS-width and other HF modification aspects after 12 months. Before implantation, CCM patients presented with lower LVEF (23.6 ± 6.2 vs. 26.3 ± 6.5%) and worse NYHA (3.03 ± 0.47 vs. 2.81 ± 0.48, both P < 0.05), compared with CRT-D patients. Follow-up improvements in NYHA (2.43 ± 0.67 vs. 2.28 ± 0.72), LVEF (30.5 ± 10.7 vs. 35.2 ± 10.5%) and TAPSE (17.2 ± 5.2 vs. 17.1 ± 4.8 to 18.9 ± 3.4 vs. 17.3 ± 3.6 mm, each P < 0.05) were comparable. The intrinsic QRS-width was stable with CCM (109.1 ± 18 vs. 111.7 ± 19.7 ms, P > 0.05), while the paced QRS-width with CRT-D after 12 months was lower than intrinsic values at baseline (157.5 ± 16.5 vs. 139.2 ± 16 ms, P < 0.05). HF hospitalizations occurred more often for CCM than CRT-D patients (45.7 vs. 16.8%/patient years, odds ratio 4.2, P < 0.001). CONCLUSIONS Chronic heart failure patients could experience comparable 12-month improvements in functional status and ventricular reverse remodelling, with appropriately implanted CCMs and CRT-Ds. Differences in HF hospitalization rates may be due to the more advanced HF of CCM patients at implantation.
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Affiliation(s)
- Goekhan Yuecel
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Leo Gaasch
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Abbass Kodeih
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Babak Yazdani
- Fifth Department of Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Stefan Pfleger
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Juergen Kuschyk
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
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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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Estep JD, Salah HM, Kapadia SR, Burkhoff D, Lala A, Butler J, Hall S, Fudim M. HFSA Scientific Statement: Update on Device Based Therapies in Heart Failure. J Card Fail 2024:S1071-9164(24)00258-6. [PMID: 39261158 DOI: 10.1016/j.cardfail.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/16/2024] [Accepted: 07/16/2024] [Indexed: 09/13/2024]
Abstract
Heart failure (HF) is 1 of the major challenges of our time, given its increase in prevalence and related mortality rates. Foundational pharmacological therapies, including angiotensin receptor neprilysin inhibitors (ARNIs), beta-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium-glucose co-transporter inhibitors (SGLTis), have been established for HF with reduced ejection fraction (HFrEF). Moreover, recent trials have established the role of SGLTis in patients with HF with preserved ejection fraction (HFpEF). However, even with these therapies, a substantial residual risk persists in both HFrEF and HFpEF. Alongside pharmacological advancements, device-based therapies have shown efficacy in HF management, including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT). More recently, devices such as cardiac contractility modulation (CCM) and baroreflex activation therapy (BAT) have been approved by the FDA, although they lack comprehensive guideline recommendations. This scientific statement outlines the unmet needs in chronic HF, reviews contemporary data and provides a framework for integrating novel device-based therapies into current clinical workflows. It emphasizes the importance of early diagnosis and phenotyping, proper patient stratification and a personalized approach to combining pharmacological and device therapies. The document also highlights the need for further research into device interactions and patient selection to optimize outcomes, while recognizing the need for a more integrated approach to treatment so as to address the unmet needs and residual risks in HF management.
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Affiliation(s)
- Jerry D Estep
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Florida, Weston, FL
| | - Husam M Salah
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Anuradha Lala
- Zena and Weil Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine, New York, NY
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX; Department of Medicine, University of Mississippi School of Medicine, Jackson, MI
| | | | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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Falco L, Valente F, De Falco A, Barbato R, Marotta L, Soviero D, Cantiello LM, Contaldi C, Brescia B, Coscioni E, Pacileo G, Masarone D. Beyond Medical Therapy-An Update on Heart Failure Devices. J Cardiovasc Dev Dis 2024; 11:187. [PMID: 39057611 PMCID: PMC11277415 DOI: 10.3390/jcdd11070187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/11/2024] [Accepted: 06/19/2024] [Indexed: 07/28/2024] Open
Abstract
Heart failure (HF) is a complex and progressive disease marked by substantial morbidity and mortality rates, frequent episodes of decompensation, and a reduced quality of life (QoL), with severe financial burden on healthcare systems. In recent years, several large-scale randomized clinical trials (RCTs) have widely expanded the therapeutic armamentarium, underlining additional benefits and the feasibility of rapid titration regimens. This notwithstanding, mortality is not declining, and hospitalizations are constantly increasing. It is widely acknowledged that even with guideline-directed medical therapy (GDMT) on board, HF patients have a prohibitive residual risk, which highlights the need for innovative treatment options. In this scenario, groundbreaking devices targeting valvular, structural, and autonomic abnormalities have become crucial tools in HF management. This has led to a full-fledged translational boost with several novel devices in development. Thus, the aim of this review is to provide an update on both approved and investigated devices.
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Affiliation(s)
- Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
| | - Fabio Valente
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
| | - Aldo De Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
| | - Raffaele Barbato
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
| | - Luigi Marotta
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
| | - Davide Soviero
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
| | - Luigi Mauro Cantiello
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
| | - Carla Contaldi
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
| | - Benedetta Brescia
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Enrico Coscioni
- Cardiac Surgery Division, AOU San Leonardo, 84100 Salerno, Italy;
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
| | - Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (F.V.); (A.D.F.); (R.B.); (L.M.); (D.S.); (L.M.C.); (C.C.); (G.P.)
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Feaster TK, Ewoldt JK, Avila A, Casciola M, Narkar A, Chen CS, Blinova K. Nonclinical evaluation of chronic cardiac contractility modulation on 3D human engineered cardiac tissues. J Cardiovasc Electrophysiol 2024; 35:895-905. [PMID: 38433304 DOI: 10.1111/jce.16222] [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] [Received: 12/27/2023] [Revised: 01/29/2024] [Accepted: 02/09/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Cardiac contractility modulation (CCM) is a medical device-based therapy delivering non-excitatory electrical stimulations to the heart to enhance cardiac function in heart failure (HF) patients. The lack of human in vitro tools to assess CCM hinders our understanding of CCM mechanisms of action. Here, we introduce a novel chronic (i.e., 2-day) in vitro CCM assay to evaluate the effects of CCM in a human 3D microphysiological system consisting of engineered cardiac tissues (ECTs). METHODS Cryopreserved human induced pluripotent stem cell-derived cardiomyocytes were used to generate 3D ECTs. The ECTs were cultured, incorporating human primary ventricular cardiac fibroblasts and a fibrin-based gel. Electrical stimulation was applied using two separate pulse generators for the CCM group and control group. Contractile properties and intracellular calcium were measured, and a cardiac gene quantitative PCR screen was conducted. RESULTS Chronic CCM increased contraction amplitude and duration, enhanced intracellular calcium transient amplitude, and altered gene expression related to HF (i.e., natriuretic peptide B, NPPB) and excitation-contraction coupling (i.e., sodium-calcium exchanger, SLC8). CONCLUSION These data represent the first study of chronic CCM in a 3D ECT model, providing a nonclinical tool to assess the effects of cardiac electrophysiology medical device signals complementing in vivo animal studies. The methodology established a standardized 3D ECT-based in vitro testbed for chronic CCM, allowing evaluation of physiological and molecular effects on human cardiac tissues.
