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Tang F, Han H, Fu S, Liu Q, Zhou S, Huang J, Xiao Y. Nonpharmacological Approaches to Managing Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2024; 17:e011269. [PMID: 38887946 PMCID: PMC11332382 DOI: 10.1161/circheartfailure.123.011269] [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: 09/25/2023] [Accepted: 04/29/2024] [Indexed: 06/20/2024]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a common subtype of heart failure marked by impaired left ventricular diastolic function and decreased myocardial compliance. Given the limited availability of evidence-based pharmacological treatments for HFpEF, there is a growing interest in nonpharmacological interventions as viable therapeutic alternatives. This review aims to explore the pathophysiology of HFpEF and present recent advancements in nonpharmacological management approaches, encompassing noninvasive therapies, invasive procedures and targeted treatments for comorbidities. An extensive literature review was undertaken to identify and synthesize emerging nonpharmacological treatment options for HFpEF, assessing their potential to enhance patient outcomes. Nonpharmacological strategies, such as vagus nerve stimulation, percutaneous pulmonary artery denervation, renal denervation, transcatheter insertion of atrial shunts and pericardial resection, demonstrate promising potential for alleviating HFpEF symptoms and improving patient prognosis. Moreover, addressing comorbidities, such as hypertension and diabetes, may offer additional therapeutic benefits. These cutting-edge techniques, in conjunction with well-established exercise therapies, pave the way for future research and clinical applications in the field. Nonpharmacological interventions hold promise for advancing HFpEF patient care and fostering a deeper understanding of these treatment approaches, which will facilitate new clinical applications and contribute to the development of more targeted therapies.
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Affiliation(s)
- Feiyang Tang
- Department of Cardiovascular Medicine, Second Xiangya Hospital (F.T., H.H., Q.L., S.Z., Y.X.), Central South University, Changsha, China
- Xiangya School of Medicine (F.T., H.H.), Central South University, Changsha, China
| | - Haofu Han
- Department of Cardiovascular Medicine, Second Xiangya Hospital (F.T., H.H., Q.L., S.Z., Y.X.), Central South University, Changsha, China
- Xiangya School of Medicine (F.T., H.H.), Central South University, Changsha, China
| | - Sheng Fu
- Division of Cardiovascular Medicine, Department of Medicine (S.F.), University of Louisville, KY
| | - Qiming Liu
- Department of Cardiovascular Medicine, Second Xiangya Hospital (F.T., H.H., Q.L., S.Z., Y.X.), Central South University, Changsha, China
| | - Shenghua Zhou
- Department of Cardiovascular Medicine, Second Xiangya Hospital (F.T., H.H., Q.L., S.Z., Y.X.), Central South University, Changsha, China
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine (J.H.), University of Louisville, KY
| | - Yichao Xiao
- Department of Cardiovascular Medicine, Second Xiangya Hospital (F.T., H.H., Q.L., S.Z., Y.X.), Central South University, Changsha, China
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Gustafsson F, Petrie MC, Komtebedde J, Swarup V, Winkler S, Hasenfuß G, Borlaug BA, Mohan RC, Flaherty JD, Sverdlov AL, Fail PS, Chung ES, Lurz P, Lilly S, Kaye DM, Cleland JGF, Cikes M, Leon MB, Cutlip DE, van Veldhuisen DJ, Solomon SD, Shah SJ. 2-Year Outcomes of an Atrial Shunt Device in HFpEF/HFmrEF: Results From REDUCE LAP-HF II. JACC. HEART FAILURE 2024; 12:1425-1438. [PMID: 38934964 DOI: 10.1016/j.jchf.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/10/2024] [Accepted: 04/18/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND The REDUCE LAP-HF II (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure II) trial found that, compared with a sham procedure, the Corvia Atrial Shunt did not improve outcomes in heart failure with preserved or mildly reduced ejection fraction. However, after 12-month follow-up, "responders" (peak-exercise pulmonary vascular resistance <1.74 WU and absence of a cardiac rhythm management device) were identified. OBJECTIVES This study sought to determine: 1) the overall efficacy and safety of the atrial shunt vs sham control after 2 years of follow-up; and 2) whether the benefits of atrial shunting are sustained in responders during longer-term follow-up or are offset by adverse effects of the shunt. METHODS The study analyzed 2-year outcomes in the overall REDUCE LAP-HF II trial, as well as in responder and nonresponder subgroups. The primary endpoint was a hierarchical composite of cardiovascular death or nonfatal ischemic/embolic stroke, total heart failure events, and change in health status. RESULTS In 621 randomized patients, there was no difference between the shunt (n = 309) and sham (n = 312) groups in the primary endpoint (win ratio: 1.01 [95% CI: 0.82-1.24]) or its individual components at 2 years. Shunt patency at 24 months was 98% in shunt-treated patients. Cardiovascular mortality and nonfatal ischemic stroke were not different between the groups; however, major adverse cardiac events were more common in those patients assigned to the shunt compared with sham (6.9% vs 2.7%; P = 0.018). More patients randomized to the shunt had an increase in right ventricular volume of ≥30% compared with the sham control (39% vs 28%, respectively; P < 0.001), but right ventricular dysfunction was uncommon and not different between the treatment groups. In responders (n = 313), the shunt was superior to sham (win ratio: 1.36 [95% CI: 1.02-1.83]; P = 0.037, with 51% fewer HF events [incidence rate ratio: 0.49 [95% CI: 0.25-0.95]; P = 0.034]). In nonresponders (n = 265), atrial shunting was inferior to sham (win ratio: 0.73 [95% CI: 0.54-0.98]). CONCLUSIONS At 2 years of follow-up in REDUCE LAP-HF II, there was no difference in efficacy between the atrial shunt and sham groups in the overall trial group. The potential clinical benefit identified in the responder group after 1 and 2 years of follow-up is currently being evaluated in the RESPONDER-HF (Re-Evaluation of the Corvia Atrial Shunt Device in a Precision Medicine Trial to Determine Efficacy in Mildly Reduced or Preserved Ejection Fraction Heart Failure) trial. (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure II [REDUCE LAP-HF II]; NCT03088033).
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Affiliation(s)
| | - Mark C Petrie
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | | | | | | | - Gerd Hasenfuß
- Heart Center, University Medical Center, Göttingen, Germany
| | | | | | - James D Flaherty
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Aaron L Sverdlov
- John Hunter Hospital, University of Newcastle, New Lambton Heights, Australia
| | - Peter S Fail
- Cardiovascular Institute of the South, Houma, Louisiana, USA
| | - Eugene S Chung
- The Lindner Research Center at The Christ Hospital, Cincinnati, Ohio, USA
| | - Philipp Lurz
- Cardiology Center, University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | | | | | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Maja Cikes
- University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Martin B Leon
- Cardiovascular Research Foundation, New York, New York, USA
| | - Donald E Cutlip
- Baim Clinical Research Institute, Boston, Massachusetts, USA
| | | | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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3
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Gulati G, Litwin SE. The Politics of HFpEF-What's Good for the Left Is Good for the Right. JAMA Cardiol 2024:2821145. [PMID: 39046754 DOI: 10.1001/jamacardio.2024.1925] [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: 07/25/2024]
Affiliation(s)
- Gaurav Gulati
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts
| | - Sheldon E Litwin
- Division of Cardiology, Medical University of South Carolina and the Ralph H. Johnson Veterans Affairs Health System, Charleston, South Carolina
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Reddy YNV, Carter RE, Sorimachi H, Omar M, Popovic D, Alogna A, Jensen MD, Borlaug BA. Dapagliflozin and Right Ventricular-Pulmonary Vascular Interaction in Heart Failure With Preserved Ejection Fraction: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2024:2821144. [PMID: 39046727 PMCID: PMC11270271 DOI: 10.1001/jamacardio.2024.1914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/17/2024] [Indexed: 07/25/2024]
Abstract
Importance Increases in pulmonary capillary wedge pressure (PCWP) during exercise reduce pulmonary artery (PA) compliance, increase pulsatile right ventricular (RV) afterload, and impair RV-PA coupling in patients with heart failure with preserved ejection fraction (HFpEF). The effects of the sodium-glucose cotransporter 2 (SGLT2) inhibitor dapagliflozin on pulmonary vascular properties and RV-PA coupling are unknown. Objective To test the effect of dapagliflozin on right ventricular performance and pulmonary vascular load during exertion in HFpEF. Design, Setting, and Participants Evaluation of the Cardiac and Metabolic Effects of Dapagliflozin in Heart Failure With Preserved Ejection Fraction (CAMEO-DAPA) randomized clinical trial demonstrated improvement in PCWP at rest and exercise over 24 weeks with dapagliflozin compared with placebo with participants recruited between February 2021 and May 2022. This secondary analysis evaluates the effects of dapagliflozin on pulsatile pulmonary vascular load and RV-PA coupling using simultaneous echocardiography and high-fidelity invasive hemodynamic testing with exercise. This was a single-center study including patients with hemodynamically confirmed HFpEF with exercise PCWP of 25 mm Hg or greater. Interventions Dapagliflozin or placebo for 24 weeks. Main Outcomes and Measures Pulsatile pulmonary vascular load (PA compliance and elastance) and right ventricular performance (PA pulsatility index, RV systolic velocity [s']/PA mean) during rest and exercise. Results Among 37 randomized participants (mean [SD] age, 67.4 [8.5] years; 25 female [65%]; mean [SD] body mass index, 34.9 [6.7]; calculated as weight in kilograms divided by height in meters squared), there was no effect of dapagliflozin on PA loading or RV-PA interaction at rest. However, with exercise, dapagliflozin improved PA compliance (placebo-corrected mean difference, 0.57 mL/mm Hg; 95% CI, 0.11-1.03 mL/mm Hg; P = .02) and decreased PA elastance (stiffness; -0.17 mm Hg/mL; 95% CI, -0.28 to -0.07 mm Hg/mL; P = .001). RV function during exercise improved, with increase in PA pulsatility index (0.33; 95% CI, 0.08-0.59; P = .01) and increase in exercise RV s' indexed to PA pressure (0.09 cm·s-1/mm Hg; 95% CI, 0.02-0.16 cm·s-1/mm Hg; P = .01). Improvements in pulsatile RV load and RV-PA coupling were correlated with reduction in right atrial (RA) pressure (PA elastance Pearson r = 0.55; P =.008; RV s'/PA elastance Pearson r = -0.60; P =.002) and PCWP (PA elastance Pearson r = 0.58; P <.001; RV s'/PA elastance Pearson r = -0.47; P = .02). Dapagliflozin increased resistance-compliance time (dapagliflozin, median [IQR] change, 0.06 [0.03-0.15] seconds; placebo, median [IQR] change, 0.01 [-0.02 to 0.05] seconds; P =.046), resulting in higher PA compliance for any exercise pulmonary vascular resistance. Conclusions and Relevance Results of this randomized clinical trial reveal that treatment with dapagliflozin for 24 weeks reduced pulsatile pulmonary vascular load and enhanced dynamic RV-PA interaction during exercise in patients with HFpEF, findings that are related to the magnitude of PCWP reduction. Benefits on dynamic right ventricular-pulmonary vascular coupling may partially explain the benefits of SGLT2 inhibitors in HFpEF. Trial Registration ClinicalTrials.gov Identifier: NCT04730947.
