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Lisi M, Luisi GA, Pastore MC, Mandoli GE, Benfari G, Ilardi F, Malagoli A, Sperlongano S, Henein MY, Cameli M, D'Andrea A. New perspectives in the echocardiographic hemodynamics multiparametric assessment of patients with heart failure. Heart Fail Rev 2024; 29:799-809. [PMID: 38507022 PMCID: PMC11189326 DOI: 10.1007/s10741-024-10398-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2024] [Indexed: 03/22/2024]
Abstract
International Guidelines consider left ventricular ejection fraction (LVEF) as an important parameter to categorize patients with heart failure (HF) and to define recommended treatments in clinical practice. However, LVEF has some technical and clinical limitations, being derived from geometric assumptions and is unable to evaluate intrinsic myocardial function and LV filling pressure (LVFP). Moreover, it has been shown to fail to predict clinical outcome in patients with end-stage HF. The analysis of LV antegrade flow derived from pulsed-wave Doppler (stroke volume index, stroke distance, cardiac output, and cardiac index) and non-invasive evaluation of LVFP have demonstrated some advantages and prognostic implications in HF patients. Speckle tracking echocardiography (STE) is able to unmask intrinsic myocardial systolic dysfunction in HF patients, particularly in those with LV preserved EF, hence allowing analysis of LV, right ventricular and left atrial (LA) intrinsic myocardial function (global peak atrial LS, (PALS)). Global PALS has been proven a reliable index of LVFP which could fill the gaps "gray zone" in the previous Guidelines algorithm for the assessment of LV diastolic dysfunction and LVFP, being added to the latest European Association of Cardiovascular Imaging Consensus document for the use of multimodality imaging in evaluating HFpEF. The aim of this review is to highlight the importance of the hemodynamics multiparametric approach of assessing myocardial function (from LVFP to stroke volume) in patients with HF, thus overcoming the limitations of LVEF.
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Affiliation(s)
- Matteo Lisi
- Department of Cardiovascular Disease-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121, Ravenna, Italy.
| | - Giovanni Andrea Luisi
- Department of Cardiovascular Disease-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121, Ravenna, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Giovanni Benfari
- Section of Cardiology, Department of Medicine, University of Verona, Verona, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Via S. Pansini 5, 80131, Naples, Italy
- Mediterranea Cardiocentro, 80122, Naples, Italy
| | - Alessandro Malagoli
- Division of Cardiology, Nephro-Cardiovascular Department, Baggiovara Hospital, Baggiovara, Italy
| | - Simona Sperlongano
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Michael Y Henein
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Matteo Cameli
- Department of Cardiovascular Disease-AUSL Romagna, Division of Cardiology, Ospedale S. Maria delle Croci, Viale Randi 5, 48121, Ravenna, Italy
| | - Antonello D'Andrea
- Department of Cardiology, Umberto I Hospital, 84014, Nocera Inferiore, SA, Italy
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Kodur N, Tang WHW. Myocardial Recovery and Relapse in Heart Failure With Improved Ejection Fraction. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2024; 26:139-160. [PMID: 38993352 PMCID: PMC11238717 DOI: 10.1007/s11936-024-01038-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/13/2024]
Abstract
Purpose of review The purpose of this review is to discuss myocardial recovery in heart failure with reduced ejection fraction (HFrEF) and to summarize the contemporary insights regarding heart failure with improved ejection fraction (HFimpEF). Recent findings Improvement in left ventricular ejection fraction (LVEF ≥ 40%) with improved prognosis can be achieved in one out of three (10-40%) patients with HFrEF treated with guideline-directed medical therapy. Clinical predictors include non-ischemic etiology of HFrEF, less abnormal blood or imaging biomarkers, and lack of specific pathogenic genetic variants. However, a subset of patients may ultimately relapse, suggesting that many patients are merely in remission rather than having fully recovered. Summary Patients with HFimpEF have improved prognosis but nonetheless remain at risk of relapse and long-term adverse events. Future studies will hopefully chart the natural history of HFimpEF and identify clinical predictors such as blood or novel imaging biomarkers that distinguish subgroups of patients based on differential trajectory and prognosis.
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Affiliation(s)
- Nandan Kodur
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, US
| | - W. H. Wilson Tang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, US
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, US
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Kasiakogias A, Ragavan A, Halliday BP. Your Heart Function Has Normalized-What Next After TRED-HF? Curr Heart Fail Rep 2023; 20:542-554. [PMID: 37999902 PMCID: PMC10746577 DOI: 10.1007/s11897-023-00636-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 11/25/2023]
Abstract
PURPOSE OF REVIEW With the widespread implementation of contemporary disease-modifying heart failure therapy, the rates of normalization of ejection fraction are continuously increasing. The TRED-HF trial confirmed that heart failure remission rather than complete recovery is typical in patients with dilated cardiomyopathy who respond to therapy. The present review outlines key points related to the management and knowledge gaps of this growing patient group, focusing on patients with non-ischaemic dilated cardiomyopathy. RECENT FINDINGS There is substantial heterogeneity among patients with normalized ejection fraction. The specific etiology is likely to affect the outcome, although a multiple-hit phenotype is frequent and may not be identified without comprehensive characterization. A monogenic or polygenic genetic susceptibility is common. Ongoing pathophysiological processes may be unraveled with advanced cardiac imaging, biomarkers, multi-omics, and machine learning technologies. There are limited studies that have investigated the withdrawal of specific heart failure therapies in these patients. Diuretics may be safely withdrawn if there is no evidence of congestion, while continued therapy with at least some disease-modifying therapy is likely to be required to reduce myocardial workload and sustain remission for the vast majority. Understanding the underlying disease mechanisms of patients with normalized ejection fraction is crucial in identifying markers of myocardial relapse and guiding individualized therapy in the future. Ongoing clinical trials should inform personalized approaches to therapy.
