1
|
Pamias-Lopez B, Ibrahim ME, Pitoulis FG. Cardiac mechanics and reverse remodelling under mechanical support from left ventricular assist devices. Front Cardiovasc Med 2023; 10:1212875. [PMID: 37600037 PMCID: PMC10433771 DOI: 10.3389/fcvm.2023.1212875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 07/05/2023] [Indexed: 08/22/2023] Open
Abstract
In recent years, development of mechanical circulatory support devices has proved to be a new treatment modality, in addition to standard pharmacological therapy, for patients with heart failure or acutely depressed cardiac function. These include left ventricular assist devices, which mechanically unload the heart when implanted. As a result, they profoundly affect the acute cardiac mechanics, which in turn, carry long-term consequences on myocardial function and structural function. Multiple studies have shown that, when implanted, mechanical circulatory assist devices lead to reverse remodelling, a process whereby the diseased myocardium reverts to a healthier-like state. Here, we start by first providing the reader with an overview of cardiac mechanics and important hemodynamic parameters. We then introduce left ventricular assist devices and describe their mode of operation as well as their impact on the hemodynamics. Changes in cardiac mechanics caused by device implantation are then extrapolated in time, and the long-term consequences on myocardial phenotype, as well as the physiological basis for these, is investigated.
Collapse
Affiliation(s)
- Blanca Pamias-Lopez
- Department of Myocardial Function, Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Michael E. Ibrahim
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| | - Fotios G. Pitoulis
- Department of Myocardial Function, Imperial College London, National Heart and Lung Institute, London, United Kingdom
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, United States
| |
Collapse
|
2
|
Chrysakis N, Xanthopoulos A, Magouliotis D, Starling RC, Drakos SG, Triposkiadis F, Skoularigis J. Myocardial Recovery. Diagnostics (Basel) 2023; 13:diagnostics13081504. [PMID: 37189604 DOI: 10.3390/diagnostics13081504] [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: 03/20/2023] [Revised: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023] Open
Abstract
In this paper, the feasibility of myocardial recovery is analyzed through a literature review. First, the phenomena of remodeling and reverse remodeling are analyzed, approached through the physics of elastic bodies, and the terms myocardial depression and myocardial recovery are defined. Continuing, potential biochemical, molecular, and imaging markers of myocardial recovery are reviewed. Then, the work focuses on therapeutic techniques that can facilitate the reverse remodeling of the myocardium. Left ventricular assist device (LVAD) systems are one of the main ways to promote cardiac recovery. The changes that take place in cardiac hypertrophy, extracellular matrix, cell populations and their structural elements, β-receptors, energetics, and several biological processes, are reviewed. The attempt to wean the patients who experienced cardiac recovery from cardiac assist device systems is also discussed. The characteristics of the patients who will benefit from LVAD are presented and the heterogeneity of the studies performed in terms of patient populations included, diagnostic tests performed, and their results are addressed. The experience with cardiac resynchronization therapy (CRT) as another way to promote reverse remodeling is also reviewed. Myocardial recovery is a phenomenon that presents with a continuous spectrum of phenotypes. There is a need for algorithms to screen suitable patients who may benefit and identify specific ways to enhance this phenomenon in order to help combat the heart failure epidemic.
Collapse
Affiliation(s)
- Nikolaos Chrysakis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| | - Dimitrios Magouliotis
- Unit of Quality Improvement, Department of Cardiothoracic Surgery, University of Thessaly, Biopolis, 41110 Larissa, Greece
| | - Randall C Starling
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT 84132, USA
| | - Filippos Triposkiadis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
- School of Medicine, European University Cyprus, Nicosia 2404, Cyprus
| | - John Skoularigis
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece
| |
Collapse
|
3
|
Tseliou E, Lavine KJ, Wever-Pinzon O, Topkara VK, Meyns B, Adachi I, Zimpfer D, Birks EJ, Burkhoff D, Drakos SG. Biology of myocardial recovery in advanced heart failure with long-term mechanical support. J Heart Lung Transplant 2022; 41:1309-1323. [PMID: 35965183 DOI: 10.1016/j.healun.2022.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022] Open
Abstract
Cardiac remodeling is an adaptive, compensatory biological process following an initial insult to the myocardium that gradually becomes maladaptive and causes clinical deterioration and chronic heart failure (HF). This biological process involves several pathophysiological adaptations at the genetic, molecular, cellular, and tissue levels. A growing body of clinical and translational investigations demonstrated that cardiac remodeling and chronic HF does not invariably result in a static, end-stage phenotype but can be at least partially reversed. One of the paradigms which shed some additional light on the breadth and limits of myocardial elasticity and plasticity is long term mechanical circulatory support (MCS) in advanced HF pediatric and adult patients. MCS by providing (a) ventricular mechanical unloading and (b) effective hemodynamic support to the periphery results in functional, structural, cellular and molecular changes, known as cardiac reverse remodeling. Herein, we analyze and synthesize the advances in our understanding of the biology of MCS-mediated reverse remodeling and myocardial recovery. The MCS investigational setting offers access to human tissue, providing an unparalleled opportunity in cardiovascular medicine to perform in-depth characterizations of myocardial biology and the associated molecular, cellular, and structural recovery signatures. These human tissue findings have triggered and effectively fueled a "bedside to bench and back" approach through a variety of knockout, inhibition or overexpression mechanistic investigations in vitro and in vivo using small animal models. These follow-up translational and basic science studies leveraging human tissue findings have unveiled mechanistic myocardial recovery pathways which are currently undergoing further testing for potential therapeutic drug development. Essentially, the field is advancing by extending the lessons learned from the MCS cardiac recovery investigational setting to develop therapies applicable to the greater, not end-stage, HF population. This review article focuses on the biological aspects of the MCS-mediated myocardial recovery and together with its companion review article, focused on the clinical aspects, they aim to provide a useful framework for clinicians and investigators.