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Affiliation(s)
- Yogesh N. V. Reddy
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Rickey E. Carter
- Department of Quantitative Health Sciences, Division of Clinical Trials & Biostatistics, Mayo Clinic, Jacksonville, Florida
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
| | - Alessio Alogna
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
- Deutsches Herzzentrum der Charité, Department of Cardiology, Angiology and Intensive Care Medicine, Berlin, Germany
| | - Michael D. Jensen
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, Rochester, Minnesota
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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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Nanayakkara S, Burkhoff D, Komtebedde J, Kaye DM. Moving Toward Understanding the "hole" story in HFpEF. J Card Fail 2024:S1071-9164(24)00196-9. [PMID: 38866177 DOI: 10.1016/j.cardfail.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 05/13/2024] [Indexed: 06/14/2024]
Affiliation(s)
- Shane Nanayakkara
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Australia
| | | | | | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Australia; Monash-Alfred-Baker Centre for Cardiovascular Research, Monash University, Melbourne, Australia.
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Patel RB, Silvestry FE, Komtebedde J, Solomon SD, Hasenfuß G, Litwin SE, Borlaug BA, Price MJ, Kawash R, Hummel SL, Cutlip DE, Leon MB, van Veldhuisen DJ, Rieth AJ, McKenzie S, Bugger H, Mazurek JA, Kapadia SR, Vanderheyden M, Ky B, Shah SJ. Atrial Shunt Device Effects on Cardiac Structure and Function in Heart Failure With Preserved Ejection Fraction: The REDUCE LAP-HF II Randomized Clinical Trial. JAMA Cardiol 2024; 9:507-522. [PMID: 38630494 PMCID: PMC11024798 DOI: 10.1001/jamacardio.2024.0520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 02/10/2024] [Indexed: 04/19/2024]
Abstract
Importance Although the results of A Study to Evaluate the Corvia Medical Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure (REDUCE LAP-HF II) trial were neutral overall, atrial shunt therapy demonstrated potential efficacy in responders (no latent pulmonary vascular disease and no cardiac rhythm management device). Post hoc analyses were conducted to evaluate the effect of shunt vs sham stratified by responder status. Objective To evaluate the effect of atrial shunt vs sham control on cardiac structure/function in the overall study and stratified by responder status. Design, Setting, and Participants This was a sham-controlled randomized clinical trial of an atrial shunt device in heart failure with preserved ejection fraction (HFpEF)/HF with mildly reduced EF (HFmrEF). Trial participants with evaluable echocardiography scans were recruited from 89 international medical centers. Data were analyzed from April 2023 to January 2024. Interventions Atrial shunt device or sham control. Main Outcome Measures Changes in echocardiographic measures from baseline to 1, 6, 12, and 24 months after index procedure. Results The modified intention-to-treat analysis of the REDUCE LAP-HF II trial included 621 randomized patients (median [IQR] age, 72.0 [66.0-77.0] years; 382 female [61.5%]; shunt arm, 309 [49.8%]; sham control arm, 312 [50.2%]). Through 24 months, 212 of 217 patients (98%) in the shunt arm with evaluable echocardiograms had patent shunts. In the overall trial population, the shunt reduced left ventricular (LV) end-diastolic volume (mean difference, -5.65 mL; P <.001), left atrial (LA) minimal volume (mean difference, -2.8 mL; P =.01), and improved LV systolic tissue Doppler velocity (mean difference, 0.69 cm/s; P <.001) and LA emptying fraction (mean difference, 1.88 percentage units; P =.02) compared with sham. Shunt treatment also increased right ventricular (RV; mean difference, 9.58 mL; P <.001) and right atrial (RA; mean difference, 9.71 mL; P <.001) volumes but had no effect on RV systolic function, pulmonary artery pressure, or RA pressure compared with sham. In the shunt arm, responders had smaller increases in RV end-diastolic volume (mean difference, 5.71 mL vs 15.18 mL; interaction P =.01), RV end-systolic volume (mean difference, 1.58 mL vs 7.89 mL; interaction P =.002), and RV/LV ratio (mean difference, 0.07 vs 0.20; interaction P <.001) and larger increases in transmitral A wave velocity (mean difference, 5.08 cm/s vs -1.97 cm/s; interaction P =.02) compared with nonresponders randomized to the shunt, suggesting greater ability to accommodate shunted blood through the pulmonary circulation enabling LA unloading. Conclusions and Relevance In this post hoc analysis of the REDUCE LAP-HF II trial, over 2 years of follow-up, atrial shunting led to reverse remodeling of left-sided chambers and increases in volume of right-sided chambers consistent with the shunt flow but no change in RV systolic function compared with sham. Changes in cardiac structure/function were more favorable in responders compared with nonresponders treated with the shunt, supporting the previously identified responder group hypothesis and mechanism, although further evaluation with longer follow-up is needed. Trial Registration ClinicalTrials.gov Identifier: NCT03088033.
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Affiliation(s)
- Ravi B. Patel
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Frank E. Silvestry
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | | | - Scott D. Solomon
- Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Gerd Hasenfuß
- Heart Centre, Georg-August Universitat, Gottigen, Germany
| | - Sheldon E. Litwin
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Rami Kawash
- Division of Cardiology, Ohio State Wexner Medical Center, Columbus
| | - Scott L. Hummel
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor
- VA Ann Arbor, Ann Arbor, Michigan
| | - Donald E. Cutlip
- Division of Cardiology, Beth Israel Medical Center, Boston, Massachusetts
| | | | - Dirk J. van Veldhuisen
- Department of Cardiology, University Medical Center, University of Groningen, Groningen, the Netherlands
| | - Andreas J. Rieth
- Department of Cardiology, Kerckhoff-Klinik, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Frankfurt am Main, Germany
| | - Scott McKenzie
- The Prince Charles Hospital, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Heiko Bugger
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Jeremy A. Mazurek
- Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia
| | | | | | - Bonnie Ky
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia
| | - Sanjiv J. Shah
- Bluhm Cardiovascular Institute, Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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8
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von Haehling S, Assmus B, Bekfani T, Dworatzek E, Edelmann F, Hashemi D, Hellenkamp K, Kempf T, Raake P, Schütt KA, Wachter R, Schulze PC, Hasenfuss G, Böhm M, Bauersachs J. Heart failure with preserved ejection fraction: diagnosis, risk assessment, and treatment. Clin Res Cardiol 2024:10.1007/s00392-024-02396-4. [PMID: 38602566 DOI: 10.1007/s00392-024-02396-4] [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: 12/05/2023] [Accepted: 02/02/2024] [Indexed: 04/12/2024]
Abstract
The aetiology of heart failure with preserved ejection fraction (HFpEF) is heterogenous and overlaps with that of several comorbidities like atrial fibrillation, diabetes mellitus, chronic kidney disease, valvular heart disease, iron deficiency, or sarcopenia. The diagnosis of HFpEF involves evaluating cardiac dysfunction through imaging techniques and assessing increased left ventricular filling pressure, which can be measured directly or estimated through various proxies including natriuretic peptides. To better narrow down the differential diagnosis of HFpEF, European and American heart failure guidelines advocate the use of different algorithms including comorbidities that require diagnosis and rigorous treatment during the evaluation process. Therapeutic recommendations differ between guidelines. Whilst sodium glucose transporter 2 inhibitors have a solid evidence base, the recommendations differ with regard to the use of inhibitors of the renin-angiotensin-aldosterone axis. Unless indicated for specific comorbidities, the use of beta-blockers should be discouraged in HFpEF. The aim of this article is to provide an overview of the current state of the art in HFpEF diagnosis, clinical evaluation, and treatment.
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Affiliation(s)
- Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
| | - Birgit Assmus
- Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, Giessen, Germany
| | - Tarek Bekfani
- Department of Cardiology and Angiology, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Elke Dworatzek
- Institute of Gender in Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frank Edelmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Djawid Hashemi
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin, Germany
| | - Kristian Hellenkamp
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
| | - Tibor Kempf
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Philipp Raake
- I. Medical Department, Cardiology, Pneumology, Endocrinology and Intensive Care Medicine, University Hospital Augsburg, University of Augsburg, Augsburg, Germany
| | - Katharina A Schütt
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Wachter
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Paul Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, FSU, Jena, Germany
| | - Gerd Hasenfuss
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Michael Böhm
- Kardiologie, Angiologie und Internistische Intensivmedizin, Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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9
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Gorter TM, Hoendermis ES, van Veldhuisen DJ. Interatrial shunting as a treatment for heart failure: Where do we stand? Eur J Heart Fail 2024; 26:1090-1092. [PMID: 38661021 DOI: 10.1002/ejhf.3251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024] Open
Affiliation(s)
- Thomas M Gorter
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elke S Hoendermis
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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10
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Dagan M, Kaye DM. Making Waves in HFpEF: Unmasking Severe Left Atrial Myopathy During Exercise. Circ Heart Fail 2024; 17:e011237. [PMID: 38567510 DOI: 10.1161/circheartfailure.123.011237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Affiliation(s)
- Misha Dagan
- Department of Cardiology, Heart Failure and Transplant Service, Alfred Hospital, Melbourne, VIC, Australia (M.D., D.M.K.)
| | - David M Kaye
- Department of Cardiology, Heart Failure and Transplant Service, Alfred Hospital, Melbourne, VIC, Australia (M.D., D.M.K.)