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Affiliation(s)
- Alexandros Kasiakogias
- Inherited Cardiac Conditions Care Group, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Aaraby Ragavan
- Inherited Cardiac Conditions Care Group, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Brian P Halliday
- Inherited Cardiac Conditions Care Group, Royal Brompton and Harefield Hospitals, Part of Guy's and St Thomas' NHS Foundation Trust, London, UK.
- National Heart and Lung Institute, Imperial College London, London, UK.
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Takada T, Nakata Y, Matsuura K, Minami Y, Kishihara M, Watanabe S, Shirotani S, Abe T, Yoshida A, Hasegawa S, Jujo K, Arai K, Suzuki A, Hagiwara N, Yamaguchi J. Left Ventricular End-Systolic Diameter May Predict Persistent Heart Failure with Reduced Ejection Fraction. Int Heart J 2023; 64:1095-1104. [PMID: 37967983 DOI: 10.1536/ihj.23-293] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
Patients with persistent heart failure (HF) with reduced ejection fraction (HFrEF) have a poorer prognosis than those with HF with improved ejection fraction (HFimpEF). However, data on the predictive value of echocardiographic parameters for persistent HFrEF are lacking. We retrospectively studied 443 patients who were diagnosed with HFrEF (EF ≤ 40%) during hospitalization and underwent echocardiography at the 1-year follow-up. We divided them into the 2 groups: HFimpEF (EF > 40%) and persistent HFrEF group at 1-year follow-up, and assessed the predictive value of echocardiographic parameters at discharge for persistent HFrEF. In total, 301/443 patients (68%) were diagnosed with persistent HFrEF and 142/443 (32%) with HFimpEF at the 1-year follow-up. Kaplan-Meier analysis revealed that the persistent HFrEF group had a poorer prognosis than the HFimpEF group (log-rank, P < 0.001). Receiver operating characteristic curve analysis revealed that left ventricular end-systolic diameter (LVESD) had the highest area under the curve (AUC) (0.70; 95% confidence interval [CI]: 0.64-0.75; cutoff value: 55 mm) among various echocardiographic parameters. LVESD was an independent predictor of persistent HFrEF at the 1-year follow-up (odds ratio: 1.07, 95%CI: 1.02-1.12) upon multivariable logistic regression analysis. The incidence of persistent HFrEF was higher in patients with an LVESD ≥ 55 mm than in those with an LVESD < 55 mm (81% versus 55%, Fisher's exact test, P < 0.001). In conclusion, an LVESD (≥ 55 mm) was associated with persistent HFrEF. Focusing on LVESD in daily practice may help clinicians with risk stratification for decision-making regarding management in patients with advanced HF refractory to guideline-directed medical therapy.
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Affiliation(s)
- Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University
| | - Yuki Nakata
- Department of Cardiology, Tokyo Women's Medical University
| | - Katsuhisa Matsuura
- Department of Cardiology, Tokyo Women's Medical University
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University
| | | | | | | | | | - Takuro Abe
- Department of Cardiology, Tokyo Women's Medical University
| | - Ayano Yoshida
- Department of Cardiology, Tokyo Women's Medical University
| | - Shun Hasegawa
- Department of Cardiology, Tokyo Women's Medical University
| | - Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University
| | - Kotaro Arai
- Department of Cardiology, Tokyo Women's Medical University
| | - Atsushi Suzuki
- Department of Cardiology, Tokyo Women's Medical University
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McElderry B, O'Neill T, Griffin BP, Kalahasti V, Barzilai B, Brateanu A. Factors Associated With Maintenance of an Improved Ejection Fraction: An Echocardiogram-Based Registry Study. J Am Heart Assoc 2023; 12:e031093. [PMID: 37889194 PMCID: PMC10727417 DOI: 10.1161/jaha.123.031093] [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: 05/20/2023] [Accepted: 10/03/2023] [Indexed: 10/28/2023]
Abstract
Background Heart failure with improved ejection fraction (EF) is increasingly recognized as a sizable and distinct entity. While the features associated with improvedEF have been explored and new guidelines have emerged, factors associated with sustaining an improved EF over time have not been defined. We aimed to assess factors associated with maintenance of an improved EF in a large real-world patient cohort. Methods and Results A total of 7070 participants with heart failure with improved EF and a subsequent echocardiogram performed after at least 9 months of follow-up were included in a retrospective cohort study conducted at the Cleveland Clinic in Cleveland, Ohio. Multiple logistic regression models, adjusted for demographics, comorbidities, and medications were built to identify characteristics and therapeutic interventions associated with maintaining an improved EF. Mean age (SD) was 64.9 (13.8) years, 62.7% were men, and 75.1% were White participants. White race and the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor-neprilysin inhibitors were associated with maintaining the EF at least 9 months after EF improvement. In contrast, male sex or having atrial fibrillation/flutter, coronary artery disease, history of myocardial infarction, presence of an implanted cardioverter-defibrillator, and use of loop diuretics were associated with a decline in EF after previously documented improvement. Conclusions Continued use of renin-angiotensin-aldosterone system inhibitors was associated with maintaining the EF beyond the initial improvement phase.