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Affiliation(s)
- Tromondae K Feaster
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Jourdan K Ewoldt
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
| | - Anna Avila
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Maura Casciola
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Akshay Narkar
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Christopher S Chen
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts, USA
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts, USA
| | - Ksenia Blinova
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, Maryland, USA
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Scarà A, Palamà Z, Robles AG, Dei LL, Borrelli A, Zanin F, Pignalosa L, Romano S, Sciarra L. Non-Pharmacological Treatment of Heart Failure-From Physical Activity to Electrical Therapies: A Literature Review. J Cardiovasc Dev Dis 2024; 11:122. [PMID: 38667740 PMCID: PMC11050051 DOI: 10.3390/jcdd11040122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Heart failure (HF) represents a significant global health challenge that is still responsible for increasing morbidity and mortality despite advancements in pharmacological treatments. This review investigates the effectiveness of non-pharmacological interventions in the management of HF, examining lifestyle measures, physical activity, and the role of some electrical therapies such as catheter ablation, cardiac resynchronization therapy (CRT), and cardiac contractility modulation (CCM). Structured exercise training is a cornerstone in this field, demonstrating terrific improvements in functional status, quality of life, and mortality risk reduction, particularly in patients with HF with reduced ejection fraction (HFrEF). Catheter ablation for atrial fibrillation, premature ventricular beats, and ventricular tachycardia aids in improving left ventricular function by reducing arrhythmic burden. CRT remains a key intervention for selected HF patients, helping achieve left ventricular reverse remodeling and improving symptoms. Additionally, the emerging therapy of CCM provides a novel opportunity for patients who do not meet CRT criteria or are non-responders. Integrating non-pharmacological interventions such as digital health alongside specific medications is key for optimizing outcomes in HF management. It is imperative to tailor approaches to individual patients in this diverse patient population to maximize benefits. Further research is warranted to improve treatment strategies and enhance patient outcomes in HF management.
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Affiliation(s)
- Antonio Scarà
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Zefferino Palamà
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
- Electrophysiology Unit “Casa di Cura Villa Verde”, 74121 Taranto, Italy
| | - Antonio Gianluca Robles
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
- Electrophysiology Unit “Casa di Cura Villa Verde”, 74121 Taranto, Italy
- Department of Cardiology, “L. Bonomo” Hospital, 76123 Andria, Italy
| | - Lorenzo-Lupo Dei
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Alessio Borrelli
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Federico Zanin
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
| | - Leonardo Pignalosa
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
| | - Silvio Romano
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Luigi Sciarra
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
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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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8
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D'Amato A, Prosperi S, Severino P, Myftari V, Labbro Francia A, Cestiè C, Pierucci N, Marek-Iannucci S, Mariani MV, Germanò R, Fanisio F, Lavalle C, Maestrini V, Badagliacca R, Mancone M, Fedele F, Vizza CD. Current Approaches to Worsening Heart Failure: Pathophysiological and Molecular Insights. Int J Mol Sci 2024; 25:1574. [PMID: 38338853 PMCID: PMC10855688 DOI: 10.3390/ijms25031574] [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: 12/17/2023] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Worsening heart failure (WHF) is a severe and dynamic condition characterized by significant clinical and hemodynamic deterioration. It is characterized by worsening HF signs, symptoms and biomarkers, despite the achievement of an optimized medical therapy. It remains a significant challenge in cardiology, as it evolves into advanced and end-stage HF. The hyperactivation of the neurohormonal, adrenergic and renin-angiotensin-aldosterone system are well known pathophysiological pathways involved in HF. Several drugs have been developed to inhibit the latter, resulting in an improvement in life expectancy. Nevertheless, patients are exposed to a residual risk of adverse events, and the exploration of new molecular pathways and therapeutic targets is required. This review explores the current landscape of WHF, highlighting the complexities and factors contributing to this critical condition. Most recent medical advances have introduced cutting-edge pharmacological agents, such as guanylate cyclase stimulators and myosin activators. Regarding device-based therapies, invasive pulmonary pressure measurement and cardiac contractility modulation have emerged as promising tools to increase the quality of life and reduce hospitalizations due to HF exacerbations. Recent innovations in terms of WHF management emphasize the need for a multifaceted and patient-centric approach to address the complex HF syndrome.
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Affiliation(s)
- Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Aurora Labbro Francia
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Claudia Cestiè
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Nicola Pierucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Stefanie Marek-Iannucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Rosanna Germanò
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
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9
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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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10
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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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11
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Pierucci N, La Fazia VM, Gianni C, Mohanty S, Lavalle C, Cishek MB, Canby RC, Natale A. Cardiac contractility modulation in a patient with refractory systolic heart failure following orthotopic heart transplant. HeartRhythm Case Rep 2024; 10:33-37. [PMID: 38264106 PMCID: PMC10801070 DOI: 10.1016/j.hrcr.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Affiliation(s)
- Nicola Pierucci
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas
- Department of Clinical Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas
| | - Carlo Lavalle
- Department of Clinical Internal Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Robert C. Canby
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas
- HCA National Medical Director of Cardiac Electrophysiology, Nashville, Tennessee
- Interventional Electrophysiology, Scripps Clinic, La Jolla, California
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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12
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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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13
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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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14
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Bierhuizen MFA, Amesz JH, De Groot NMS, Taverne YJHJ. Commentary: Acute effects of cardiac contractility modulation stimulation in conventional 2D and 3D human induced pluripotent stem cell-derived cardiomyocyte models. Front Physiol 2023; 14:1130674. [PMID: 36846319 PMCID: PMC9948438 DOI: 10.3389/fphys.2023.1130674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 01/23/2023] [Indexed: 02/11/2023] Open
Affiliation(s)
- Mark F. A. Bierhuizen
- Translational Electrophysiology Lab, Lowlands Institute of Bioelectric Medicine, Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands,Translational Cardiothoracic Surgery Research Lab, Lowlands Institute of Bioelectric Medicine, Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jorik H. Amesz
- Translational Electrophysiology Lab, Lowlands Institute of Bioelectric Medicine, Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands,Translational Cardiothoracic Surgery Research Lab, Lowlands Institute of Bioelectric Medicine, Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Natasja M. S. De Groot
- Translational Electrophysiology Lab, Lowlands Institute of Bioelectric Medicine, Department of Cardiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Yannick J. H. J. Taverne
- Translational Cardiothoracic Surgery Research Lab, Lowlands Institute of Bioelectric Medicine, Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands,*Correspondence: Yannick J. H. J. Taverne,
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15
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Talha KM, Anker SD, Burkhoff D, Filippatos G, Lam CSP, Stone GW, Wazni O, Butler J. Role of Cardiac Contractility Modulation in Heart Failure With a Higher Ejection Fraction. J Card Fail 2022; 28:1717-1726. [PMID: 36122819 DOI: 10.1016/j.cardfail.2022.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/20/2022] [Accepted: 08/30/2022] [Indexed: 11/19/2022]
Abstract
Cardiac contractility modulation (also known as CCM) is a novel device therapy that delivers nonexcitatory electric stimulation to cardiac myocytes during the absolute refractory period, and it has been shown to improve functional status and clinical outcomes in patients with heart failure (HF) with reduced ejection fraction (HFrEF). CCM therapy is currently recommended for a subset of patients with advanced HFrEF who are not candidates for cardiac resynchronization therapy. A growing body of evidence demonstrates the benefit of CCM therapy in patients with HFrEF and with ejection fraction at the upper end of the spectrum and in patients with HF and with mildly reduced ejection fraction (HFmrEF). Experimental studies have also observed reversal of pathological biomolecular intracellular changes with CCM therapy in HF with preserved ejection fraction (HFpEF), indicating the potential for clinically meaningful benefits of CCM therapy in these patients. In this review, we sought to discuss the basis of CCM therapy and its potential for management of patients with HF with higher ejection fractions.
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Affiliation(s)
- Khawaja M Talha
- Department of Medicine, University of Mississippi Medical Centre, Jackson, Mississippi, USA
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany; DZHK (German Center for Cardiovascular Research) Berlin partner site, Charité Universitätsmedizin Berlin, Germany
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Oussama Wazni
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Centre, Jackson, Mississippi, USA; Baylor Heart and Vascular Institute, Baylor University Medical Centre, Dallas, Texas, USA.