- Baker Heart and Diabetes Institute, Melbourne, VIC, Australia (D.M.K.)
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11
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Ameri P, Mercurio V, Pollesello P, Anker MS, Backs J, Bayes-Genis A, Borlaug BA, Burkhoff D, Caravita S, Chan SY, de Man F, Giannakoulas G, González A, Guazzi M, Hassoun PM, Hemnes AR, Maack C, Madden B, Melenovsky V, Müller OJ, Papp Z, Pullamsetti SS, Rainer PP, Redfield MM, Rich S, Schiattarella GG, Skaara H, Stellos K, Tedford RJ, Thum T, Vachiery JL, van der Meer P, Van Linthout S, Pruszczyk P, Seferovic P, Coats AJS, Metra M, Rosano G, Rosenkranz S, Tocchetti CG. A roadmap for therapeutic discovery in pulmonary hypertension associated with left heart failure. A scientific statement of the Heart Failure Association (HFA) of the ESC and the ESC Working Group on Pulmonary Circulation & Right Ventricular Function. Eur J Heart Fail 2024; 26:707-729. [PMID: 38639017 PMCID: PMC11182487 DOI: 10.1002/ejhf.3236] [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: 07/26/2023] [Revised: 02/23/2024] [Accepted: 03/28/2024] [Indexed: 04/20/2024] Open
Abstract
Pulmonary hypertension (PH) associated with left heart failure (LHF) (PH-LHF) is one of the most common causes of PH. It directly contributes to symptoms and reduced functional capacity and negatively affects right heart function, ultimately leading to a poor prognosis. There are no specific treatments for PH-LHF, despite the high number of drugs tested so far. This scientific document addresses the main knowledge gaps in PH-LHF with emphasis on pathophysiology and clinical trials. Key identified issues include better understanding of the role of pulmonary venous versus arteriolar remodelling, multidimensional phenotyping to recognize patient subgroups positioned to respond to different therapies, and conduct of rigorous pre-clinical studies combining small and large animal models. Advancements in these areas are expected to better inform the design of clinical trials and extend treatment options beyond those effective in pulmonary arterial hypertension. Enrichment strategies, endpoint assessments, and thorough haemodynamic studies, both at rest and during exercise, are proposed to play primary roles to optimize early-stage development of candidate therapies for PH-LHF.
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Affiliation(s)
- Pietro Ameri
- Department of Internal Medicine, University of Genova, Genoa, Italy
- Cardiac, Thoracic, and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Piero Pollesello
- Content and Communication, Branded Products, Orion Pharma, Espoo, Finland
| | - Markus S Anker
- Deutsches Herzzentrum der Charité, Klinik für Kardiologie, Angiologie und Intensivmedizin (Campus CBF), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johannes Backs
- Institute of Experimental Cardiology, University Hospital Heidelberg, University of Heidelberg and DZHK (German Centre for Cardiovascular Research), Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Barry A Borlaug
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine (BG), Italy
- Department of Cardiology, Istituto Auxologico Italiano IRCCS Ospedale San Luca, Milan, Italy
| | - Stephen Y Chan
- Pittsburgh Heart, Lung, and Blood Vascular Medicine Institute, Division of Cardiology, Department of Medicine, University of Pittsburgh School of Medicine and UPMC, Pittsburgh, PA, USA
| | - Frances de Man
- PHEniX laboratory, Department of Pulmonary Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, The Netherlands
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aránzazu González
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Marco Guazzi
- University of Milan, Milan, Italy
- Cardiology Division, San Paolo University Hospital, Milan, Italy
| | - Paul M Hassoun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cristoph Maack
- Comprehensive Heart Failure Center (CHFC) and Medical Clinic I, University Clinic Würzburg, Würzburg, Germany
| | | | - Vojtech Melenovsky
- Department of Cardiology, Institute for Clinical and Experimental Medicine - IKEM, Prague, Czech Republic
| | - Oliver J Müller
- Department of Internal Medicine V, University Hospital Schleswig-Holstein, and German Centre for Cardiovascular Research (DZHK), Partner site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Zoltan Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Soni Savai Pullamsetti
- Department of Internal Medicine and Excellence Cluster Cardio-Pulmonary Institute (CPI), Justus-Liebig University, Giessen, Germany
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz, Austria
- BioTechMed Graz, Graz, Austria
- Department of Medicine, St. Johann in Tirol General Hospital, St. Johann in Tirol, Austria
| | | | - Stuart Rich
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gabriele G Schiattarella
- Max-Rubner Center (CMR), Department of Cardiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
- Translational Approaches in Heart Failure and Cardiometabolic Disease, Max Delbrück Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- Division of Cardiology, Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Hall Skaara
- Pulmonary Hypertension Association Europe, Vienna, Austria
| | - Kostantinos Stellos
- Department of Cardiovascular Research, European Center for Angioscience (ECAS), Heidelberg University, Mannheim, Germany
- German Centre for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauf-Forschung, DZHK), Heidelberg/Mannheim Partner Site, Heidelberg and Mannheim, Germany
- Department of Cardiology, University Hospital Mannheim, Heidelberg University, Mannheim, Germany
- Biosciences Institute, Vascular Biology and Medicine Theme, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Hannover, Germany
| | - Jean Luc Vachiery
- Department of Cardiology, Hopital Universitaire de Bruxelles Erasme, Brussels, Belgium
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sophie Van Linthout
- Berlin Institute of Health (BIH) at Charité, BIH Center for Regenerative Therapies, University of Medicine, Berlin, Germany
- German Center for Cardiovascular Research (DZHK, partner site Berlin), Berlin, Germany
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade University Medical Center, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Marco Metra
- Cardiology. ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Stephan Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne (CMMC), Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences, Interdepartmental Center for Clinical and Translational Research (CIRCET), and Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
- Center for Basic and Clinical Immunology Research (CISI), Federico II University, Naples, Italy
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12
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Rodés-Cabau J, Lindenfeld J, Abraham WT, Zile MR, Kar S, Bayés-Genís A, Eigler N, Holcomb R, Núñez J, Lee E, Perl ML, Moravsky G, Pfeiffer M, Boehmer J, Gorcsan J, Bax JJ, Anker S, Stone GW. Interatrial shunt therapy in advanced heart failure: Outcomes from the open-label cohort of the RELIEVE-HF trial. Eur J Heart Fail 2024; 26:1078-1089. [PMID: 38561314 DOI: 10.1002/ejhf.3215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/19/2023] [Accepted: 01/07/2024] [Indexed: 04/04/2024] Open
Abstract
AIMS Heart failure (HF) outcomes remain poor despite optimal guideline-directed medical therapy (GDMT). We assessed safety, effectiveness, and transthoracic echocardiographic (TTE) outcomes during the 12 months after Ventura shunt implantation in the RELIEVE-HF open-label roll-in cohort. METHODS AND RESULTS Eligibility required symptomatic HF despite optimal GDMT with ≥1 HF hospitalization in the prior year or elevated natriuretic peptides. The safety endpoint was device-related major adverse cardiovascular or neurological events at 30 days, compared to a prespecified performance goal. Effectiveness evaluations included the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline, 1, 3, 6, and 12 months and TTE at baseline and 12 months. Overall, 97 patients were enrolled and implanted at 64 sites. Average age was 70 ± 11 years, 97% were in New York Heart Association class III, and half had left ventricular ejection fraction (LVEF) ≤40%. The safety endpoint was achieved (event rate 0%, p < 0.001). KCCQ overall summary score was improved by 12-16 points at all follow-up timepoints (all p < 0.004), with similar outcomes in patients with reduced and preserved LVEF. At 12 months, left ventricular end-systolic and end-diastolic volumes were reduced (p = 0.020 and p = 0.038, respectively), LVEF improved (p = 0.009), right ventricular end-systolic and end-diastolic areas were reduced (p = 0.001 and p = 0.030, respectively), and right ventricular fractional area change (p < 0.001) and tricuspid annular plane systolic excursion (p < 0.001) improved. CONCLUSION Interatrial shunting with the Ventura device was safe and resulted in favourable clinical effects in patients with HF, regardless of LVEF. Improvements of left and right ventricular structure and function were consistent with reverse myocardial remodelling. These results would support the potential of this shunt device as a treatment for HF.