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Affiliation(s)
| | - Thomas O'Neill
- Case Western Reserve University, School of MedicineClevelandOHUSA
| | - Brian P. Griffin
- Department of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
- Cleveland ClinicLerner College of MedicineClevelandOHUSA
| | - Vidyasagar Kalahasti
- Department of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
- Cleveland ClinicLerner College of MedicineClevelandOHUSA
| | - Benico Barzilai
- Department of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
| | - Andrei Brateanu
- Department of MedicineCleveland ClinicClevelandOHUSA
- Cleveland ClinicLerner College of MedicineClevelandOHUSA
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Matsuura K, Shimizu T. Cardiac cell sheet engineering for regenerative medicine and tissue modeling. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2023; 199:179-197. [PMID: 37678971 DOI: 10.1016/bs.pmbts.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
Stem cell biology and tissue engineering are essential techniques for cardiac tissue construction. We have succeeded in fabricating human cardiac tissue using the mass production technology of human iPS cell-derived cardiomyocytes and cell sheet engineering, and we are developing regenerative medicine and tissue models to apply this tissue to heart disease research. Cardiac tissue fabrication and tissue functional evaluation technologies for contractile and electrophysiological function are indispensable, which lead to the functional improvement of bioengineered human cardiac tissue.
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Affiliation(s)
- Katsuhisa Matsuura
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University.
| | - Tatsuya Shimizu
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University
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Lund LH, Zeymer U, Clark AL, Barrios V, Damy T, Drożdż J, Fonseca C, Kalus S, Ferber PC, Koch C, Maggioni AP. Association between sacubitril/valsartan initiation and changes in left ventricular ejection fraction: Insights from ARIADNE registry. Int J Cardiol 2023; 370:279-286. [PMID: 36216094 DOI: 10.1016/j.ijcard.2022.10.012] [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: 08/08/2022] [Revised: 09/29/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022]
Abstract
AIMS We tested the hypothesis that initiation versus non-initiation of sacubitril/valsartan is associated with a more favorable subsequent change in left ventricular ejection fraction (LVEF) in a real-world setting. METHODS A prospective, non-randomized, double-arm, open-label, cohort study had been conducted across 687 centers in 17 European countries enrolling HFrEF patients aged ≥18 years with symptoms of HF (New York Heart Association [NYHA] II-IV) and "reduced LVEF". For the current analysis, 2602 patients with LVEF measured at baseline and follow-up were chosen, of which 860 (33%, mean age 67 years, 26% women) were started on sacubitril/valsartan at baseline and 1742 (67%, 68 years, 23% women) were not. Patients started on sacubitril/valsartan had higher NYHA class and lower LVEF. RESULTS LVEF increased from mean 32.7% to 38.1% in the sacubitril/valsartan group versus from 35.9% to 38.7% in the non-sacubitril/valsartan group (mean difference in increase 2.6%, p < 0.001). LVEF increased from baseline in 64% versus 53% of patients and increased by ≥5% (absolute %) in 50% versus 35% of patients in the sacubitril/valsartan versus non-sacubitril/valsartan groups, respectively. In the overall cohort, initiation of sacubitril/valsartan was independently associated with any increase in LVEF (adjusted odds ratio [OR] 1.49 [1.26-1.75]) and with increase by ≥5% (OR 1.65 [1.39-1.95]). CONCLUSION Initiating versus not initiating sacubitril/valsartan was independently associated with a greater subsequent increase in LVEF in this real-world setting. Reverse cardiac remodeling may be one mechanism of benefit of sacubitril/valsartan.
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Affiliation(s)
- Lars H Lund
- Department of Medicine, Karolinska Institutet, And Heart Vascular and Neuro Theme Karolinska University Hospital, Stockholm, Sweden.
| | - Uwe Zeymer
- Klinikum Ludwigshafen and Institut für Herzinfarktforschung, Ludwigshafen-am-Rhein, Germany
| | - Andrew L Clark
- Castle Hill Hospital, Kingston Upon Hull, United Kingdom
| | | | - Thibaud Damy
- University Hospital Henri Mondor, Créteil, France
| | | | - Candida Fonseca
- Hospital de Sao Francisco Xavier, CHLO, NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Stefanie Kalus
- GKM Gesellschaft für Therapieforschung mbH, Munich, Germany
| | | | | | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy; Maria Cecilia Hospital, GVM Care & Research, Italy
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