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16
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Linde C, Grabowski M, Ponikowski P, Rao I, Stagg A, Tschöpe C. Cardiac contractility modulation therapy improves health status in patients with heart failure with preserved ejection fraction: a pilot study (CCM-HFpEF). Eur J Heart Fail 2022; 24:2275-2284. [PMID: 35855646 PMCID: PMC10087783 DOI: 10.1002/ejhf.2619] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS This pilot study aimed to assess the potential benefits of cardiac contractility modulation (CCM) in patients with heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS This was a prospective, multicentre, single-arm, pilot study of CCM therapy in patients with HFpEF and New York Heart Association (NYHA) class II or III. Echocardiographic parameters were measured by an echo core laboratory to determine study eligibility. After CCM device implantation, patients were followed for 24 weeks. Overall, 47 patients (mean age 74.3 ± 4.4 years, 70.2% female) were enrolled, with left ventricular ejection fraction of 59 ± 4.4%, 63.8% with hypertension, 46.8% with atrial fibrillation, 40.4% with diabetes, 31.9% with at least one heart failure hospitalization in the prior year, 61.7% in NYHA class III, and Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score of 48.9 ± 21.7. The primary efficacy endpoint (mean change in the KCCQ overall summary score) improved by 18.0 ± 16.6 points (p < 0.001) and there was an event-free rate of 93.6% for the primary safety endpoint (device- and procedure-related complications), as adjudicated by an independent physician committee. CONCLUSION This pilot study demonstrates that the benefits of CCM may extend to the HFpEF patient population. The significant improvement in health status observed, with no obvious impact on safety, suggests that utilization of CCM for patients with HFpEF could prove to be promising.
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Affiliation(s)
- Cecilia Linde
- Heart, Vascular and Neurology Theme, Karolinska University Hospital and the Karolinska Institutet, Stockholm, Sweden
| | - Marcin Grabowski
- Department of Cardiology, Medical University of Warsaw, Department of Cardiology, Warsaw, Poland
| | | | - Ishu Rao
- Department of Heart Diseases, Medical University, Wroclaw University Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Angela Stagg
- Clinical and Data Operations, Impulse Dynamics (USA), Inc, Marlton, NJ, USA
| | - Carsten Tschöpe
- Berlin Institute of Health Center for Regenerative Therapies, and Department of Cardiology, Charité University Medicine Berlin, Campus Virchow Klinikum, Berlin, Germany
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17
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Feaster TK, Feric N, Pallotta I, Narkar A, Casciola M, Graziano MP, Aschar-Sobbi R, Blinova K. Acute effects of cardiac contractility modulation stimulation in conventional 2D and 3D human induced pluripotent stem cell-derived cardiomyocyte models. Front Physiol 2022; 13:1023563. [PMID: 36439258 PMCID: PMC9686332 DOI: 10.3389/fphys.2022.1023563] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/28/2022] [Indexed: 11/11/2022] Open
Abstract
Cardiac contractility modulation (CCM) is a medical device therapy whereby non-excitatory electrical stimulations are delivered to the myocardium during the absolute refractory period to enhance cardiac function. We previously evaluated the effects of the standard CCM pulse parameters in isolated rabbit ventricular cardiomyocytes and 2D human induced pluripotent stem cell-derived cardiomyocyte (hiPSC-CM) monolayers, on flexible substrate. In the present study, we sought to extend these results to human 3D microphysiological systems to develop a robust model to evaluate various clinical CCM pulse parameters in vitro. HiPSC-CMs were studied in conventional 2D monolayer format, on stiff substrate (i.e., glass), and as 3D human engineered cardiac tissues (ECTs). Cardiac contractile properties were evaluated by video (i.e., pixel) and force-based analysis. CCM pulses were assessed at varying electrical ‘doses’ using a commercial pulse generator. A robust CCM contractile response was observed for 3D ECTs. Under comparable conditions, conventional 2D monolayer hiPSC-CMs, on stiff substrate, displayed no contractile response. 3D ECTs displayed enhanced contractile properties including increased contraction amplitude (i.e., force), and accelerated contraction and relaxation slopes under standard acute CCM stimulation. Moreover, 3D ECTs displayed enhanced contractility in a CCM pulse parameter-dependent manner by adjustment of CCM pulse delay, duration, amplitude, and number relative to baseline. The observed acute effects subsided when the CCM stimulation was stopped and gradually returned to baseline. These data represent the first study of CCM in 3D hiPSC-CM models and provide a nonclinical tool to assess various CCM device signals in 3D human cardiac tissues prior to in vivo animal studies. Moreover, this work provides a foundation to evaluate the effects of additional cardiac medical devices in 3D ECTs.
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Affiliation(s)
- Tromondae K. Feaster
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Nicole Feric
- Valo Health Inc, Alexandria Center for Life Sciences, New York, NY, United States
| | - Isabella Pallotta
- Valo Health Inc, Alexandria Center for Life Sciences, New York, NY, United States
| | - Akshay Narkar
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Maura Casciola
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, United States
| | - Michael P. Graziano
- Valo Health Inc, Alexandria Center for Life Sciences, New York, NY, United States
| | - Roozbeh Aschar-Sobbi
- Valo Health Inc, Alexandria Center for Life Sciences, New York, NY, United States
| | - Ksenia Blinova
- Office of Science and Engineering Laboratories, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD, United States
- *Correspondence: Ksenia Blinova,
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18
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Masarone D, Kittleson MM, De Vivo S, D’Onofrio A, Ammendola E, Nigro G, Contaldi C, Martucci ML, Errigo V, Pacileo G. The Effects of Device-Based Cardiac Contractility Modulation Therapy on Left Ventricle Global Longitudinal Strain and Myocardial Mechano-Energetic Efficiency in Patients with Heart Failure with Reduced Ejection Fraction. J Clin Med 2022; 11:5866. [PMID: 36233734 PMCID: PMC9573486 DOI: 10.3390/jcm11195866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Virtually all patients with heart failure with reduced ejection fraction have a reduction of myocardial mechano-energetic efficiency (MEE). Cardiac contractility modulation (CCM) is a novel therapy for the treatment of patients with HFrEF, in whom it improves the quality of life and functional capacity, reduces hospitalizations, and induces biventricular reverse remodeling. However, the effects of CCM on MEE and global longitudinal strain (GLS) are still unknown; therefore, this study aims to evaluate whether CCM therapy can improve the MEE of patients with HFrEF. METHODS We enrolled 25 patients with HFrEF who received an Optimizer Smart implant (the device that develops CCM therapy) between January 2018 and January 2021. Clinical and echocardiographic evaluations were performed in all patients 24 h before and six months after CCM therapy. RESULTS At six months, follow-up patients who underwent CCM therapy showed an increase of left ventricular ejection fraction (30.8 ± 7.1 vs. 36.1 ± 6.9%; p = 0.032) as well a rise of GLS 10.3 ± 2.7 vs. -12.9 ± 4.2; p = 0.018), of MEE (32.2 ± 10.1 vs. 38.6 ± 7.6 mL/s; p = 0.013) and of MEE index (18.4 ± 6.3 vs. 24.3 ± 6.7 mL/s/g; p = 0.022). CONCLUSIONS CCM therapy increased left ventricular performance, improving left ventricular ejection fraction, GLS, as well as MEE and MEEi.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Michelle M. Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, CA 90048, USA
| | - Stefano De Vivo
- Electrophysiology Unit, Department of Cardiology, AORN dei Colli Monaldi Hospital, 80131 Naples, Italy
| | - Antonio D’Onofrio
- Electrophysiology Unit, Department of Cardiology, AORN dei Colli Monaldi Hospital, 80131 Naples, Italy
| | - Ernesto Ammendola
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Gerardo Nigro
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Carla Contaldi
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Maria L. Martucci
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Vittoria Errigo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy
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19