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Affiliation(s)
- Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Québec, Canada
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Michael R Zile
- Division of Cardiology, Medical University of South Carolina, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | - Saibal Kar
- Cardiovascular Institute of Los Robles Health System, Los Robles, CA, USA
| | - Antoni Bayés-Genís
- Department of Cardiology, Germans Trias Heart Institute, Germans Trias University Hospital, Badalona, Spain
- CIBERCV, Madrid, Spain
| | - Neal Eigler
- V-Wave, Agoura Hills, California and Division of Cardiology, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
| | | | - Julio Núñez
- Department of Cardiology, University of Valencia, Valencia, Spain
| | - Elizabeth Lee
- Division of Cardiology, Rochester General Hospital, Rochester, NY, USA
| | - Michal Laufer Perl
- Division of Cardiology, Sammy Ofer Heart Center, Tel Aviv Sourasky Medical Center, Tel Aviv-Yafo, Israel
| | - Gil Moravsky
- Division of Cardiology, Shamir Medical Center (Assaf HaRofeh), Be'er Ya'akov, Israel
| | - Michael Pfeiffer
- Division of Cardiology, Penn State Heart and Vascular Institute, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - John Boehmer
- Division of Cardiology, Penn State Heart and Vascular Institute, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - John Gorcsan
- Division of Cardiology, Penn State Heart and Vascular Institute, Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Stefan Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité University, Berlin, Germany
| | - Gregg W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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13
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Backhaus SJ, Schulz A, Lange T, Evertz R, Kowallick JT, Hasenfuß G, Schuster A. Rest and exercise-stress estimated pulmonary capillary wedge pressure using real-time free-breathing cardiovascular magnetic resonance imaging. J Cardiovasc Magn Reson 2024; 26:101032. [PMID: 38431079 PMCID: PMC10950869 DOI: 10.1016/j.jocmr.2024.101032] [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: 11/10/2023] [Revised: 01/08/2024] [Accepted: 02/26/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND Identification of increased pulmonary capillary wedge pressure (PCWP) by right heart catheterization (RHC) is the reference standard for the diagnosis of heart failure with preserved ejection fraction (HFpEF). Recently, cardiovascular magnetic resonance (CMR) imaging estimation of PCWP at rest was introduced as a non-invasive alternative. Since many patients are only identified during physiological exercise-stress, we hypothesized that novel exercise-stress CMR-derived PCWP emerges superior compared to its assessment at rest. METHODS The HFpEF-Stress Trial prospectively recruited 75 patients with exertional dyspnea and diastolic dysfunction who then underwent rest and exercise-stress RHC and CMR. HFpEF was defined according to PCWP (overt HFpEF ≥15 mmHg at rest, masked HFpEF ≥25 mmHg during exercise-stress). CMR-derived PCWP was calculated based on previously published formula using left ventricular mass and either biplane left atrial volume (LAV) or monoplane left atrial area (LAA). RESULTS LAV (rest/stress: r = 0.50/r = 0.55, p < 0.001) and LAA PCWP (rest/stress: r = 0.50/r = 0.48, p < 0.001) correlated significantly with RHC-derived PCWP while numerically overestimating PCWP at rest and underestimating PCWP during exercise-stress. LAV and LAA PCWP showed good diagnostic accuracy to detect HFpEF (area under the receiver operating characteristic curve (AUC) LAV rest 0.73, stress 0.81; LAA rest 0.72, stress 0.77) with incremental diagnostic value for the detection of masked HFpEF using exercise-stress (AUC LAV rest 0.54 vs stress 0.67, p = 0.019, LAA rest 0.52 vs stress 0.66, p = 0.012). LAV but not LAA PCWP during exercise-stress was a predictor for 24 months hospitalization independent of a medical history for atrial fibrillation (hazard ratio (HR) 1.26, 95% confidence interval 1.02-1.55, p = 0.032). CONCLUSION Non-invasive PCWP correlates well with the invasive reference at rest and during exercise stress. There is overall good diagnostic accuracy for HFpEF assessment using CMR-derived estimated PCWP despite deviations in absolute agreement. Non-invasive exercise derived PCWP may particularly facilitate detection of masked HFpEF in the future.
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Affiliation(s)
- Sören J Backhaus
- Department of Cardiology, Campus Kerckhoff of the Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine-Main, Bad Nauheim, Germany.
| | - Alexander Schulz
- University Medical Center Göttingen, Department of Cardiology and Pneumology, Georg-August University, Göttingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
| | - Torben Lange
- University Medical Center Göttingen, Department of Cardiology and Pneumology, Georg-August University, Göttingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
| | - Ruben Evertz
- University Medical Center Göttingen, Department of Cardiology and Pneumology, Georg-August University, Göttingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
| | - Johannes T Kowallick
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany; University Medical Center Göttingen (UMG), Institute for Diagnostic and Interventional Radiology, Göttingen, Germany.
| | - Gerd Hasenfuß
- University Medical Center Göttingen, Department of Cardiology and Pneumology, Georg-August University, Göttingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
| | - Andreas Schuster
- University Medical Center Göttingen, Department of Cardiology and Pneumology, Georg-August University, Göttingen, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
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14
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Wu Y, Song M, Wu M, Lin L. Advances in device-based treatment of heart failure with preserved ejection fraction: evidence from clinical trials. ESC Heart Fail 2024; 11:13-27. [PMID: 37986663 PMCID: PMC10804156 DOI: 10.1002/ehf2.14562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/10/2023] [Accepted: 10/02/2023] [Indexed: 11/22/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a group of clinical syndromes that exhibit a remarkably heterogeneous phenotype, characterized by symptoms and signs of heart failure, left ventricular diastolic dysfunction, elevated levels of natriuretic peptides, and an ejection fraction greater than or equal to 50%. With the aging of the population and the escalating prevalence of hypertension, obesity, and diabetes, the incidence of HFpEF is progressively rising. Drug therapy options for HFpEF are currently limited, and the associated high risk of cardiovascular mortality and heart failure rehospitalization significantly impact patients' quality of life and longevity while imposing a substantial economic burden on society. Recent research indicates that certain device-based therapies may serve as valuable adjuncts to drug therapy in patients with specific phenotypes of HFpEF, effectively improving symptoms and quality of life while reducing the risk of readmission for heart failure. These include inter-atrial shunt and greater splanchnic nerve ablation to reduce left ventricular filling pressure, implantable heart failure monitor to guide diuresis, left atrial pacing to correct interatrial dyssynchrony, cardiac contractility modulation to enhance cardiac calcium handling, as well as renal denervation, baroreflex activation therapy, and vagus nerve stimulation to restore the autonomic imbalance. In this review, we provide a comprehensive overview of the mechanisms and clinical evidence pertaining to these devices, with the aim of enhancing therapeutic strategies for HFpEF.
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Affiliation(s)
- Ying Wu
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Meiyan Song
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Meifang Wu
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Liming Lin
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
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Omote K, Sorimachi H, Obokata M, Verbrugge FH, Omar M, Popovic D, Reddy YNV, Pislaru SV, Pellikka PA, Borlaug BA. Biatrial myopathy in heart failure with preserved ejection fraction. Eur J Heart Fail 2024; 26:288-298. [PMID: 38059338 DOI: 10.1002/ejhf.3104] [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] [Received: 08/31/2023] [Revised: 10/27/2023] [Accepted: 11/30/2023] [Indexed: 12/08/2023] Open
Abstract
AIM Left atrial (LA) myopathy is increasingly recognized as an important phenotypic trait in heart failure (HF) with preserved ejection fraction (HFpEF). Right atrial (RA) remodelling and dysfunction also develop in HFpEF, but little data are available regarding the clinical characteristics and pathophysiology among patients with isolated LA, RA, or biatrial myopathy. METHODS AND RESULTS Patients with HFpEF underwent invasive haemodynamic exercise testing, comprehensive imaging including speckle tracking strain echocardiography, and clinical follow-up at Mayo Clinic between 2006 and 2018. LA myopathy was defined as LA volume index >34 ml/m2 and/or LA reservoir strain ≤24% and RA myopathy by RA volume index >39 ml/m2 in men and >33 ml/m2 in women and/or RA reservoir strain ≤19.8%. Of 476 consecutively evaluated patients with HFpEF defined by invasive exercise testing with evaluable atrial structure/function, 125 (26%) had no atrial myopathy, 147 (31%) had isolated LA myopathy, 184 (39%) had biatrial myopathy, and 20 (4%) had isolated RA myopathy. Patients with HFpEF and biatrial myopathy had more atrial fibrillation, poorer left ventricular systolic and diastolic function, more severe pulmonary vascular disease, tricuspid regurgitation, ventricular interdependence and right ventricular dysfunction, and poorer cardiac output reserve with exercise. There were 94 patients with events over a median follow-up of 2.9 (interquartile range 1.4-4.6) years. Individuals with biatrial myopathy had an 84% higher risk of HF hospitalization or death as compared to those with isolated LA myopathy (hazard ratio 1.84; 95% confidence interval 1.16-2.92, p = 0.01). CONCLUSIONS Biatrial myopathy identifies patients with more advanced HFpEF characterized by more severe pulmonary vascular disease, right HF, poorer cardiac reserve, and a greater risk for adverse outcomes. Further study is required to define optimal strategies to treat and prevent biatrial myopathy in HFpEF.
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Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Frederik H Verbrugge
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Centre for Cardiovascular Diseases, University Hospital Brussels, Jette, Belgium
| | - Massar Omar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center Odense, Odense University Hospital, Odense, Denmark
| | - Dejana Popovic
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Yogesh N V Reddy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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16
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Chouairi F, Levin A, Biegus J, Fudim M. Emerging devices for heart failure management. Prog Cardiovasc Dis 2024; 82:125-134. [PMID: 38242194 DOI: 10.1016/j.pcad.2024.01.011] [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: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/21/2024]
Abstract
There have been significant advances in the treatment of heart failure (HF) in recent years, driven by significant strides in guideline-directed medical therapy (GDMT). Despite this, HF is still associated with high levels of morbidity and mortality, and most patients do not receive optimal medical therapy. In conjunction with the improvement of GDMT, novel device therapies have been developed to better treat HF. These devices include technology capable of remotely monitoring HF physiology, devices that modulate the autonomic nervous system, and those that structurally change the heart with the ultimate aim of addressing the root causes of HF physiology As these device therapies gradually integrate into the fabric of HF patient care, it becomes increasingly important for modern cardiologists to become familiar with them. Hence, the objective of this review is to shed light on currently emerging devices for the treatment of HF.
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Affiliation(s)
- Fouad Chouairi
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Allison Levin
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Duke Clinical Research Institute, Durham, NC, USA.