Collapse
Affiliation(s)
- Eleni Tseliou
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Kory J Lavine
- Division of Cardiology, Washington University School of Medicine, St Louis, MO
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Bart Meyns
- Department of Cardiology and Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Iki Adachi
- Division of Cardiac Surgery, Texas Children's Hospital, Houston, TX
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Daniel Burkhoff
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY; Cardiovascular Research Foundation (CRF), New York, NY
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT.
| |
Collapse
|
4
|
Wang F, Li Z, Song T, Jia Y, Qi L, Ren L, Chen S. Proteomics study on the effect of silybin on cardiomyopathy in obese mice. Sci Rep 2021; 11:7136. [PMID: 33785854 PMCID: PMC8009917 DOI: 10.1038/s41598-021-86717-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/19/2021] [Indexed: 12/29/2022] Open
Abstract
Due to the increase in the number of obese individuals, the incidence of obesity-related complications such as cardiovascular disease and type 2 diabetes is higher. The aim of the present study was to explore the effects of silybin on protein expression in obese mice. Firstly, serum was collected, and it was used to detect serum lipids and other serological indicators. Secondly, total protein from epididymal adipose tissue was extracted for differential expression analysis by quantitative tandem mass tag (TMT) combined with liquid chromatography-tandem mass spectrometry (LC-MS/MS), followed by bioinformatics and protein-protein interaction (PPI) network analyses of these proteins. Lastly, real-time polymerase chain reaction (RT-PCR) and parallel reaction monitoring (PRM) were used to further validate the expression of identified differentially expressed proteins (DEPs) at the mRNA and protein level, respectively. The results revealed that silybin could improve abnormal lipid metabolism caused by the high fat diet in obese mice. A total of 341, 538 and 243 DEPs were found in the high fat/control (WF/WC), silybin/high fat (WS/WF) and WS/WC groups, respectively. These DEPs mainly participated in lipid metabolism and energy metabolism. Notably, tropomyosin 1 (TPM1), myosin light chain 2 (MYL2), myosin heavy chain 11 (MYH11) and other DEPs were involved in hypertrophic cardiomyopathy, dilated cardiomyopathy and other pathways. Silybin could protect cardiac function by inducing the protein expression of TPM1, MYL2 and MYH11 in the adipose tissue of obese mice.
Collapse
Affiliation(s)
- Fei Wang
- Department of Endocrinology, Hebei General Hospital, Graduate School of Hebei Medical University, Shijiazhaung, China
| | - Zelin Li
- Department of Endocrinology, Hebei General Hospital, Graduate School of Hebei Medical University, Shijiazhaung, China
| | - Tiantian Song
- Department of Endocrinology, Hebei General Hospital, Graduate School of Hebei Medical University, Shijiazhaung, China
| | - Yujiao Jia
- Department of Endocrinology, Hebei General Hospital, Graduate School of Hebei Medical University, Shijiazhaung, China
| | - Licui Qi
- Department of Endocrinology, Hebei General Hospital, Graduate School of Hebei North University, Shijiazhaung, China
| | - Luping Ren
- Department of Endocrinology, Hebei General Hospital, Shijiazhaung, 050000, Hebei, China
| | - Shuchun Chen
- Department of Endocrinology, Hebei General Hospital, Graduate School of Hebei North University, No. 348 Heping West Road, Shijiazhaung, 050000, Hebei, China.
| |
Collapse
|
5
|
Wilcox J, Yancy CW. Stopping medication for heart failure with improved ejection fraction. Lancet 2019; 393:8-10. [PMID: 30429051 DOI: 10.1016/s0140-6736(18)32825-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Jane Wilcox
- Northwestern University, Feinberg School of Medicine, Department of Internal Medicine/Division of Cardiology, Chicago, IL 60611, USA
| | - Clyde W Yancy
- Northwestern University, Feinberg School of Medicine, Department of Internal Medicine/Division of Cardiology, Chicago, IL 60611, USA.
| |
Collapse
|
6
|
Dandel M, Hetzer R. Recovery of failing hearts by mechanical unloading: Pathophysiologic insights and clinical relevance. Am Heart J 2018; 206:30-50. [PMID: 30300847 DOI: 10.1016/j.ahj.2018.09.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 09/08/2018] [Indexed: 12/23/2022]
Abstract
By reduction of ventricular wall-tension and improving the blood supply to vital organs, ventricular assist devices (VADs) can eliminate the major pathophysiological stimuli for cardiac remodeling and even induce reverse remodeling occasionally accompanied by clinically relevant reversal of cardiac structural and functional alterations allowing VAD explantation, even if the underlying cause for the heart failure (HF) was dilated cardiomyopathy. Accordingly, a tempting potential indication for VADs in the future might be their elective implantation as a therapeutic strategy to promote cardiac recovery in earlier stages of HF, when the reversibility of morphological and functional alterations is higher. However, the low probability of clinically relevant cardiac improvement after VAD implantation and the lack of criteria which can predict recovery already before VAD implantation do not allow so far VAD implantations primarily designed as a bridge to cardiac recovery. The few investigations regarding myocardial reverse remodeling at cellular and sub-cellular level in recovered patients who underwent VAD explantation, the differences in HF etiology and pre-implant duration of HF in recovered patients and also the differences in medical therapy used by different institutions during VAD support make it currently impossible to understand sufficiently all the biological processes and mechanisms involved in cardiac improvement which allows even VAD explantation in some patients. This article aims to provide an overview of the existing knowledge about VAD-promoted cardiac improvement focusing on the importance of bench-to-bedside research which is mandatory for attaining the future goal to use long-term VADs also as therapy-devices for reversal of chronic HF.