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Yücel G, Fastner C, Hetjens S, Toepel M, Schmiel G, Yazdani B, Husain-Syed F, Liebe V, Rudic B, Akin I, Borggrefe M, Kuschyk J. Impact of baseline left ventricular ejection fraction on long-term outcomes in cardiac contractility modulation therapy. Pacing Clin Electrophysiol 2022; 45:639-648. [PMID: 35262210 DOI: 10.1111/pace.14478] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 01/31/2022] [Accepted: 02/20/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiac contractility modulation (CCM), being reserved for patients with symptomatic chronic heart failure (HF) and narrow QRS complex under guideline directed medical therapy, can recover initially reduced left ventricular ejection fraction (LVEF); however, the influence of pre-implantation LVEF on long-term outcomes is not fully understood. This study aimed to compare the effects of lower and higher pre-implantation LVEF on long-term outcomes in CCM-therapy. METHODS One-hundred seventy-two patients from our single-centre registry were retrospectively included (2002 - 2019). Follow-up data were collected up to five years after implantation. Patients were divided into Group 1 (baseline LVEF≤ 30%) and Group 2 (≥ 31%). Both groups were compared based on differences in survival, echocardiographic- and clinical parameters including LVEF, tricuspid annular plane systolic excursion (TAPSE), NYHA class or Minnesota living with heart failure questionnaire-score (MLWHFQ). RESULTS 11 % of the patients did have a LVEF ≥ 31%. Mean LVEF±SD for both groups were 21.98±5.4 vs. 35.2±3.7%, respectively. MLWHFQ (47±21.2 vs. 42±21.4) and mean peak oxygen consumption (VO2, 13.6±4.1 vs. 12.7±2.8 ml/kg/min) were comparable between both groups. LVEF-grouping did not influence survival. Lower baseline LVEF resulted in significantly better recovery of echocardiographic parameters such as LVEF and TAPSE. Irrespective from baseline LVEF, both groups showed nearly comparable improvements for clinical parameters like NYHA-class and MLWHFQ. CONCLUSION Long-term biventricular systolic recovery potential in CCM-therapy might be better for pre-implantation LVEF values ≤ 30%, whereas clinical parameters such as NYHA-class can improve irrespective from baseline LVEF. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Gökhan Yücel
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,Partner Site, Heidelberg-Mannheim, DZHK (German Centre for Cardiovascular Research), Mannheim, Germany
| | - Christian Fastner
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,Partner Site, Heidelberg-Mannheim, DZHK (German Centre for Cardiovascular Research), Mannheim, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Matthias Toepel
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany
| | - Gereon Schmiel
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany
| | - Babak Yazdani
- Fifth Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany
| | - Faeq Husain-Syed
- Department of Internal Medicine II, Division of Nephrology, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Giessen, Germany
| | - Volker Liebe
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,Partner Site, Heidelberg-Mannheim, DZHK (German Centre for Cardiovascular Research), Mannheim, Germany
| | - Boris Rudic
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,Partner Site, Heidelberg-Mannheim, DZHK (German Centre for Cardiovascular Research), Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,Partner Site, Heidelberg-Mannheim, DZHK (German Centre for Cardiovascular Research), Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,Partner Site, Heidelberg-Mannheim, DZHK (German Centre for Cardiovascular Research), Mannheim, Germany
| | - Jürgen Kuschyk
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM), University of Heidelberg, Mannheim, Germany.,Partner Site, Heidelberg-Mannheim, DZHK (German Centre for Cardiovascular Research), Mannheim, Germany
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20
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Masarone D, Petraio A, Fiorentino A, Dellegrottaglie S, Valente F, Ammendola E, Nigro G, Pacileo G. Use of Cardiac Contractility Modulation as Bridge to Transplant in an Obese Patient With Advanced Heart Failure: A Case Report. Front Cardiovasc Med 2022; 9:833143. [PMID: 35252403 PMCID: PMC8889036 DOI: 10.3389/fcvm.2022.833143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/25/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiac contractility modulation (CCM) is a novel device-based therapy in patients with heart failure with reduced ejection fraction (HFrEF). In randomized clinical trials and real-life studies, CCM has been shown to improve exercise tolerance and quality of life, reverse left ventricular remodeling and reduce hospitalization in patients with HFrEF. In this case report, we describe for the first time the use of CCM as a "bridge to transplant" in a young obese patient with advanced heart failure due to non-ischemic dilated cardiomyopathy. The patient had a poor quality of life and frequent heart failure-related hospitalizations despite the optimal medical therapy and, due to obesity, a suitable heart donor was unlikely to be identified in the short term and due to severe obesity risk of complications after implantation of a left ventricular assist device (LVAD) was very high.
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Affiliation(s)
- Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Andrea Petraio
- Heart Transplant Unit, Department of Cardiac Surgery and Transplants, AORN dei Colli, Monaldi Hospital, Naples, Italy
| | | | - Santo Dellegrottaglie
- Division of Cardiology, Ospedale Accreditato Villa dei Fiori, Naples, Italy
- Marie-Josee and Henry R. Kravis Center for Cardiovascular Health, Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fabio Valente
- Heart Failure Unit, Department of Cardiology, AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Ernesto Ammendola
- Heart Failure Unit, Department of Cardiology, AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Department of Medical Translational Sciences, Monaldi Hospital, University of Campania “Luigi Vanvitelli,”Naples, Italy
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli, Monaldi Hospital, Naples, Italy
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21
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Abstract
PURPOSE OF REVIEW Heart failure often progresses despite optimal medical and device therapies, and advanced mechanical circulatory support has limited availability and substantial associated morbidity. Cardiac contractility modulation (CCM) provides nonexcitatory stimulation to ventricular myocardium which increases cardiac contractility without increasing oxygen demand. This review describes the emerging role of CCM in heart failure treatment. RECENT FINDINGS The FIX-HF-5C2 study demonstrated similar safety and efficacy profile of the two-lead Optimizer device in comparison with the prior three-lead system, thereby decreasing procedural complexity and minimizing endocardial hardware. The FIX-HF-5C trial underscored the benefit of CCM in patients with mild-moderate left ventricular dysfunction (ejection fraction, 25-45%) with New York Heart Association (NYHA) Class III symptoms. The summarized randomized trial data show consistent improvements in peak VO2, 6-min walk distance, and NYHA functional class with CCM. Future trials are planned to determine the role of CCM in heart failure patients with preserved ejection fraction, obligate ventricular pacing, and atrial arrhythmias. SUMMARY Nonexcitatory extracellular electric potentials can facilitate inotropic improvements in the failing heart. The mechanism of CCM does not increase myocardial oxygen consumption and has been shown to mitigate heart failure symptoms, decrease hospitalizations, and work in synergy with guideline-directed therapy for heart failure.
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Use of Cardiac Contractility Modulation in an Older Patient with Non-Ischemic Dilated Cardiomyopathy: A Case Report. Clin Pract 2021; 11:835-840. [PMID: 34842623 PMCID: PMC8628722 DOI: 10.3390/clinpract11040098] [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: 10/12/2021] [Revised: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 11/17/2022] Open
Abstract
Cardiac contractility modulation (CCM) is a novel device-based therapy used in patients with HFrEF. CCM therapy is associated with an improvement in exercise tolerance, increased quality of life, reduced HF hospitalizations, and reverse remodelling of the left ventricle in patients with HFrEF. In this case, we report the clinical benefit of CCM in an older patient with advanced HFrEF due to ischemic dilated cardiomyopathy with frequent heart failure-related hospitalizations and poor quality of life despite optimal medical therapy.