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Khan MS, Paracha AA, Biegus J, Espriella RDL, Núñez J, Santos-Gallego CG, Yaranov D, Fudim M. Preload Reduction Therapies in Heart Failure. Heart Fail Clin 2024; 20:71-81. [PMID: 37953023 DOI: 10.1016/j.hfc.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Preload reserve represents an important concept in the normal physiologic responses of the body to meet the changing metabolic demands. The recruitment of preload in healthy patients leads to an increase in effective circulating blood volume with a concomitant increase in cardiac output. However, in the setting of heart failure (HF), preload augmentation may precipitate HF decompensation. In this review, we focus on the role of splanchnic nerve modulation and pharmacological therapeutic interventions to prevent HF decompensation through preload reduction. Furthermore, we explore the emerging device-based approaches for cardiac preload reduction while reviewing the ongoing clinical trials.
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Affiliation(s)
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Poland
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, Fundación de Investigación INCLIVA, Valencia, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, Fundación de Investigación INCLIVA, Valencia, Spain; Department of Medicine, University of Valencia, Valencia, Spain; CIBER Cardiovascular, Madrid, Spain
| | - Carlos G Santos-Gallego
- Cardiology Department, Mount Sinai Hospital, NYC; Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, NYC
| | | | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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18
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Salah HM, Baratto C, Yaranov DM, Rommel KP, Achanta S, Caravita S, Reddy Vasanthu VK, Fudim M. Interatrial Shunt Devices. Heart Fail Clin 2024; 20:61-69. [PMID: 37953022 PMCID: PMC11232059 DOI: 10.1016/j.hfc.2023.05.003] [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] [Indexed: 11/14/2023]
Abstract
Elevated left atrial pressure during exercise is a hallmark of heart failure (HF) and is associated with adverse left atrial remodeling and poor outcomes. To decompress the pressure-overloaded left atrium in patients with HF, several device-based approaches have been developed to create a permanent, pressure-dependent, left-to-right interatrial shunt. Such approaches are currently in various stages of investigations in both HF with reduced ejection fraction (EF) and HF with preserved EF. This review discusses the evolution of the concept of left atrial decompression and summarizes the current landscape of device-based approaches used for left atrial decompression.
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Affiliation(s)
- Husam M Salah
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Claudia Baratto
- Division of Cardiology, Dyspnea and Pulmonary Hypertension Clinic, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Dmitry M Yaranov
- Baptist Heart Institute, Baptist Memorial Hospital, Memphis, TN, USA
| | - Karl-Philipp Rommel
- Deptartment of Cardiology, Heart Center at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany; Cardiovacular Research Foundation, New York, NY, USA
| | | | - Sergio Caravita
- Division of Cardiology, Dyspnea and Pulmonary Hypertension Clinic, Ospedale San Luca IRCCS Istituto Auxologico Italiano, Milano, Italy; Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Province of Bergamo, Italy
| | | | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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19
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Saito Y, Obokata M. Diagnostic and therapeutic implications of obesity in heart failure with preserved ejection fraction. Eur J Heart Fail 2024; 26:190-192. [PMID: 38192167 DOI: 10.1002/ejhf.3128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/20/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
- Yuki Saito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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20
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Litwin SE, Komtebedde J, Seidler T, Borlaug BA, Winkler S, Solomon SD, Eicher JC, Mazimba S, Khawash R, Sverdlov AL, Hummel SL, Bugger H, Boenner F, Hoendermis E, Cikes M, Demers C, Silva G, van Empel V, Starling RC, Penicka M, Cutlip DE, Leon MB, Kitzman DW, van Veldhuisen DJ, Shah SJ. Obesity in heart failure with preserved ejection fraction: Insights from the REDUCE LAP-HF II trial. Eur J Heart Fail 2024; 26:177-189. [PMID: 37989800 DOI: 10.1002/ejhf.3092] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 10/23/2023] [Accepted: 11/12/2023] [Indexed: 11/23/2023] Open
Abstract
AIMS Obesity is causally related to the development of heart failure with preserved ejection fraction (HFpEF) but complicates the diagnosis and treatment of this disorder. We aimed to determine the relationship between severity of obesity and clinical, echocardiographic and haemodynamic parameters in a large cohort of patients with documented HFpEF. METHODS AND RESULTS The REDUCE LAP-HF II trial randomized 626 patients with ejection fraction ≥40% and exercise pulmonary capillary wedge pressure (PCWP) ≥25 mmHg to atrial shunt or sham procedure. We tested for associations between body mass index (BMI), clinical characteristics, cardiac structural and functional abnormalities, physical limitations, quality of life and outcomes with atrial shunt therapy. Overall, 60.9% of patients had BMI ≥30 kg/m2 . As the severity of obesity increased, symptoms (Kansas City Cardiomyopathy Questionnaire score) and 6-min walk distance worsened. More severe obesity was associated with lower natriuretic peptide levels despite more cardiac remodelling, higher cardiac filling pressures, and higher cardiac output. Lower cut points for E/e' were needed to identify elevated PCWP in more obese patients. Strain measurements in all four chambers were maintained as BMI increased. Pulmonary vascular resistance at rest and exercise decreased with higher BMI. Obesity was associated with more first and recurrent heart failure events. However, there was no significant interaction between obesity and treatment effects of the atrial shunt. CONCLUSIONS Increasing severity of obesity was associated with greater cardiac remodelling, higher right and left ventricular filling pressures, higher cardiac output and increased subsequent heart failure events. Despite significant obesity, many HFpEF patients have preserved right heart and pulmonary vascular function and thus, may be appropriate candidates for atrial shunt therapy.
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Affiliation(s)
- Sheldon E Litwin
- Medical University of South Carolina, Charleston, SC, USA
- Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | | | | | | | | | | | | | - Sula Mazimba
- University of Virginia, Charlottesville, VA, USA
| | | | - Aaron L Sverdlov
- John Hunter Hospital, Newcastle, Australia
- University of Newcastle, Newcastle, NSW, Australia
| | - Scott L Hummel
- University of Michigan and VA Ann Arbor, Ann Arbor, MI, USA
| | | | - Florian Boenner
- Division of Cardiology, Pulmonology, and Vascular Medicine Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Elke Hoendermis
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Maja Cikes
- Department of Cardiovascular Diseases, University Hospital Center, University of Zagreb School of Medicine, Zagreb, Croatia
| | | | | | | | | | | | | | - Martin B Leon
- Cardiovascular Research Foundation, New York, NY, USA
| | - Dalane W Kitzman
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Dirk J van Veldhuisen
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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21
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Habel N, Infeld M, Bernknopf J, Meyer M, Lustgarten D. Rationale and design of the PACE HFpEF trial: Physiologic accelerated pacing as a holistic treatment of heart failure with preserved ejection fraction. Heart Rhythm O2 2024; 5:41-49. [PMID: 38312209 PMCID: PMC10837182 DOI: 10.1016/j.hroo.2023.12.001] [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] [Indexed: 02/06/2024] Open
Abstract
Background In heart failure with preserved ejection fraction (HFpEF), it has been assumed that pharmacologic heart rate suppression should provide clinical benefits through an increase in diastolic filling time. Contrary to this assumption, heart rate lowering in patients with preserved left ventricular ejection fraction and hypertension or coronary artery disease results in adverse outcomes and suggests that the opposite may be beneficial. Namely, shortening the diastolic filling time with a higher heart rate might normalize the elevated filling pressures that are the sine qua non of HFpEF. Initial clinical studies that assessed the effects of accelerated heart rates in pacemaker patients with preclinical and overt HFpEF provide support for this latter hypothesis, having shown improvements in quality of life, natriuretic peptide and activity levels, and atrial fibrillation burden. Objective The study sought to determine the effects of continued resting heart rate elevation with and without superimposed nocturnal pacing in HFpEF patients without standard pacing indication. Methods The physiologic accelerated pacing as treatment for heart failure with preserved ejection fraction (PACE HFpEF) trial is an investigator-initiated, prospective, patient-blinded multiple crossover pilot study that assesses the impact of accelerated pacing on quality of life, physical activity, N-terminal pro-B-type natriuretic peptide, and echocardiographic measures of cardiac structure and function. Results Twenty patients were enrolled and underwent dual-chamber pacemaker implantation under U.S. Food and Drug Administration investigational device exemption with both atrial and ventricular physiologic lead placement targeting the Bachmann bundle and the His bundle. Conclusion This manuscript describes the rationale and design of the PACE HFpEF trial, which tests the safety and feasibility of continuous accelerated physiological pacing as a treatment strategy in HFpEF.
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Affiliation(s)
- Nicole Habel
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
| | - Margaret Infeld
- Cardiovascular Center, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts
| | - Jacob Bernknopf
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Markus Meyer
- Lillehei Heart Institute, Department of Medicine, University of Minnesota College of Medicine, Minneapolis, Minnesota
| | - Daniel Lustgarten
- Department of Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont
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22
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Baratto C, Caravita S, Vachiéry JL. Pulmonary Hypertension Associated with Left Heart Disease. Semin Respir Crit Care Med 2023; 44:810-825. [PMID: 37709283 DOI: 10.1055/s-0043-1772754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
Pulmonary hypertension (PH) is a common complication of diseases affecting the left heart, mostly found in patients suffering from heart failure, with or without preserved left ventricular ejection fraction. Initially driven by a passive increase in left atrial pressure (postcapillary PH), several mechanisms may lead in a subset of patient to significant structural changes of the pulmonary vessels or a precapillary component. In addition, the right ventricle may be independently affected, which results in right ventricular to pulmonary artery uncoupling and right ventricular failure, all being associated with a worse outcome. The differential diagnosis of PH associated with left heart disease versus pulmonary arterial hypertension (PAH) is especially challenging in patients with cardiovascular comorbidities and/or heart failure with preserved ejection fraction (HFpEF). A stepwise approach to diagnosis is proposed, starting with a proper clinical multidimensional phenotyping to identify patients in whom hemodynamic confirmation is deemed necessary. Provocative testing (exercise testing, fluid loading, or simple leg raising) is useful in the cath laboratory to identify patients with abnormal response who are more likely to suffer from HFpEF. In contrast with group 1 PH, management of PH associated with left heart disease must focus on the treatment of the underlying condition. Some PAH-approved targets have been unsuccessfully tried in clinical studies in a heterogeneous group of patients, some even leading to an increase in adverse events. There is currently no approved therapy for PH associated with left heart disease.