Collapse
|
7
|
Kempton A, Cefalu M, Justice C, Baich T, Derbala M, Canan B, Janssen PML, Mohler PJ, Smith SA. Altered regulation of cardiac ankyrin repeat protein in heart failure. Heliyon 2018; 4:e00514. [PMID: 29560432 PMCID: PMC5857524 DOI: 10.1016/j.heliyon.2018.e00514] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/22/2017] [Accepted: 01/11/2018] [Indexed: 11/17/2022] Open
Abstract
Background Left ventricular assist devices (LVADs) have revolutionized and improved the care of the sickest heart failure (HF) patients, and it is imperative that they receive appropriate ventricular unloading. Assessing this critical parameter with current methodologies (labs, imaging) is usually suboptimal in this patient population. Hence it is imperative to elucidate the molecular underpinnings involved in ventricular unloading. We have previously identified the cytoskeletal protein βII spectrin as an essential nodal protein involved in post-translational targeting and βII spectrin protein levels are significantly altered in multiple forms of human and animal HF. We therefore hypothesized that the βII spectrin pathway would play a critical role in LVAD remodeling. Methods Human heart failure samples were obtained from patients undergoing heart transplantation. Wild type (WT) mice and our previously validated βII spectrin conditional knock out (βII cKO) mice were used for animal experiments. Transaortic constriction (TAC) was performed on WT mice. Protein expression was assessed via immunoblots, and protein interactions were assessed with co-immunoprecipitation. Transcriptome analysis was performed using isolated whole hearts from control adult WT mice (n = 3) compared to βII cKO spectrin mice (n = 3). Results We report that hearts from mice selectively lacking βII spectrin expression in cardiomyocytes displayed altered transcriptional regulation of cardiac ankyrin repeat protein (CARP). Notably, CARP protein expression is increased after TAC. Additionally, our findings illustrate that prior to LVAD support, CARP levels are elevated in HF patients compared to normal healthy controls. Further, for the first time in a LVAD population, we show that elevated CARP levels in HF patients return to normal following LVAD support. Conclusion Our findings illustrate that CARP is a dynamic molecule that responds to reduced afterload and stress, and has the potential to serve as a prognostic biomarker to assess for an adequate response to LVAD therapy.
Collapse
Affiliation(s)
- Amber Kempton
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Matt Cefalu
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Cody Justice
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Tesla Baich
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Mohamed Derbala
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Benjamin Canan
- Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH, USA
| | - Paul M L Janssen
- Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH, USA
| | - Peter J Mohler
- Department of Internal Medicine (Division of Cardiology), The Ohio State University College of Medicine, Columbus, OH, USA.,Department of Physiology and Cell Biology, The Ohio State University, Columbus, OH, USA.,Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| | - Sakima A Smith
- Department of Internal Medicine (Division of Cardiology), The Ohio State University College of Medicine, Columbus, OH, USA.,Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH, USA
| |
Collapse
|
8
|
Chaggar PS, Williams SG, Yonan N, Fildes J, Venkateswaran R, Shaw SM. Myocardial recovery with mechanical circulatory support. Eur J Heart Fail 2016; 18:1220-1227. [DOI: 10.1002/ejhf.575] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/24/2016] [Accepted: 04/28/2016] [Indexed: 01/18/2023] Open
Affiliation(s)
- Parminder S. Chaggar
- The Transplant Unit; University Hospital of South Manchester; Southmoor Road Manchester M23 9LT UK
- The Manchester Collaborative Centre for Inflammation Research; University of Manchester; Manchester UK
| | - Simon G. Williams
- The Transplant Unit; University Hospital of South Manchester; Southmoor Road Manchester M23 9LT UK
| | - Nizar Yonan
- The Transplant Unit; University Hospital of South Manchester; Southmoor Road Manchester M23 9LT UK
| | - James Fildes
- The Transplant Unit; University Hospital of South Manchester; Southmoor Road Manchester M23 9LT UK
- The Manchester Collaborative Centre for Inflammation Research; University of Manchester; Manchester UK
| | - Rajamiyer Venkateswaran
- The Transplant Unit; University Hospital of South Manchester; Southmoor Road Manchester M23 9LT UK
| | - Steven M. Shaw
- The Transplant Unit; University Hospital of South Manchester; Southmoor Road Manchester M23 9LT UK
| |
Collapse
|
9
|
Abstract
Unlike diet and exercise, which individuals can modulate according to their lifestyle, aging is unavoidable. With normal or healthy aging, the heart undergoes extensive vascular, cellular, and interstitial molecular changes that result in stiffer less compliant hearts that experience a general decline in organ function. Although these molecular changes deemed cardiac remodeling were once thought to be concomitant with advanced cardiovascular disease, they can be found in patients without manifestation of clinical disease. It is now mostly acknowledged that these age-related mechanical changes confer vulnerability of the heart to cardiovascular stresses associated with disease, such as hypertension and atherosclerosis. However, recent studies have aimed at differentiating the initial compensatory changes that occur within the heart with age to maintain contractile function from the maladaptive responses associated with disease. This work has identified new targets to improve cardiac function during aging. Spanning invertebrate to vertebrate models, we use this review to delineate some hallmarks of physiological versus pathological remodeling that occur in the cardiomyocyte and its microenvironment, focusing especially on the mechanical changes that occur within the sarcomere, intercalated disc, costamere, and extracellular matrix.