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Feaster TK, Casciola M, Narkar A, Blinova K. Acute effects of cardiac contractility modulation on human induced pluripotent stem cell-derived cardiomyocytes. Physiol Rep 2021; 9:e15085. [PMID: 34729935 PMCID: PMC8564440 DOI: 10.14814/phy2.15085] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/04/2021] [Accepted: 10/08/2021] [Indexed: 12/20/2022] Open
Abstract
Cardiac contractility modulation (CCM) is an intracardiac therapy whereby nonexcitatory electrical simulations are delivered during the absolute refractory period of the cardiac cycle. We previously evaluated the effects of CCM in isolated adult rabbit ventricular cardiomyocytes and found a transient increase in calcium and contractility. In the present study, we sought to extend these results to human cardiomyocytes using human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) to develop a robust model to evaluate CCM in vitro. HiPSC-CMs (iCell Cardiomyocytes2 , Fujifilm Cellular Dynamic, Inc.) were studied in monolayer format plated on flexible substrate. Contractility, calcium handling, and electrophysiology were evaluated by fluorescence- and video-based analysis (CellOPTIQ, Clyde Biosciences). CCM pulses were applied using an A-M Systems 4100 pulse generator. Robust hiPSC-CMs response was observed at 14 V/cm (64 mA) for pacing and 28 V/cm (128 mA, phase amplitude) for CCM. Under these conditions, hiPSC-CMs displayed enhanced contractile properties including increased contraction amplitude and faster contraction kinetics. Likewise, calcium transient amplitude increased, and calcium kinetics were faster. Furthermore, electrophysiological properties were altered resulting in shortened action potential duration (APD). The observed effects subsided when the CCM stimulation was stopped. CCM-induced increase in hiPSC-CMs contractility was significantly more pronounced when extracellular calcium concentration was lowered from 2 mM to 0.5 mM. This study provides a comprehensive characterization of CCM effects on hiPSC-CMs. These data represent the first study of CCM in hiPSC-CMs and provide an in vitro model to assess physiologically relevant mechanisms and evaluate safety and effectiveness of future cardiac electrophysiology medical devices.
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Affiliation(s)
- Tromondae K. Feaster
- Office of Science and Engineering LaboratoriesCenter for Devices and Radiological HealthUS Food and Drug AdministrationSilver SpringMarylandUSA
| | - Maura Casciola
- Office of Science and Engineering LaboratoriesCenter for Devices and Radiological HealthUS Food and Drug AdministrationSilver SpringMarylandUSA
| | - Akshay Narkar
- Office of Science and Engineering LaboratoriesCenter for Devices and Radiological HealthUS Food and Drug AdministrationSilver SpringMarylandUSA
| | - Ksenia Blinova
- Office of Science and Engineering LaboratoriesCenter for Devices and Radiological HealthUS Food and Drug AdministrationSilver SpringMarylandUSA
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Abraham WT. Cardiac Resynchronization Therapy and Cardiac Contractility Modulation in Patients with Advanced Heart Failure: How to Select the Right Candidate? Heart Fail Clin 2021; 17:599-606. [PMID: 34511208 DOI: 10.1016/j.hfc.2021.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cardiac resynchronization therapy is a well-established treatment of heart failure with reduced left ventricular ejection fraction and a wide QRS complex. Cardiac contractility modulation therapy is an emerging electrical treatment indicated for use in patients with symptomatic heart failure caused by moderate-to-severe systolic left ventricular dysfunction (left ventricular ejection fraction ranging from 25% to 45%), with no indication for cardiac resynchronization therapy. Cardiac contractility modulation therapy improves functional status, exercise capacity, quality of life, and possibly prevents hospital admissions in indicated patients. An algorithm for patient selection for these two forms of electrical therapy for heart failure is presented.
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Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, 473 West 12th Avenue, Suite 200, Columbus, OH 43065, USA.
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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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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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Barnes A, Campbell C, Weiss R, Kahwash R. Cardiac Contractility Modulation in Heart Failure: Mechanisms and Clinical Evidence. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00852-8] [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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28
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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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29
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Gagno G, Zoppo F. Insights on arrhythmia termination and type 2 breaks after ICD therapy delivery. Pacing Clin Electrophysiol 2020; 43:1039-1047. [DOI: 10.1111/pace.14030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/15/2020] [Accepted: 08/02/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Giulia Gagno
- Dipartimento di Cardiologia Università degli Studi di Trieste, Azienda Sanitaria Universitaria Giuliano, Isontina Trieste Italy
| | - Franco Zoppo
- Elettrofisiologia, Unità Operativa di Cardiologia, Ospedale Civile di Gorizia Azienda Sanitaria Universitaria Giuliano, Isontina Trieste Italy
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30
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Cardiac contractility modulation for the treatment of heart failure with reduced ejection fraction. Heart Fail Rev 2020; 26:217-226. [PMID: 32852661 DOI: 10.1007/s10741-020-10017-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/21/2020] [Indexed: 12/11/2022]
Abstract
There has been a progressive evolution in the management of patients with chronic heart failure and reduced ejection fraction (HFrEF), including cardiac resynchronisation therapy (CRT) in those that fulfil pre-defined criteria. However, there exists a significant proportion with refractory symptoms in whom CRT devices are not clinically indicated or ineffective. Cardiac contractility modulation (CCM) is a novel therapy that incorporates administration of non-excitatory electrical impulses to the interventricular septum during the absolute refractory period. Implantation is analogous to a traditional transvenous pacemaker system, but with the use of two right ventricular leads. Mechanistic studies have shown augmentation of left ventricular contractility and beneficial global effects on reverse remodeling, primarily through alterations in calcium handling. This appears to occur without increasing myocardial oxygen consumption. Data from clinical trials have shown translational improvements in functional capacity and quality of life, though long-term outcome data are lacking. This review explores the rationale, evidence base and limitations of this nascent technology.
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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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Merchant FM, Sayadi O, Sohn K, Weiss EH, Puppala D, Doddamani R, Singh JP, Heist EK, Owen C, Kulkarni K, Armoundas AA. Real-Time Closed-Loop Suppression of Repolarization Alternans Reduces Arrhythmia Susceptibility In Vivo. Circ Arrhythm Electrophysiol 2020; 13:e008186. [PMID: 32434448 DOI: 10.1161/circep.119.008186] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Repolarization alternans (RA) has been implicated in the pathogenesis of ventricular arrhythmias and sudden cardiac death. METHODS We have developed a real-time, closed-loop system to record and analyze RA from multiple intracardiac leads, and deliver dynamically R-wave triggered pacing stimuli during the absolute refractory period. We have evaluated the ability of this system to control RA and reduce arrhythmia susceptibility, in vivo. RESULTS R-wave triggered pacing can induce RA, the magnitude of which can be modulated by varying the amplitude, pulse width, and size of the pacing vector. Using a swine model (n=9), we demonstrate that to induce a 1 µV change in the alternans voltage on the body surface, coronary sinus and left ventricle leads, requires a delivered charge of 0.04±0.02, 0.05±0.025, and 0.06±0.033 µC, respectively, while to induce a one unit change of the Kscore, requires a delivered charge of 0.93±0.73, 0.32±0.29, and 0.33±0.37 µC, respectively. For all body surface and intracardiac leads, both Δ(alternans voltage) and ΔKscore between baseline and R-wave triggered paced beats increases consistently with an increase in the pacing pulse amplitude, pulse width, and vector spacing. Additionally, we show that the proposed method can be used to suppress spontaneously occurring alternans (n=7), in the presence of myocardial ischemia. Suppression of RA by pacing during the absolute refractory period results in a significant reduction in arrhythmia susceptibility, evidenced by a lower Srank score during programmed ventricular stimulation compared with baseline before ischemia. CONCLUSIONS We have developed and evaluated a novel closed-loop method to dynamically modulate RA in a swine model. Our data suggest that suppression of RA directly reduces arrhythmia susceptibility and reinforces the concept that RA plays a critical role in the pathophysiology of arrhythmogenesis.