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Affiliation(s)
- Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
| | - Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano, IRCCS, Ospedale San Luca, Milano, Italy
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Bergamo, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, HUB Hôpital Erasme, Université Libre de Bruxelles, Bruxelles, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Germany
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23
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Gustafsson F. Interatrial shunt devices for heart failure. Nat Rev Cardiol 2023; 20:717-718. [PMID: 37626203 DOI: 10.1038/s41569-023-00923-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Affiliation(s)
- Finn Gustafsson
- Department of Cardiology, Rigshospitalet and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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24
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Schmidt KH, Bikou O, Blindt R, Bruch L, Felgendreher R, Hohenforst-Schmidt W, Holt S, Ladage D, Pfeuffer-Jovic E, Rieth A, Schmeisser A, Schnitzler K, Stadler S, Steringer-Mascherbauer R, Yogeswaran A, Kuebler WM. [Pulmonary hypertension associated with left heart disease (group 2)]. Pneumologie 2023; 77:926-936. [PMID: 37963482 DOI: 10.1055/a-2145-4792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Pulmonary hypertension associated with left heart disease (PH-LHD) corresponds to group two of pulmonary hypertension according to clinical classification. Haemodynamically, this group includes isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH). PH-LHD is defined by an mPAP > 20 mmHg and a PAWP > 15 mmHg, pulmonary vascular resistance (PVR) with a cut-off value of 2 Wood Units (WU) is used to differentiate between IpcPH and CpcPH. A PVR greater than 5 WU indicates a dominant precapillary component. PH-LHD is the most common form of pulmonary hypertension, the leading cause being left heart failure with preserved (HFpEF) or reduced ejection fraction (HFmrEF, HFrEF), valvular heart disease and, less commonly, congenital heart disease. The presence of pulmonary hypertension is associated with increased symptom burden and poorer outcome across the spectrum of left heart disease. Differentiating between group 1 pulmonary hypertension with cardiac comorbidities and PH-LHD, especially due to HFpEF, is a particular challenge. Therapeutically, no general recommendation for the use of PDE5 inhibitors in HFpEF-associated CpcPH can be made at this time. There is currently no reliable rationale for the use of PAH drugs in IpcPH, nor is therapy with endothelin receptor antagonists or prostacyclin analogues recommended for all forms of PH-LHD.
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Affiliation(s)
- Kai Helge Schmidt
- Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin Mainz, Mainz, Deutschland
| | - Olympia Bikou
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, München, Deutschland
| | - Rüdiger Blindt
- Kardio Bremen, Rotes Kreuz Krankenhaus Bremen, Bremen, Deutschland
| | - Leonhard Bruch
- Klinik für Innere Medizin und Kardiologie, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Deutschland
| | | | | | - Stephan Holt
- Praxis am Steintor, Recklinghausen, Recklinghausen, Deutschland
| | - Dennis Ladage
- Klinik für Pneumologie, Kliniken Maria Hilf Mönchengladbach, Mönchengladbach, Deutschland
| | | | - Andreas Rieth
- Abteilung für Kardiologie, Kerckhoff-Klinik Bad Nauheim, Bad Nauheim, Deutschland
| | - Alexander Schmeisser
- Zentrum für Innere Medizin, Universitätsklinik für Kardiologie und Angiologie Magdeburg, Magdeburg, Deutschland
| | - Katharina Schnitzler
- Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Stefan Stadler
- Klinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | | | - Athiththan Yogeswaran
- Department of Internal Medicine, Member of the German Center for Lung Research, Universities of Giessen and Marburg Lung Center, Justus-Liebig-University Giessen, Giessen, Deutschland
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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25
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Jagadeesan V, Gray WA, Shah SJ. Atrial Shunt Therapy for Heart Failure: An Update. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101203. [PMID: 39131067 PMCID: PMC11307404 DOI: 10.1016/j.jscai.2023.101203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 08/13/2024]
Abstract
Transcatheter atrial shunt therapies, designed to dynamically lower left atrial (LA) pressure by shunting blood into the larger reservoir of the right atrium and central veins, have been developed as a novel treatment for heart failure (HF) over the past 10+ years. Several atrial shunt devices and procedures are currently in development with several pivotal randomized clinical trials (RCT) underway; however, only 2 sham-controlled RCT (both with the Atrial Shunt Device [Corvia Medical] in HF with EF ≥ 40%) have been reported thus far; a mechanistic RCT (n = 44) that demonstrated a reduction in exercise LA pressure at 1 month and a pivotal RCT (n = 626) that was neutral with no difference in outcomes or health status between shunt and sham groups. Subsequent analyses of the single completed pivotal RCT found that peak exercise pulmonary vascular resistance <1.74 WU plus the absence of a cardiac rhythm management device identified a responder group that benefited from LA unloading with atrial shunt implantation, a finding that is currently being confirmed in a follow-up RCT. Here we provide a comprehensive review of the field of atrial shunt therapeutics with a description of the following: (1) current HF treatment; (2) rationale and history of atrial shunt development; (3) design of and accumulated evidence for the various atrial shunt devices and procedures under investigation; (4) unanswered questions in the field; and (5) future considerations. Atrial shunts represent a potential innovative therapeutic for HF but the optimal design/approach and phenotype of HF most likely to benefit are yet to be determined.
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Affiliation(s)
- Vikrant Jagadeesan
- West Virginia Heart and Vascular Institute, West Virginia School of Medicine, Morgantown, West Virginia
| | - William A. Gray
- Main Line Health System, Thomas Jefferson University, Wynnewood, Pennsylvania
| | - Sanjiv J. Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Bluhm Cardiovascular Institute, Northwestern Medicine, Chicago, Illinois
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26
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Patel RB, Reddy VY, Komtebedde J, Wegerich SW, Sekaric J, Swarup V, Walton A, Laurent G, Chetcuti S, Rademann M, Bergmann M, McKenzie S, Bugger H, Bruno RR, Herrmann HC, Nair A, Gupta DK, Lim S, Kapadia S, Gordon R, Vanderheyden M, Noel T, Bailey S, Gertz ZM, Trochu JN, Cutlip DE, Leon MB, Solomon SD, van Veldhuisen DJ, Auricchio A, Shah SJ. Atrial Fibrillation Burden and Atrial Shunt Therapy in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2023; 11:1351-1362. [PMID: 37480877 DOI: 10.1016/j.jchf.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is a common comorbidity in patients with heart failure with preserved ejection fraction (HFpEF) and in heart failure with mildly reduced ejection fraction (HFmrEF). OBJECTIVES This study sought to describe AF burden and its clinical impact among individuals with HFpEF and HFmrEF who participated in a randomized clinical trial of atrial shunt therapy (REDUCE LAP-HF II [A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure]) and to evaluate the effect of atrial shunt therapy on AF burden. METHODS Study investigators characterized AF burden among patients in the REDUCE LAP-HF II trial by using ambulatory cardiac patch monitoring at baseline (median patch wear time, 6 days) and over a 12-month follow-up (median patch wear time, 125 days). The investigators determined the association of baseline AF burden with long-term clinical events and examined the effect of atrial shunt therapy on AF burden over time. RESULTS Among 367 patients with cardiac monitoring data at baseline and follow-up, 194 (53%) had a history of AF or atrial flutter (AFL), and median baseline AF burden was 0.012% (IQR: 0%-1.3%). After multivariable adjustment, baseline AF burden ≥0.012% was significantly associated with heart failure (HF) events (HR: 2.00; 95% CI: 1.17-3.44; P = 0.01) both with and without a history of AF or AFL (P for interaction = 0.68). Adjustment for left atrial reservoir strain attenuated the baseline AF burden-HF event association (HR: 1.71; 95% CI: 0.93-3.14; P = 0.08). Of the 367 patients, 141 (38%) had patch-detected AF during follow-up without a history of AF or AFL. Atrial shunt therapy did not change AF incidence or burden during follow-up. CONCLUSIONS In HFpEF and HFmrEF, nearly 40% of patients have subclinical AF by 1 year. Baseline AF burden, even at low levels, is associated with HF events. Atrial shunt therapy does not affect AF incidence or burden. (A Study to Evaluate the Corvia Medical, Inc IASD System II to Reduce Elevated Left Atrial Pressure in Patients with Heart Failure [REDUCE LAP-HF II]; NCT03088033).