Collapse
Affiliation(s)
- Ayla O Sessions
- From the Biomedical Sciences Program (A.O.S., A.J.E.) and Department of Bioengineering, University of California, San Diego, La Jolla (A.J.E.); and Sanford Consortium for Regenerative Medicine, La Jolla, CA (A.J.E.)
| | - Adam J Engler
- From the Biomedical Sciences Program (A.O.S., A.J.E.) and Department of Bioengineering, University of California, San Diego, La Jolla (A.J.E.); and Sanford Consortium for Regenerative Medicine, La Jolla, CA (A.J.E.).
| |
Collapse
|
10
|
Advanced (stage D) heart failure: a statement from the Heart Failure Society of America Guidelines Committee. J Card Fail 2015; 21:519-34. [PMID: 25953697 DOI: 10.1016/j.cardfail.2015.04.013] [Citation(s) in RCA: 243] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 04/20/2015] [Accepted: 04/23/2015] [Indexed: 12/26/2022]
Abstract
We propose that stage D advanced heart failure be defined as the presence of progressive and/or persistent severe signs and symptoms of heart failure despite optimized medical, surgical, and device therapy. Importantly, the progressive decline should be primarily driven by the heart failure syndrome. Formally defining advanced heart failure and specifying when medical and device therapies have failed is challenging, but signs and symptoms, hemodynamics, exercise testing, biomarkers, and risk prediction models are useful in this process. Identification of patients in stage D is a clinically important task because treatments are inherently limited, morbidity is typically progressive, and survival is often short. Age, frailty, and psychosocial issues affect both outcomes and selection of therapy for stage D patients. Heart transplant and mechanical circulatory support devices are potential treatment options in select patients. In addition to considering indications, contraindications, clinical status, and comorbidities, treatment selection for stage D patients involves incorporating the patient's wishes for survival versus quality of life, and palliative and hospice care should be integrated into care plans. More research is needed to determine optimal strategies for patient selection and medical decision making, with the ultimate goal of improving clinical and patient centered outcomes in patients with stage D heart failure.
Collapse
|
11
|
Mahr C, Gundry RL. Hold or fold--proteins in advanced heart failure and myocardial recovery. Proteomics Clin Appl 2014; 9:121-33. [PMID: 25331159 DOI: 10.1002/prca.201400100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 09/17/2014] [Accepted: 10/14/2014] [Indexed: 12/14/2022]
Abstract
Advanced heart failure (AHF) describes the subset of heart failure patients refractory to conventional medical therapy. For some AHF patients, the use of mechanical circulatory support (MCS) provides an intermediary "bridge" step for transplant-eligible patients or an alternative therapy for transplant-ineligible patients. Over the past 20 years, clinical observations have revealed that approximately 1% of patients with MCS undergo significant reverse remodeling to the point where the device can be explanted. Unfortunately, it is unclear why some patients experience durable, sustained myocardial remission, while others redevelop heart failure (i.e. which hearts "hold" and which hearts "fold"). In this review, we outline unmet clinical needs related to treating patients with MCS, provide an overview of protein dynamics in the reverse-remodeling process, and propose specific areas where we expect MS and proteomic analyses will have significant impact on our understanding of disease progression, molecular mechanisms of recovery, and provide new markers with prognostic value that can positively impact patient care. Complimentary perspectives are provided with the goal of making this important topic accessible and relevant to both a clinical and basic science audience, as the intersection of these disciplines is required to advance the field.
Collapse
Affiliation(s)
- Claudius Mahr
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | | |
Collapse
|
12
|
Bayeva M, Sawicki KT, Butler J, Gheorghiade M, Ardehali H. Molecular and cellular basis of viable dysfunctional myocardium. Circ Heart Fail 2014; 7:680-91. [PMID: 25028350 DOI: 10.1161/circheartfailure.113.000912] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Marina Bayeva
- From the Division of Cardiology, Department of Medicine, Northwestern University School of Medicine, Chicago, IL (M.B., K.T.S., M.G., H.A.); and Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.B.)
| | - Konrad Teodor Sawicki
- From the Division of Cardiology, Department of Medicine, Northwestern University School of Medicine, Chicago, IL (M.B., K.T.S., M.G., H.A.); and Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.B.)
| | - Javed Butler
- From the Division of Cardiology, Department of Medicine, Northwestern University School of Medicine, Chicago, IL (M.B., K.T.S., M.G., H.A.); and Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.B.)
| | - Mihai Gheorghiade
- From the Division of Cardiology, Department of Medicine, Northwestern University School of Medicine, Chicago, IL (M.B., K.T.S., M.G., H.A.); and Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.B.)
| | - Hossein Ardehali
- From the Division of Cardiology, Department of Medicine, Northwestern University School of Medicine, Chicago, IL (M.B., K.T.S., M.G., H.A.); and Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA (J.B.).