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Affiliation(s)
- Faisal M Merchant
- Cardiology Division, Emory University School of Medicine, Atlanta, GA (F.M.M.).,Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Omid Sayadi
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Kwanghyun Sohn
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Eric H Weiss
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology Cambridge (E.H.W., A.A.A.)
| | - Dheeraj Puppala
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Rajiv Doddamani
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Jagmeet P Singh
- Cardiology Division, Cardiac Arrhythmia Service (J.P.S., E.K.H.), Massachusetts General Hospital, Boston
| | - E Kevin Heist
- Cardiology Division, Cardiac Arrhythmia Service (J.P.S., E.K.H.), Massachusetts General Hospital, Boston
| | - Chris Owen
- Neurosurgery Division (C.O.), Massachusetts General Hospital, Boston
| | - Kanchan Kulkarni
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston
| | - Antonis A Armoundas
- Cardiovascular Research Center (F.M.M., O.S., K.S., E.H.W., D.P., R.D., K.K., A.A.A.), Massachusetts General Hospital, Boston.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology Cambridge (E.H.W., A.A.A.)
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Campbell CM, Kahwash R, Abraham WT. Optimizer Smart in the treatment of moderate-to-severe chronic heart failure. Future Cardiol 2020; 16:13-25. [DOI: 10.2217/fca-2019-0044] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cardiac contractility modulation, also referred to as CCM™, by the Optimizer Smart device is an innovative intracardiac device-based therapy that has been recently US FDA-approved for the treatment of patients with chronic heart failure, left ventricular ejection fraction (LVEF) between 25 and 45%, QRS <130 ms who remain symptomatic despite optimal medical therapy. Clinical trials demonstrate that CCM therapy is safe and effective in reducing heart failure hospitalization and improving heart failure symptoms, quality of life and functional performance. This novel device-based therapeutic offers benefits to patients who do not otherwise qualify for cardiac resynchronization therapy. CCM expands the indication beyond the traditional LVEF cutoff of 35% to a newer group including patients who fall in midrange LVEF group, up to 45%.
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Affiliation(s)
- Courtney M Campbell
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 200 Davis Heart & Lung Institute, 473 W 12th Ave, Columbus, OH 43210, USA
| | - Rami Kahwash
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 200 Davis Heart & Lung Institute, 473 W 12th Ave, Columbus, OH 43210, USA
| | - William T Abraham
- Department of Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, 200 Davis Heart & Lung Institute, 473 W 12th Ave, Columbus, OH 43210, USA
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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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35
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Kulkarni K, Merchant FM, Kassab MB, Sana F, Moazzami K, Sayadi O, Singh JP, Heist EK, Armoundas AA. Cardiac Alternans: Mechanisms and Clinical Utility in Arrhythmia Prevention. J Am Heart Assoc 2019; 8:e013750. [PMID: 31617437 PMCID: PMC6898836 DOI: 10.1161/jaha.119.013750] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Kanchan Kulkarni
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | | | - Mohamad B. Kassab
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Furrukh Sana
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Kasra Moazzami
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Omid Sayadi
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
| | - Jagmeet P. Singh
- Cardiology DivisionCardiac Arrhythmia ServiceMassachusetts General HospitalBostonMA
| | - E. Kevin Heist
- Cardiology DivisionCardiac Arrhythmia ServiceMassachusetts General HospitalBostonMA
| | - Antonis A. Armoundas
- Cardiovascular Research CenterMassachusetts General HospitalBostonMA
- Institute for Medical Engineering and ScienceMassachusetts Institute of TechnologyCambridgeMA
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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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Abraham WT, Kuck KH, Goldsmith RL, Lindenfeld J, Reddy VY, Carson PE, Mann DL, Saville B, Parise H, Chan R, Wiegn P, Hastings JL, Kaplan AJ, Edelmann F, Luthje L, Kahwash R, Tomassoni GF, Gutterman DD, Stagg A, Burkhoff D, Hasenfuß G. A Randomized Controlled Trial to Evaluate the Safety and Efficacy of Cardiac Contractility Modulation. JACC. HEART FAILURE 2018; 6:874-883. [PMID: 29754812 DOI: 10.1016/j.jchf.2018.04.010] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 04/24/2018] [Accepted: 04/24/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study sought to confirm a subgroup analysis of the prior FIX-HF-5 (Evaluate Safety and Efficacy of the OPTIMIZER System in Subjects With Moderate-to-Severe Heart Failure) study showing that cardiac contractility modulation (CCM) improved exercise tolerance (ET) and quality of life in patients with ejection fractions between 25% and 45%. BACKGROUND CCM therapy for New York Heart Association (NYHA) functional class III and IV heart failure (HF) patients consists of nonexcitatory electrical signals delivered to the heart during the absolute refractory period. METHODS A total of 160 patients with NYHA functional class III or IV symptoms, QRS duration <130 ms, and ejection fraction ≥25% and ≤45% were randomized to continued medical therapy (control, n = 86) or CCM (treatment, n = 74, unblinded) for 24 weeks. Peak Vo2 (primary endpoint), Minnesota Living With Heart Failure questionnaire, NYHA functional class, and 6-min hall walk were measured at baseline and at 12 and 24 weeks. Bayesian repeated measures linear modeling was used for the primary endpoint analysis with 30% borrowing from the FIX-HF-5 subgroup. Safety was assessed by the percentage of patients free of device-related adverse events with a pre-specified lower bound of 70%. RESULTS The difference in peak Vo2 between groups was 0.84 (95% Bayesian credible interval: 0.123 to 1.552) ml O2/kg/min, satisfying the primary endpoint. Minnesota Living With Heart Failure questionnaire (p < 0.001), NYHA functional class (p < 0.001), and 6-min hall walk (p = 0.02) were all better in the treatment versus control group. There were 7 device-related events, yielding a lower bound of 80% of patients free of events, satisfying the primary safety endpoint. The composite of cardiovascular death and HF hospitalizations was reduced from 10.8% to 2.9% (p = 0.048). CONCLUSIONS CCM is safe, improves exercise tolerance and quality of life in the specified group of HF patients, and leads to fewer HF hospitalizations. (Evaluate Safety and Efficacy of the OPTIMIZER System in Subjects With Moderate-to-Severe Heart Failure; NCT01381172).