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Illinois, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | - Gabriel Laurent
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | - Stanley Chetcuti
- Division of Cardiology, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Matthias Rademann
- Department of Cardiology, University of Giessen, Bad Nauheim, Germany
| | - Martin Bergmann
- Department of Interventional Cardiology, Cardiologicum, Hamburg, Germany
| | - Scott McKenzie
- School of Medicine, University of Queensland, The Prince Charles Hospital, Brisbane, Australia
| | - Heiko Bugger
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology, and Vascular Medicine, Faculty of Medicine, University Hospital Dusseldorf, Heinrich-Heine-University Dusseldorf, Dusseldorf, Germany
| | - Howard C Herrmann
- Division of Cardiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ajith Nair
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Deepak K Gupta
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott Lim
- Division of Cardiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Samir Kapadia
- Division of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert Gordon
- Division of Cardiology, NorthShore University Health System, Evanston, Illinois, USA
| | | | - Thomas Noel
- Southern Medical Group, P.A., Tallahassee, Florida, USA
| | - Steven Bailey
- Division of Cardiology, Louisiana State University School of Medicine, Baton Rouge, Louisiana, USA
| | - Zachary M Gertz
- Division of Cardiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Jean-Noël Trochu
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Donald E Cutlip
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Martin B Leon
- Columbia University Irving Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Scott D Solomon
- Division of Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Angelo Auricchio
- Division of Cardiology, Ticino Cardiocentro Institute, Lugano, Switzerland
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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27
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Oakland HT, Shah SJ. Comprehensive Investigation of Latent Pulmonary Vascular Disease: An Important Exercise for a Novel HFpEF Phenotype. JACC. HEART FAILURE 2023; 11:1439-1442. [PMID: 37480882 DOI: 10.1016/j.jchf.2023.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 05/30/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Hannah T Oakland
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, Connecticut, USA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
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28
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Caravita S, Baratto C, Filippo A, Soranna D, Dewachter C, Zambon A, Perego GB, Muraru D, Senni M, Badano LP, Parati G, Vachiéry JL, Fudim M. Shedding Light on Latent Pulmonary Vascular Disease in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2023; 11:1427-1438. [PMID: 37115127 DOI: 10.1016/j.jchf.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] [Received: 10/31/2022] [Revised: 02/27/2023] [Accepted: 03/03/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Among patients with heart failure with preserved ejection fraction (HFpEF), a distinct hemodynamic phenotype has been recently described, ie, latent pulmonary vascular disease (HFpEF-latentPVD), defined by exercise pulmonary vascular resistance (PVR) >1.74 WU. OBJECTIVES This study aims to explore the pathophysiological significance of HFpEF-latentPVD. METHODS The authors analyzed a cohort of patients who had undergone supine exercise right heart catheterization with cardiac output (CO) measured by direct Fick method, between 2016 and 2021. HFpEF-latentPVD patients were compared with HFpEF control patients. RESULTS Out of 86 HFpEF patients, 21% qualified as having HFpEF-latentPVD, 78% of whom had PVR >2 WU at rest. Patients with HFpEF-latentPVD were older, with a higher pretest probability of HFpEF, and more frequently experienced atrial fibrillation and at least moderate tricuspid regurgitation (P < 0.05). PVR trajectories differed between HFpEF-latentPVD patients and HFpEF control patients (Pinteraction = 0.008), slightly increasing in the former and reducing in the latter. HFpEF-latentPVD patients displayed more frequent hemodynamically significant tricuspid regurgitation during exercise (P = 0.002) and had more impaired CO and stroke volume reserve (P < 0.05). Exercise PVR was correlated with mixed venous O2 tension (R2 = 0.33) and stroke volume (R2 = 0.31) in HFpEF-latentPVD patients. The HFpEF-latentPVD patients had had higher dead space ventilation during exercise and higher PaCO2 (P < 0.05), which correlated with resting PVR (R2 = 0.21). Event-free survival was reduced in HFpEF-latentPVD patients (P < 0.05). CONCLUSIONS The results suggest that when CO is measured by direct Fick, few HFpEF patients have isolated latent PVD (ie, normal PVR at rest, becoming abnormal during exercise). HFpEF-latentPVD patients present with CO limitation to exercise, associated with dynamic tricuspid regurgitation, altered ventilatory control, and pulmonary vascular hyperreactivity, portending a poor prognosis.
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Affiliation(s)
- Sergio Caravita
- Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy; Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy.
| | - Aurora Filippo
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Davide Soranna
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - Céline Dewachter
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Antonella Zambon
- Biostatistic Unit, IRCCS Istituto Auxologico Italiano, Milano, Italy; Department of Statistics and Quantitative Methods, Università di Milano-Bicocca, Milano, Italy
| | | | - Denisa Muraru
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Michele Senni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Luigi P Badano
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Gianfranco Parati
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Ospedale San Luca, Milano, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy
| | - Jean-Luc Vachiéry
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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Hahn RT, Link MS. Absence of Atrial Fibrillation Reduction in REDUCE LAP-HF II. JACC. HEART FAILURE 2023; 11:1363-1364. [PMID: 37480878 DOI: 10.1016/j.jchf.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/07/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Rebecca T Hahn
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York, USA.
| | - Mark S Link
- University of Texas, Southwestern Medical Center, Dallas, Texas, USA
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension associated with left heart disease (PHLHD) is common and associated with adverse prognosis. Proper diagnosis is critical to avoid inappropriate treatment. Practical approaches to noninvasive diagnosis are available, though invasive hemodynamics including volume loading or exercise are often necessary for definitive diagnosis. Treatment strategies and research in the field is rapidly evolving. RECENT FINDINGS Combined pre and post capillary pulmonary hypertension is associated with remodeling of the pulmonary vasculature that is proportional to the severity of the pulmonary hypertension. Even quite mild elevation of pulmonary vascular resistance (PVR), (greater than 2.0 Wood units (WU)) is associated with adverse outcome. Guideline-directed medical therapy (GDMT) for left heart failure has rapidly evolved, including approval of SGLT2 inhibitors for treatment of heart failure with preserved ejection fraction (HFpEF). However, full implementation of GDMT is lagging. Utilization of implanted pulmonary artery pressure monitoring can facilitate patient management in selected patient phenotypes and has been utilized to demonstrate improvement in pulmonary pressures with emerging therapies in HFpEF including SGLT2 inhibitors and sacubitril/valsartan. A variety of shunt devices to create a left-to-right shunt in order to decompress the left heart are available or undergoing clinical trials. There is concern that there could be adverse response to such devices in patients who have even mild elevation of pulmonary vascular resistance. Sleep disordered breathing is common in PHLHD and should be aggressively sought out and treated. SUMMARY Even mild elevation in pulmonary vascular resistance is associated with adverse outcome. A systematic approach to diagnosis of PHLHD is essential. Guideline-directed medical therapy for PHLHD prioritizes optimal management of the left heart disease. Pulmonary artery pressure sensors are useful in selected patients.
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Affiliation(s)
- Robert P Frantz
- Department of Cardiovascular Medicine, Rochester, Minnesota, USA
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31
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Nanayakkara S, Kaye DM. No longer from pillar to post: The first effective step in treating heart failure with preserved ejection fraction. Eur J Heart Fail 2023; 25:1632-1634. [PMID: 37608627 DOI: 10.1002/ejhf.3007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/13/2023] [Accepted: 08/17/2023] [Indexed: 08/24/2023] Open
Affiliation(s)
| | - David M Kaye
- The Alfred, Baker Heart and Diabetes Institute, Monash University, Melbourne, VIC, Australia
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32
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Litwin SE, Komtebedde J, Hu M, Burkhoff D, Hasenfuß G, Borlaug BA, Solomon SD, Zile MR, Mohan RC, Khawash R, Sverdlov AL, Fail P, Chung ES, Kaye DM, Blair J, Eicher JC, Hummel SL, Zirlik A, Westenfeld R, Hayward C, Gorter TM, Demers C, Shetty R, Lewis G, Starling RC, Patel S, Gupta DK, Morsli H, Penicka M, Cikes M, Gustafsson F, Silvestry FE, Rowin EJ, Cutlip DE, Leon MB, Kitzman DW, Kleber FX, Shah SJ. Exercise-Induced Left Atrial Hypertension in Heart Failure With Preserved Ejection Fraction. JACC. HEART FAILURE 2023; 11:1103-1117. [PMID: 36939661 PMCID: PMC11185159 DOI: 10.1016/j.jchf.2023.01.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Many patients with heart failure and preserved ejection fraction have no overt volume overload and normal resting left atrial (LA) pressure. OBJECTIVES This study sought to characterize patients with normal resting LA pressure (pulmonary capillary wedge pressure [PCWP] <15 mm Hg) but exercise-induced left atrial hypertension (EILAH). METHODS The REDUCE LAP-HF II (A Study to Evaluate the Corvia Medical, Inc. IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure) trial randomized 626 patients with ejection fraction ≥40% and exercise PCWP ≥25 mm Hg to atrial shunt or sham procedure. The primary trial outcome, a hierarchical composite of death, heart failure hospitalization, intensification of diuretics, and change in health status was compared between patients with EILAH and those with heart failure and resting left atrial hypertension (RELAH). RESULTS Patients with EILAH (29%) had similar symptom severity, but lower natriuretic peptide levels, higher 6-minute walk distance, less atrial fibrillation, lower left ventricular mass, smaller LA volumes, lower E/e', and better LA strain. PCWP was lower at rest, but had a larger increase with exercise in EILAH. Neither group as a whole had a significant effect from shunt therapy vs sham. Patients with EILAH were more likely to have characteristics associated with atrial shunt responsiveness (peak exercise pulmonary vascular resistance <1.74 WU) and no pacemaker (63% vs 46%; P < 0.001). The win ratio for the primary outcome was 1.56 (P = 0.08) in patients with EILAH and 1.51 (P = 0.04) in those with RELAH when responder characteristics were present. CONCLUSIONS Patients with EILAH had similar symptom severity but less advanced myocardial and pulmonary vascular disease. This important subgroup may be difficult to diagnose without invasive exercise hemodynamics, but it has characteristics associated with favorable response to atrial shunt therapy. (A Study to Evaluate the Corvia Medical, Inc. IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure [REDUCE LAP-HF TRIAL II]; NCT03088033).