| |
Collapse
|
13
|
Dandel M, Knosalla C, Hetzer R. Contribution of ventricular assist devices to the recovery of failing hearts: a review and the Berlin Heart Center Experience. Eur J Heart Fail 2013; 16:248-63. [DOI: 10.1002/ejhf.18] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 08/25/2013] [Accepted: 09/27/2013] [Indexed: 11/09/2022] Open
Affiliation(s)
- Michael Dandel
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin D-13353 Germany
- DZHK (German Centre for Cardiovascular Research); Berlin Germany
| | - Christoph Knosalla
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin D-13353 Germany
- DZHK (German Centre for Cardiovascular Research); Berlin Germany
| | - Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery; Deutsches Herzzentrum Berlin; Berlin D-13353 Germany
- DZHK (German Centre for Cardiovascular Research); Berlin Germany
| |
Collapse
|
14
|
Abstract
Heart failure is associated with remodeling that consists of adverse cellular, structural, and functional changes in the myocardium. Until recently, this was thought to be unidirectional, progressive, and irreversible. However, irreversibility has been shown to be incorrect because complete or partial reversal can occur that can be marked after myocardial unloading with a left ventricular assist device (LVAD). Patients with chronic advanced heart failure can show near-normalization of nearly all structural abnormalities of the myocardium or reverse remodeling after LVAD support. However, reverse remodeling does not always equate with clinical recovery. The molecular changes occurring after LVAD support are reviewed, both those demonstrated with LVAD unloading alone in patients bridged to transplantation and those occurring in the myocardium of patients who have recovered enough myocardial function to have the device removed. Reverse remodeling may be attributable to a reversal of the pathological mechanisms that occur in remodeling or the generation of new pathways. A reduction in cell size occurs after LVAD unloading, which does not necessarily correlate with improved cardiac function. However, some of the changes in both the cardiac myocyte and the matrix after LVAD support are specific to myocardial recovery. In the myocyte, increases in the cytoskeletal proteins and improvements in the Ca²⁺ handling pathway seem to be specifically associated with myocardial recovery. Changes in the matrix are complex, but excessive scarring appears to limit the ability for recovery, and the degree of fibrosis in the myocardium at the time of implantation may predict the ability to recover.
Collapse
Affiliation(s)
- Emma J Birks
- Department of Cardiovascular Medicine, University of Louisville, Louisville, KY, USA.
| |
Collapse
|
15
|
Cabiati M, Caselli C, Caruso R, Prescimone T, Verde A, Botta L, Parodi O, Ry SD, Giannessi D. High peripheral levels of h-FABP are associated with poor prognosis in end-stage heart failure patients with mechanical circulatory support. Biomark Med 2013; 7:481-92. [DOI: 10.2217/bmm.13.6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To associate the time-course of h-FABP and N-terminal pro B-type natriuretic peptide (NT-proBNP)after left ventricular assist device (LVAD) implantation to outcome in end-stage heart failure patients. Materials & methods: Patients (n = 14, NYHA class III/IV; left ventricular ejection fraction <25% were enrolled; ten survived up to 1 month after LVAD (survivors) and four died of multiorgan failure within 2 weeks (nonsurvivors). Blood samples were obtained at admission; at 4, 24 and 72 h; and at 1 and 4 weeks after LVAD. Results: h-FABP significantly increases after surgery, decreasing since 72 h in all patients. At 72 h all survivor patients present h-FABP lower than the median value. N-terminal pro B-type natriuretic peptide is not associated with patient outcome at any time. Conclusion: High h-FABP levels, indicating the presence of more severe myocardial damage, are associated with a poor prognosis in patients with LVAD, suggesting that an early cardiac injury marker could improve the prediction of clinical outcome.
Collapse
Affiliation(s)
- Manuela Cabiati
- CNR Institute of Clinical Physiology, Laboratory of Cardiovascular Biochemistry, Via G Moruzzi 1, 56121 Pisa, Italy
| | - Chiara Caselli
- CNR Institute of Clinical Physiology, Laboratory of Cardiovascular Biochemistry, Via G Moruzzi 1, 56121 Pisa, Italy
| | | | - Tommaso Prescimone
- CNR Institute of Clinical Physiology, Laboratory of Cardiovascular Biochemistry, Via G Moruzzi 1, 56121 Pisa, Italy
| | - Alessandro Verde
- Cardiothoracic & Vascular Department, Niguarda Ca’ Granda Hospital, Milan, Italy
| | - Luca Botta
- Cardiothoracic & Vascular Department, Niguarda Ca’ Granda Hospital, Milan, Italy
| | | | - Silvia Del Ry
- CNR Institute of Clinical Physiology, Laboratory of Cardiovascular Biochemistry, Via G Moruzzi 1, 56121 Pisa, Italy
| | - Daniela Giannessi
- CNR Institute of Clinical Physiology, Laboratory of Cardiovascular Biochemistry, Via G Moruzzi 1, 56121 Pisa, Italy.