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Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio.
| | - Karl-Heinz Kuck
- Department of Cardiology, ASKLEPIOS Klinik St. Georg, Hamburg, Germany
| | - Rochelle L Goldsmith
- Exercise Physiology Laboratory, Columbia University Medical Center, New York, New York
| | - JoAnn Lindenfeld
- Department of Heart Failure and Transplant, Vanderbilt Heart, Nashville, Tennessee
| | - Vivek Y Reddy
- Department of Cardiac Arrhythmia Services, The Mount Sinai Hospital, New York, New York
| | - Peter E Carson
- Medical Intensive Care Unit, Washington VA Medical Center, Washington, DC
| | - Douglas L Mann
- Cardiovascular Division, Medicine, Washington University School of Medicine, St. Louis, Missouri
| | | | - Helen Parise
- R. P. Chiacchierini Consulting, Gaithersburg, Maryland
| | | | - Phi Wiegn
- Department of Clinical Cardiac Electrophysiology, Dallas VA Medical Center, Dallas, Texas
| | - Jeffrey L Hastings
- Department of Clinical Cardiac Electrophysiology, Dallas VA Medical Center, Dallas, Texas
| | - Andrew J Kaplan
- Department of Clinical Cardiac Electrophysiology, Cardiovascular Associates of Mesa, Mesa, Arizona
| | - Frank Edelmann
- Department of Cardiology and Pneumology, Universität Göttingen, Göttingen, Germany
| | - Lars Luthje
- Department of Cardiology and Pneumology, Universität Göttingen, Göttingen, Germany
| | - Rami Kahwash
- Department of Heart Failure & Transplantation, The Ohio State University Heart and Vascular Center, Columbus, Ohio
| | - Gery F Tomassoni
- Department of Clinical Cardiac Electrophysiology, Baptist Health Lexington, Lexington, Kentucky
| | - David D Gutterman
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Angela Stagg
- Clinical Trials, Impulse Dynamics, Orangeburg, New York
| | | | - Gerd Hasenfuß
- Heart Center of Göttingen, University Medical Center Göttingen, Göttingen, Germany
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Abstract
Heart failure is a major health problem worldwide and, despite effective therapies, is expected to grow by almost 50 % over the next 15 years. Five-year mortality remains high at 50 % over 5 years. Because of the economic burden and large impact on quality of life, substantial effort has focused on treatments with multiple medical (beta-blockers, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ARB), aldosterone antagonists, and combination of ARB/neprilysin blockers, ivabradine) and device therapies (ICD, CRT) which have been implemented to reduce disease burden and mortality. However, in the past decade only two new medical therapies and no devices have been approved by the US FDA for the treatment of heart failure. This review highlights the preclinical and clinical literature, and the implantation procedure, related to a relatively new therapeutic device for heart failure; cardiac contractility modulation (CCM). CCM delivers a biphasic high-voltage bipolar signal to the RV septum during the absolute refractory period, eliciting an acute increase in global contractility, and chronically producing a sustained improvement in quality of life, exercise tolerance, and heart failure symptoms. The technology is used commercially in Europe with nearly 3000 patients implanted worldwide. Indications include patients with reduced EF and normal or slightly prolonged QRS duration, thus filling an important therapeutic gap among the 2/3 of patients with heart failure who do not meet criteria for CRT. The mechanism by which CCM provides benefit can be seen at the cellular level where improved calcium handling (phosphorylation of phospholamban, upregulation of SERCA-2A), reversal of the fetal myocyte gene program associated with heart failure, and reverse remodeling are observed. Recent retrospective studies indicate a long-term mortality benefit. A pivotal randomized controlled study is currently being completed in the USA. CCM appears to be an effective, safe technology for the treatment of heart failure with reduced ejection fraction.
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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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40
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Sprenkeler DJ, Vos MA. Post-extrasystolic Potentiation: Link between Ca(2+) Homeostasis and Heart Failure? Arrhythm Electrophysiol Rev 2016; 5:20-6. [PMID: 27403289 DOI: 10.15420/aer.2015.29.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Post-extrasystolic potentiation (PESP) describes the phenomenon of increased contractility of the beat following an extrasystole and has been attributed to changes in Ca(2+) homeostasis. While this effect has long been regarded to be a normal physiological phenomenon, a number of reports describe an enhanced potentiation of the post-extrasystolic beat in heart failure patients. The exact mechanism of this increased PESP is unknown, but disruption of normal Ca(2+) handling in heart failure may be the underlying cause. The use of PESP as a prognostic marker or therapeutic intervention have recently regained new attention, however, the value of the application of PESP in the clinic is still under debate. In this review, the mechanism of PESP with regard to Ca(2+) in the normal and failing heart will be discussed and the possible diagnostic and therapeutic role of this phenomenon will be explored.
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Affiliation(s)
| | - Marc A Vos
- University Medical Center Utrecht, Utrecht, The Netherlands
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41
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Ito BR, Covell JW, Curtis GP. Low Intensity Epicardial Pacing During the Absolute Refractory Period Augments Left Ventricular Function Mediated by Local Catecholamine Release. J Cardiovasc Electrophysiol 2016; 27:1102-9. [PMID: 27279561 DOI: 10.1111/jce.13027] [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: 04/15/2016] [Revised: 05/17/2016] [Accepted: 05/24/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND Biventricular epicardial (Epi) pacing can augment left ventricular (LV) function in heart failure. We postulated that these effects might involve catecholamine release from local autonomic nerve activation. To evaluate this hypothesis we applied low intensity Epi electrical stimuli during the absolute refractory period (ARP), thus avoiding altered activation sequence. METHODS Anesthetized pigs (n = 6) were instrumented with an LV pressure (LVP) transducer, left atrial (LA) and LV Epi pacing electrodes, and sonomicrometer segment length (SL) gauges placed proximal and remote to the LV stimulation site. A catheter was placed into the great cardiac vein adjacent to the LV pacing site for norepinephrine (NE) analysis. During LA pacing at constant rate, 3 pulses (0.8 milliseconds, 2-3x threshold) were applied to the LV Epi electrodes during the ARP. An experimental run consisted of baseline, stimulation (10 minutes), and recovery (5 minutes), repeated 3 times before and after β1 - receptor blockade (BB, metoprolol). RESULTS ARP stimulation produced significant increases in cardiac function reflected by elevated LVP, LV, dP/dtmax , and reduced time to LV dP/dtmax . This was accompanied by increased coronary NE levels and increases in LVP versus SL loop area in the remote myocardial segment. In contrast, the proximal segment exhibited early shortening and decreased loop area. BB abolished the changes in SL and LV function despite continued NE release. CONCLUSION These results demonstrate that ARP EPI stimulation induces NE release mediating augmented global LV function. This effect may contribute to the beneficial effect of biventricular Epi pacing in heart failure in some patients.
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Affiliation(s)
- Bruce R Ito
- Donald P. Shiley Bioscience Center, San Diego State University, San Diego, California, USA. .,University of California, San Diego, California, USA.
| | | | - Guy P Curtis
- Scripps Clinic and Research, San Diego and La Jolla, California, USA
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42
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Abraham WT, Lindenfeld J, Reddy VY, Hasenfuss G, Kuck KH, Boscardin J, Gibbons R, Burkhoff D. A randomized controlled trial to evaluate the safety and efficacy of cardiac contractility modulation in patients with moderately reduced left ventricular ejection fraction and a narrow QRS duration: study rationale and design. J Card Fail 2014; 21:16-23. [PMID: 25285748 DOI: 10.1016/j.cardfail.2014.09.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 11/29/2022]
Abstract
Cardiac contractility modulation (CCM) signals are nonexcitatory electrical signals delivered during the cardiac absolute refractory period that enhance the strength of cardiac muscular contraction. The FIX-HF-5 study was a prospective randomized study comparing CCM plus optimal medical therapy (OMT) to OMT alone that included 428 New York Heart Association (NYHA) functional class III or IV heart failure patients with ejection fraction (EF) ≤45% according to core laboratory assessment. The study met its primary safety end point, but did not reach its primary efficacy end point: a responders analysis of changes in ventilatory anaerobic threshold (VAT). However, in a prespecified subgroup analysis, significant improvements in primary and secondary end points, including the responder VAT end point, were observed in patients with EFs ranging from 25% to 45%, who constituted about one-half of the study subjects. We therefore designed a new study to prospectively confirm the efficacy of CCM in this population. A hierarchic bayesian statistical analysis plan was developed to take advantage of the data already available from the first study. In addition, based on technical difficulties encountered in reliably quantifying VAT and the relatively large amount of nonquantifiable studies, the primary efficacy end point was changed to peak VO2, with significant measures incorporated to minimize the influence of placebo effect. In this paper, we provide the details and rationale of the FIX-HF-5C study design to study CCM plus OMT compared with OMT alone in subjects with normal QRS duration, NYHA functional class III or IV, and EF 25%-45%. This study is registered on www.clinicaltrials.gov with identifier no. NCT01381172.
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Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - JoAnn Lindenfeld
- Division of Cardiology, University of Colorado, Denver, Colorado
| | - Vivek Y Reddy
- Division of Cardiology, Helmsley Electrophysiology Center, Mount Sinai School of Medicine, New York, New York
| | - Gerd Hasenfuss
- Department of Cardiology and Pneumology, Georg-August University Goettingen, Goettingen, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology, The Asklepios Klinik St. Georg, Hamburg, Germany
| | - John Boscardin
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Robert Gibbons
- Department of Health Studies, University of Chicago, Chicago, Illinois
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University, New York, New York.
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43
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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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Merchant FM, Sayadi O, Moazzami K, Puppala D, Armoundas AA. T-wave alternans as an arrhythmic risk stratifier: state of the art. Curr Cardiol Rep 2014; 15:398. [PMID: 23881581 DOI: 10.1007/s11886-013-0398-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Microvolt level T-wave alternans (MTWA), a phenomenon of beat-to-beat variability in the repolarization phase of the ventricles, has been closely associated with an increased risk of ventricular tachyarrhythmic events (VTE) and sudden cardiac death (SCD) during medium- and long-term follow-up. Recent observations also suggest that heightened MTWA magnitude may be closely associated with short-term risk of impending VTE. At the subcellular and cellular level, perturbations in calcium transport processes likely play a primary role in the genesis of alternans, which then secondarily lead to alternans of action potential morphology and duration (APD). As such, MTWA may play a role not only in risk stratification but also more fundamentally in the pathogenesis of VTE. In this paper, we outline recent advances in understanding the pathogenesis of MTWA and also the utility of T-wave alternans testing for clinical risk stratification. We also highlight emerging clinical applications for MTWA.
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Affiliation(s)
- Faisal M Merchant
- Cardiology Division, Emory University School of Medicine, Atlanta, GA, USA
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Winter J, Brack KE, Ng GA. Cardiac contractility modulation in the treatment of heart failure: initial results and unanswered questions. Eur J Heart Fail 2014; 13:700-10. [DOI: 10.1093/eurjhf/hfr042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- James Winter
- Department of Cardiovascular Sciences; University of Leicester; Clinical Sciences Wing, Glenfield Hospital Leicester LE3 9QP UK
| | - Kieran E. Brack
- Department of Cardiovascular Sciences; University of Leicester; Clinical Sciences Wing, Glenfield Hospital Leicester LE3 9QP UK
| | - G. André Ng
- Department of Cardiovascular Sciences; University of Leicester; Clinical Sciences Wing, Glenfield Hospital Leicester LE3 9QP UK
- Leicester NIHR Biomedical Research Unit in Cardiovascular Disease; Glenfield Hospital; Leicester LE3 9QP UK
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47
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Comparison of left ventricular reverse remodeling induced by cardiac contractility modulation and cardiac resynchronization therapy in heart failure patients with different QRS durations. Int J Cardiol 2013; 167:889-93. [DOI: 10.1016/j.ijcard.2012.01.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 01/13/2012] [Accepted: 01/21/2012] [Indexed: 11/15/2022]
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48
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Armoundas AA, Weiss EH, Sayadi O, Laferriere S, Sajja N, Mela T, Singh JP, Barrett CD, Kevin Heist E, Merchant FM. A novel pacing method to suppress repolarization alternans in vivo: implications for arrhythmia prevention. Heart Rhythm 2012; 10:564-72. [PMID: 23274372 DOI: 10.1016/j.hrthm.2012.12.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Repolarization alternans (RA), a pattern of ventricular repolarization that repeats on an every other beat basis, has been closely linked with the substrate associated with ventricular tachycardia/ventricular fibrillation. OBJECTIVE To evaluate a novel method to suppress RA. METHODS We have developed a novel method to dynamically (on R-wave detection) trigger pacing pulses during the absolute refractory period. We have tested the ability of this method to control RA in a structurally normal swine heart in vivo. RESULTS RA induced by triggered pacing can be measured from both intracardiac and body surface leads and the amplitude of R-wave triggered pacing-induced alternans can be locally modulated by varying the amplitude and width of the pacing pulse. We have estimated that to induce a 1 μV change in alternans voltage on the body surface, coronary sinus, and left ventricle leads, a triggered pacing pulse delivered in the right ventricle of 0.04±0.02, 0.05±0.025, and 0.06±0.033 μC, respectively, is required. Similarly, to induce a 1 unit change in Kscore (ratio of alternans peak to noise), a pacing stimulus of 0.93±0.73, 0.32±0.29, and 0.33±0.37 μC, respectively, is required. We have been able to demonstrate that RA can be suppressed by R-wave triggered pacing from a site that is within or across ventricles. Lastly, we have demonstrated that the proposed method can be used to suppress spontaneously occurring alternans in the diseased heart. CONCLUSION We have developed a novel method to suppress RA in vivo.
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Affiliation(s)
- Antonis A Armoundas
- Harvard-MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, Cambridge, Massachusetts; Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02129, USA.
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49
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Kwong JSW, Sanderson JE, Yu CM. Cardiac contractility modulation for heart failure: a meta-analysis of randomized controlled trials. Pacing Clin Electrophysiol 2012; 35:1111-8. [PMID: 22734676 DOI: 10.1111/j.1540-8159.2012.03449.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiac contractility modulation (CCM) emerges as a promising device treatment for heart failure (HF). This meta-analysis aimed to systematically review the latest available randomized evidence on the effectiveness and safety of CCM in HF. METHODS The Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE were searched in November 2011 to identify eligible randomized controlled trials comparing CCM with sham treatment or usual care. Primary outcomes of interest were all-cause mortality, all-cause hospitalizations, and adverse effects. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated for dichotomous data using a random-effects model. RESULTS Three studies enrolling 641 participants were included. Pooled analysis showed that, compared to control, CCM did not significantly improve all-cause mortality (n = 629, RR 1.19, 95% CI 0.50-2.86, P = 0.69), nor was there a favorable effect in all-cause hospitalizations. No increase in adverse effects with CCM was observed. CONCLUSIONS Meta-analysis of data from small randomized trials suggests that CCM, although with no clear benefits in improving clinical outcomes, is not associated with worsening prognosis. Large, well-designed trials are needed to confirm its role in HF patients for whom cardiac resynchronization therapy is contraindicated or unsuccessful.
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Affiliation(s)
- Joey S W Kwong
- Institute of Vascular Medicine, Li Ka Shing Institute of Health Sciences, S.H. Ho Cardiovascular Disease and Stroke Centre, Heart Education And Research Training (HEART) Centre and Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, N.T., Hong Kong SAR, China
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Cornelussen RN, Splett V, Klepfer RN, Stegemann B, Kornet L, Prinzen FW. Electrical modalities beyond pacing for the treatment of heart failure. Heart Fail Rev 2011; 16:315-25. [PMID: 21104313 PMCID: PMC3074071 DOI: 10.1007/s10741-010-9206-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In this review, we report on electrical modalities, which do not fit the definition of pacemaker, but increase cardiac performance either by direct application to the heart (e.g., post-extrasystolic potentiation or non-excitatory stimulation) or indirectly through activation of the nervous system (e.g., vagal or sympathetic activation). The physiological background of the possible mechanisms of these electrical modalities and their potential application to treat heart failure are discussed.
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Affiliation(s)
- Richard N Cornelussen
- Research and Technology, Medtronic Bakken Research Center BV, Endepolsdomein 5, 6229 GW Maastricht, The Netherlands.
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