| |
Collapse
|
16
|
George RS, Birks EJ, Cheetham A, Webb C, Smolenski RT, Khaghani A, Yacoub MH, Kelion A. The effect of long-term left ventricular assist device support on myocardial sympathetic activity in patients with non-ischaemic dilated cardiomyopathy. Eur J Heart Fail 2013; 15:1035-43. [PMID: 23610136 DOI: 10.1093/eurjhf/hft059] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Dilated cardiomyopathy (DCM) patients have abundant levels of norepinephrine secondary to failure of the norepinephrine transporter uptake mechanism. Little is known about the effects of an LV assist device (LVAD) on cardiac sympathetic innervations and norepinephrine transporter dysfunction. This study examines the effects of continuous-flow HeartMate II LVAD on cardiac sympathetic innervations using [(123)I]metaiodobenzylguanidine ([(123)I]MIBG) nuclear imaging. METHODS AND RESULTS After injecting 431 ± 21 MBq of [(123)I]MIBG, planar scintigraphy was performed at 15 min and 4 h in 14 consecutive non-diabetic non-ischaemic DCM patients. Scans were executed early post-LVAD implantation (T1) and prior to either device explantation for myocardial recovery or transplant listing (T2). [(123)I]MIBG measured parameters included early and delayed heart-mediastinum (H/M) ratios and washout rate (W/O). Catecholamine levels were measured using liquid chromatography-mass spectrometry. Following 208.4 ± 85.5 days of LVAD support, both early and delayed H/M ratios increased by 42.1% (P < 0.001) and 54.7% (P < 0.001), respectively. The W/O rate decreased by 46% (P = 0.003). Plasma norepinephrine, epinephrine, and dopamine decreased significantly in correlation with [(123)I]MIBG parameters. Ten patients had recovered and had their device explanted as they had demonstrated a higher percentage change in delayed H/M ratio, W/O rate, and norepinephrine levels. Linear regression analysis revealed a strong correlation between percentage changes in both norepinephrine and epinephrine and myocardial recovery. CONCLUSION Combination therapy with LVAD and drug resulted in enhancement of [(123)I]MIBG uptake in DCM patients.
Collapse
|
17
|
Myokarderholung unter mechanischer Ventrikelentlastung und Entwöhnung vom ventrikulären Unterstützungssystem. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2012. [DOI: 10.1007/s00398-012-0939-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
18
|
Effects of Left Ventricular Assist Device (LVAD) Placement on Myocardial Oxidative Stress Markers. Heart Lung Circ 2012; 21:586-97. [DOI: 10.1016/j.hlc.2012.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Revised: 04/20/2012] [Accepted: 04/23/2012] [Indexed: 11/18/2022]
|
19
|
Drakos SG, Kfoury AG, Stehlik J, Selzman CH, Reid BB, Terrovitis JV, Nanas JN, Li DY. Bridge to recovery: understanding the disconnect between clinical and biological outcomes. Circulation 2012; 126:230-41. [PMID: 22777666 PMCID: PMC3714227 DOI: 10.1161/circulationaha.111.040261] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Stavros G Drakos
- Division of Cardiology, University of Utah School of Medicine, Salt Lake City, USA.
| | | | | | | | | | | | | | | |
Collapse
|
20
|
|
21
|
Abstract
The use of left ventricular assist devices to induce substantial myocardial recovery with explantation of the device, bridge to recovery (BTR), is an exciting but currently grossly underused application. Recently acquired knowledge relating to BTR and its mechanisms offers unprecedented opportunities to streamline its use and unravel some of the secrets of heart failure with much wider implications. This article reviews the status, challenges, and future of cardiac recovery.
Collapse
Affiliation(s)
- Michael Ibrahim
- Heart Science Centre, Magdi Yacoub Institute, Harefield Hospital, London, UK
| | | | | |
Collapse
|
22
|
Dullens HFJ, Schipper MEI, van Kuik J, Sohns W, Scheenstra M, van Wichen DF, Van Oosterhout MFM, de Jonge N, de Weger RA. Integrin expression during reverse remodeling in the myocardium of heart failure patients. Cardiovasc Pathol 2011; 21:291-8. [PMID: 22100988 DOI: 10.1016/j.carpath.2011.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Revised: 07/14/2011] [Accepted: 09/27/2011] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The main anchoring proteins of myocardial cells with each other and with the extracellular matrix are integrins present in the membranes of myocardial cells. These integrins are important for maintaining the architecture of the myocardial tissue and the mechanotransduction in the heart. Heart failure leads to various alterations in the myocardium, such as changes in morphology, and in expression of mRNAs, miRNAs, and proteins. Left ventricular assist device (LVAD) support in heart failure patients has been described to induce reverse remodeling of the myocardium and thus to (some degree of) reversal of the aforementioned alterations. In this study, we evaluated whether changes in expression of integrins α-1, -3, -5, -6, -7, -10, -11 and β-1, -3, -5 and -6 play a role during reverse remodeling. METHODS Three-step immunoperoxidase staining procedures were applied on frozen heart tissue sections to locate the various integrins tested. Integrin mRNA expression was established by standard Q-PCR procedures. RESULTS It was shown that mRNA expression of several integrins changes significantly during LVAD support, however without subsequent changes in immunohistochemical detectable quantities. Various integrins showed different locations within the myocardium. CONCLUSION LVAD-induced reversed remodeling did not result in significant integrin protein expression, although changes in integrin mRNA expression suggested an adaptation to unloading.
Collapse
Affiliation(s)
- Hub F J Dullens
- Molecular and Immuno Pathology, Department of Pathology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Platelet activation in heart failure patients supported by the HeartMate II ventricular assist device. Int J Artif Organs 2011; 34:461-8. [PMID: 21725928 DOI: 10.5301/ijao.2011.8459] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Thromboembolic events have been observed in heart failure (HF) patients supported by long-term mechanical circulatory support (MCS) devices. It has been hypothesized that these adverse events may be the result of platelet activation associated with high rotational speeds common to axial flow pumps. In this study, markers of platelet activation were investigated in HF patients supported by a HeartMate II left ventricular assist device (LVAD). METHODS The study group consisted of 34 HF patients supported by a HeartMate II axial flow LVAD implanted for destination therapy (DT). This patient population was 94% male (31 M, 3 F), supported by LVAD for 30 to 723 days (average 268 days), and with an anticoagulation regimen of Coumadin (0-8 mg daily dose) and aspirin (0-325 mg daily dose). Platelet adhesion markers (soluble P-selectin and solube CD40 ligand), platelet count (PC), hematocrit (Hct), and creatinine (Cr) were measured. RESULTS The soluble P-selectin marker was within normal platelet activity limits for all end points. The soluble CD40 ligand marker indicated platelet inactivity for all end points. Despite high shear stresses associated with a high-speed axial flow pump, the HeartMate II had no discernable effect on platelet activation. Current clinical doses of aspirin also appear to have little effect on platelet activation. Platelet count, hematocrit, and creatinine were normal in these patients over duration of support. CONCLUSIONS There were no discernable changes in platelet activation markers soluble P-selectin and soluble CD40 ligand in HF patients support by HeartMate II LVAD independently of length of support, anti-platelet, and anti-coagulation regimens.
Collapse
|
24
|
Affiliation(s)
- Magdi H. Yacoub
- From Imperial College London, Harefield Heart Science Centre, Middlesex, UB9 6JH, United Kingdom
| | - Cesare M. Terracciano
- From Imperial College London, Harefield Heart Science Centre, Middlesex, UB9 6JH, United Kingdom
| |
Collapse
|
25
|
Ambardekar AV, Buttrick PM. Reverse remodeling with left ventricular assist devices: a review of clinical, cellular, and molecular effects. Circ Heart Fail 2011; 4:224-33. [PMID: 21406678 DOI: 10.1161/circheartfailure.110.959684] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Amrut V Ambardekar
- Division of Cardiology, University of Colorado Denver, Aurora, CO 80045, USA.
| | | |
Collapse
|
26
|
Felkin LE, Lara-Pezzi EA, Hall JL, Birks EJ, Barton PJR. Reverse Remodelling and Recovery from Heart Failure Are Associated with Complex Patterns of Gene Expression. J Cardiovasc Transl Res 2011; 4:321-31. [DOI: 10.1007/s12265-011-9267-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Accepted: 02/15/2011] [Indexed: 11/30/2022]
|
27
|
Molecular Changes Occurring During Reverse Remodelling Following Left Ventricular Assist Device Support. J Cardiovasc Transl Res 2010; 3:635-42. [DOI: 10.1007/s12265-010-9220-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 08/20/2010] [Indexed: 10/19/2022]
|
28
|
Abstract
Patients with chronic advanced heart failure unloaded by left ventricular assist devices can show improvement in their myocardial function and some can show "reverse remodeling" to the extent that their myocardial function improves sufficiently for the device to be removed. Furthermore, recent data suggest that combining mechanical support with adjuvant drug therapy can increase the rate and proportion of recovery as well as its durability. This article will review the evidence for myocardial recovery in patients with chronic heart failure and whether it is a "real" phenomenon.
Collapse
Affiliation(s)
- Emma J Birks
- University of Louisville and Jewish Hospital, Louisville, KY 40202, USA.
| |
Collapse
|
29
|
Duration of left ventricular assist device support: Effects on abnormal calcium cycling and functional recovery in the failing human heart. J Heart Lung Transplant 2010; 29:554-61. [DOI: 10.1016/j.healun.2009.10.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Revised: 10/22/2009] [Accepted: 10/26/2009] [Indexed: 11/18/2022] Open
|
30
|
Mohapatra B, Vick GW, Fraser CD, Clunie SK, Towbin JA, Sinagra G, Vatta M. Short-term mechanical unloading and reverse remodeling of failing hearts in children. J Heart Lung Transplant 2009; 29:98-104. [PMID: 19783184 DOI: 10.1016/j.healun.2009.06.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 06/13/2009] [Accepted: 06/20/2009] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Mechanical support using a left ventricular assist device (LVAD) can lead to functional recovery of the myocardium in patients with end-stage heart failure (HF). Molecular remodeling, cytoskeletal disruption, and apoptosis activation are associated with abnormal gene expression in the failing ventricular myocardium of HF subjects and can normalize in response to medium- and long-term mechanical unloading in adults. However, there is little knowledge of the changes in gene expression after short-term mechanical support in children with HF. METHODS We evaluated left ventricular biopsies from 4 children with HF. The children had implantation of a continuous- or a pulsatile-flow LVAD for 8 to 16 days before undergoing heart transplantation. At the time of LVAD insertion and removal, we performed quantitative real-time polymerase chain reaction (QPCR) to study the expression of 326 genes encoding for structural, transcriptional, and signaling pathways proteins, and immunoblot analysis on dystrophin and apoptotic factors. RESULTS Short-term LVAD therapy significantly decreased brain natriuretic peptide (BNP) levels from pre-LVAD (3,584.5 +/- 378.3 pg/ml [95% CI]) to post-LVAD (447.5 +/- 52.7 pg/ml [95% CI]) in 2 patients in whom comparative BNP measurements were available. In addition, short-term LVAD therapy reduced HF and apoptosis markers, whereas it upregulated structural proteins, including dystrophin, as well as pro-hypertrophic and pro-inotropic markers. Furthermore, LVAD therapy normalized expression of genes involved in calcium homeostasis, cell growth, and differentiation. CONCLUSIONS Our pilot study suggests that even short-term LVAD therapy in children with severe HF can reverse molecular remodeling. This favorable effect should be taken into consideration in eligible children with significant ventricular dysfunction.
Collapse
Affiliation(s)
- Bhagyalaxmi Mohapatra
- Department of Pediatric Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas 77030, USA
| | | | | | | | | | | | | |
Collapse
|
31
|
Schipper MEI, van Kuik J, de Jonge N, Dullens HFJ, de Weger RA. Changes in regulatory microRNA expression in myocardium of heart failure patients on left ventricular assist device support. J Heart Lung Transplant 2009; 27:1282-5. [PMID: 19059107 DOI: 10.1016/j.healun.2008.09.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Revised: 08/28/2008] [Accepted: 09/03/2008] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Left ventricular assist device support in heart failure patients leads to changes in mRNA and protein expression in the myocardium. METHODS MicroRNA's are important regulators of various cellular processes, so changes in their expression were tested by Q-PCR methods. RESULTS LVAD support (independently of the duration) leads to a decrease of the expression of miR-1, miR-133a and miR-133b in DCM patients but to an increase in expression in IHD patients. The expression of miR's pre- and post-LVAD in heart failure patients was low compared to the level of miR's in control myocardial tissue. CONCLUSIONS Alterations in miRs expression might also be important during repair processes in IHD patients.
Collapse
|
32
|
Malliaras KG, Terrovitis JV, Drakos SG, Nanas JN. Reverse cardiac remodeling enabled by mechanical unloading of the left ventricle. J Cardiovasc Transl Res 2008; 2:114-25. [PMID: 20559975 DOI: 10.1007/s12265-008-9057-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2008] [Accepted: 09/05/2008] [Indexed: 01/28/2023]
Abstract
Cardiac remodeling is a characteristic and basic component of heart failure progression and is associated with a poor prognosis. Attenuating or reversing remodeling is an accepted goal of heart failure therapy. Cardiac mechanical support with left ventricular assist devices, in addition to its established role as "bridge to transplantation" or "destination therapy" in patients not eligible for cardiac transplantation, offers the potential for significant and sustained myocardial recovery through reverse remodeling. This review discusses the emerging role of left ventricular assist devices as a "bridge to recovery". Clinical and basic aspects of cardiac remodeling and cardiac reverse remodeling enabled by mechanical unloading, potential candidates for this modality of treatment as well as unresolved issues regarding the use of mechanical circulatory support as a bridge to recovery are discussed.
Collapse
|
33
|
Abstract
PURPOSE OF REVIEW There is considerable increase in the use of left ventricular assist devices for the treatment of severe heart failure. Traditionally viewed as a bridge to transplantation and more recently as a destination therapy, left ventricular assist device support is now recognized to offer potential for myocardial recovery through reverse remodeling, a potential that is further enhanced by combination with pharmacologic therapy. In this study, we examine the molecular changes associated with left ventricular assist device support and how these may contribute to the recovery process. RECENT FINDINGS Studies in both patients and experimental models have demonstrated that improved function is associated with alterations in several key pathways including cell survival, cytokine signaling, calcium handling, adrenergic receptor signaling, cytoskeletal and contractile proteins, energy metabolism, extracellular matrix, and endothelial and microvascular functions. Moreover, the unique research opportunities offered by left ventricular assist device analysis are beginning to distinguish changes associated with recovery from those of mechanical unloading alone and identify potential predictors and novel therapeutic targets capable of enhancing myocardial repair. SUMMARY Significant progress has been made toward revealing molecular changes associated with myocardial recovery from heart failure. These studies also offer new insight into the pathogenesis of heart failure and point to novel therapeutic strategies.
Collapse
|
34
|
Klotz S, Jan Danser AH, Burkhoff D. Impact of left ventricular assist device (LVAD) support on the cardiac reverse remodeling process. PROGRESS IN BIOPHYSICS AND MOLECULAR BIOLOGY 2008; 97:479-96. [PMID: 18394685 DOI: 10.1016/j.pbiomolbio.2008.02.002] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
With improved technology and expanding indications for use, left ventricular assist devices (LVADs) are assuming a greater role in the care of patients with end-stage heart failure. Following LVAD implantation with the intention of bridge to transplant, it became evident that some patients exhibit substantial recovery of ventricular function. This prompted explantation of some devices in lieu of transplantation, the so-called bridge-to-recovery (BTR) therapy. However, clinical outcomes following these experiences are not always successful. Patients treated in this fashion have often progressed rapidly back to heart failure. Special knowledge has emerged from studies of hearts supported by LVADs that provides insights into the basic mechanisms of ventricular remodeling and possible limits of ventricular recovery. In general, it was these studies that spawned the concept of reverse remodeling now recognized as an important goal of many heart failure treatments. Important examples of myocardial and/or ventricular properties that do not regress towards normal during LVAD support include abnormal extracellular matrix metabolism, increased tissue angiotensin levels, myocardial stiffening and partial recovery of gene expression involved with metabolism. Nevertheless, studies of LVAD-heart interactions have led to the understanding that although we once considered the end-stage failing heart of patients near death to be irreversibly diseased, an unprecedented degree of myocardial recovery is possible, when given sufficient mechanical unloading and restoration of more normal neurohormonal milieu. Evidence supporting and unsupporting the notion of reverse remodeling and clinical implications of this process will be reviewed.
Collapse
Affiliation(s)
- Stefan Klotz
- Department of Thoracic and Cardiovascular Surgery, University Hospital Muenster, Albert-Schweitzer-Str. 33, Muenster, Germany.
| | | | | |
Collapse
|