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Affiliation(s)
- Sheldon E Litwin
- Medical University of South Carolina, Charleston, South Carolina, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA.
| | | | - Mo Hu
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York City, New York, USA
| | | | | | | | - Michael R Zile
- Medical University of South Carolina, Charleston, South Carolina, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | | | | | - Aaron L Sverdlov
- John Hunter Hospital, New Castle, New South Wales, Australia; University of Newcastle, New Castle, New South Wales, Australia
| | - Peter Fail
- Cardiovascular Institute of the South, Houma, Louisiana, USA
| | | | | | - John Blair
- University of Chicago, Chicago, Illinois, USA
| | | | - Scott L Hummel
- University of Michigan Health Systems, Ann Arbor, Michigan, USA; Veterans Affairs Ann Arbor, Ann Arbor, Michigan, USA
| | | | - Ralf Westenfeld
- Division of Cardiology, Pulmonology, and Vascular Medicine Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | | | - Thomas M Gorter
- University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Catherine Demers
- McMaster University and Hamilton Health Sciences, Hamilton, Canada
| | | | - Gregory Lewis
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Sanjay Patel
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia; Sydney Medical School, The University of Sydney, New South Wales, Australia; The Heart Research Institute, Sydney, New South Wales, Australia
| | - Deepak K Gupta
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hakim Morsli
- Sarasota Memorial Hospital, Sarasota, Florida, USA
| | | | - Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine and University Hospital Center, Zagreb, Croatia
| | | | | | | | - Donald E Cutlip
- Baim Clinical Research Institute, Boston, Massachusetts, USA
| | - Martin B Leon
- Cardiovascular Research Foundation, New York City, New York, USA
| | - Dalane W Kitzman
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Iaconelli A, Cuthbert J, Kazmi S, Maffia P, Clark AL, Cleland JGF, Pellicori P. Inferior vena cava diameter is associated with prognosis in patients with chronic heart failure independent of tricuspid regurgitation velocity. Clin Res Cardiol 2023; 112:1077-1086. [PMID: 36894788 PMCID: PMC10359207 DOI: 10.1007/s00392-023-02178-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 02/22/2023] [Indexed: 03/11/2023]
Abstract
AIMS A high, Doppler-derived, tricuspid regurgitation velocity (TRV) indicates pulmonary hypertension, which may contribute to right ventricular dysfunction and worsening tricuspid regurgitation leading to systemic venous congestion, reflected by an increase in inferior vena cava (IVC) diameter. We hypothesized that venous congestion rather than pulmonary hypertension would be more strongly associated with prognosis. METHODS AND RESULTS 895 patients with chronic heart failure (CHF) (median (25th and 75th centile) age 75 (67-81) years, 69% men, LVEF 44 (34-55)% and NT-proBNP 1133 (423-2465) pg/ml) were enrolled. Compared to patients with normal IVC (< 21 mm) and TRV (≤ 2.8 m/s; n = 504, 56%), those with high TRV but normal IVC (n = 85, 9%) were older, more likely to be women and to have LVEF ≥ 50%, whilst those with dilated IVC but normal TRV (n = 142, 16%) had more signs of congestion and higher NT-proBNP. Patients (n = 164, 19%) with both dilated IVC and high TRV had the most signs of congestion and the highest NT-proBNP. During follow-up of 860 (435-1121) days, 239 patients died. Compared to those with both normal IVC and TRV (reference), patients with high TRV but normal IVC did not have a significantly increased mortality (HR: 1.41; CI: 0.87-2.29; P = 0.16). Risk was higher for patients with a dilated IVC but normal TRV (HR: 2.51; CI: 1.80-3.51; P < 0.001) or both a dilated IVC and elevated TRV (HR: 3.27; CI: 2.40-4.46; P < 0.001). CONCLUSION Amongst ambulatory patients with CHF, a dilated IVC is more closely associated with an adverse prognosis than an elevated TRV.
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Affiliation(s)
- Antonio Iaconelli
- School of Cardiovascular & Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Joe Cuthbert
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston-Upon-Hull, East Riding of Yorkshire, HU6 7RX, UK
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, Kingston-Upon-Hull, East Riding of Yorkshire, HU6 5JQ, UK
| | - Syed Kazmi
- Department of Cardiorespiratory Medicine, Centre for Clinical Sciences, Hull York Medical School, University of Hull, Kingston-Upon-Hull, East Riding of Yorkshire, HU6 7RX, UK
| | - Pasquale Maffia
- School of Cardiovascular & Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- School of Infection & Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull University Teaching Hospitals Trust, Castle Road, Cottingham, Kingston-Upon-Hull, East Riding of Yorkshire, HU6 5JQ, UK
| | - John G F Cleland
- School of Cardiovascular & Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Pierpaolo Pellicori
- School of Cardiovascular & Metabolic Health, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
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34
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Redfield MM. Building Better Defects: Novel Atrial Septal Defect Strategies for Cardiovascular Therapy. JACC. HEART FAILURE 2023; 11:1131-1134. [PMID: 37178086 DOI: 10.1016/j.jchf.2023.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/28/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Margaret M Redfield
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota, USA.
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35
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Udelson JE, Barker CM, Wilkins G, Wilkins B, Gooley R, Lockwood S, Potter BJ, Meduri CU, Fail PS, Solet DJ, Feldt K, Kriegel JM, Shaburishvili T. No-Implant Interatrial Shunt for HFpEF: 6-Month Outcomes From Multicenter Pilot Feasibility Studies. JACC. HEART FAILURE 2023; 11:1121-1130. [PMID: 37115132 DOI: 10.1016/j.jchf.2023.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 01/24/2023] [Accepted: 03/24/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Most approaches to the creation of an interatrial shunt require placement of a permanent implant to maintain patency. OBJECTIVES The goal of this study was to investigate the safety and efficacy of a no-implant interatrial shunt for patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with mildly reduced ejection fraction (HFmrEF). METHODS This was a multicenter, uncontrolled study of patients with HFpEF/HFmrEF and NYHA functional class ≥II, ejection fraction >40%, and pulmonary capillary wedge pressure (PCWP) during supine exercise ≥25 mm Hg with PCWP-to-right atrial gradient ≥5 mm Hg. Follow-up was through 6 months with imaging to assess shunt durability. RESULTS A total of 28 patients were enrolled: mean age was 68 ± 9 years, and 68% were female. Baseline resting and peak exercise PCWP were 19 ± 7 mm Hg and 40 ± 11 mm Hg, respectively. All procedures displayed technical success with confirmation of left-to-right flow (shunt diameter 7.1 ± 0.9 mm). At 1 month, peak exercise PCWP decreased 5.4 ± 9.6 mm Hg (P = 0.011) with no change in right atrial pressure. There were no serious device or procedure-related adverse events through 6 months. Mean 6-minute walk distance increased 101 ± 71 meters (P < 0.001); Kansas City Cardiomyopathy Questionnaire Overall Summary Score increased 26 ± 19 points (P < 0.001); N-terminal pro-B-type natriuretic peptide decreased 372 ± 857 pg/mL (P = 0.018); and shunt patency was confirmed with unchanged diameter. CONCLUSIONS In these feasibility studies of a no-implant interatrial shunt, HFpEF/HFmrEF shunts exhibited stability with favorable safety and early efficacy signals. The results show promise toward this new approach for treating patients with HFpEF/HFmrEF and an appropriate hemodynamic profile. (Evaluation of the Safety and Feasibility of a Percutaneously Created Interatrial Shunt to Alleviate Heart Failure Symptoms in Patients With Chronic Heart Failure and Preserved or Mid-Range Left Ventricular Ejection Fraction [ALLEVIATE-HF-1]; NCT04583527; Evaluation of the Safety and Effectiveness of a Percutaneously Created Interatrial Shunt to Alleviate Heart Failure Symptoms in Patients With Chronic Heart Failure and Preserved or Mid-Range Left Ventricular Ejection Fraction [ALLEVIATE-HF-2]; NCT04838353).
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Affiliation(s)
- James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, Massachusetts, USA.
| | - Colin M Barker
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | | | | | - Brian J Potter
- Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | | | - Peter S Fail
- Cardiovascular Institute of the South, Houma, Louisiana, USA
| | - Darrell J Solet
- Cardiovascular Institute of the South, Houma, Louisiana, USA
| | - Kari Feldt
- Karolinska University Hospital, Stockholm, Sweden
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36
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Salah HM, Fudim M, Burkhoff D. Device Interventions for Heart Failure. JACC. HEART FAILURE 2023; 11:1039-1054. [PMID: 37611987 DOI: 10.1016/j.jchf.2023.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 08/25/2023]
Abstract
Despite remarkable advances in drug therapy for heart failure (HF), the residual HF-related morbidity, mortality, and hospitalizations remain substantial across all HF phenotypes, and significant proportions of patients with HF remain symptomatic despite optimal drug therapy. Driven by these unmet clinical needs, the exponential growth of transcatheter interventions, and a recent shift in the regulatory landscape of device-based therapies, novel device-based interventions have emerged as a potential therapy for various phenotypes of HF. Device-based interventions can overcome some of the limitations of drug therapy (eg, intolerance, nonadherence, inconsistent delivery, and recurrent and long-term cost) and can target some HF-related pathophysiologic pathways more effectively than drug therapy. This paper reviews the current evolving landscape of device-based interventions in HF and highlights critical points related to implementation of these therapies in the current workflow of HF management.
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Affiliation(s)
- Husam M Salah
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York, New York, USA.
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37
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Borlaug BA, Alkhouli M. A Different Path to Relief?: The Left Atrium to Coronary Sinus Shunt for Heart Failure. JACC Cardiovasc Interv 2023; 16:1381-1383. [PMID: 37316148 DOI: 10.1016/j.jcin.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/11/2023] [Indexed: 06/16/2023]
Affiliation(s)
- Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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38
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Ltaief Z, Yerly P, Liaudet L. Pulmonary Hypertension in Left Heart Diseases: Pathophysiology, Hemodynamic Assessment and Therapeutic Management. Int J Mol Sci 2023; 24:9971. [PMID: 37373119 PMCID: PMC10298585 DOI: 10.3390/ijms24129971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
Pulmonary hypertension (PH) associated with left heart diseases (PH-LHD), also termed group 2 PH, represents the most common form of PH. It develops through the passive backward transmission of elevated left heart pressures in the setting of heart failure, either with preserved (HFpEF) or reduced (HFrEF) ejection fraction, which increases the pulsatile afterload of the right ventricle (RV) by reducing pulmonary artery (PA) compliance. In a subset of patients, progressive remodeling of the pulmonary circulation resulted in a pre-capillary phenotype of PH, with elevated pulmonary vascular resistance (PVR) further increasing the RV afterload, eventually leading to RV-PA uncoupling and RV failure. The primary therapeutic objective in PH-LHD is to reduce left-sided pressures through the appropriate use of diuretics and guideline-directed medical therapies for heart failure. When pulmonary vascular remodeling is established, targeted therapies aiming to reduce PVR are theoretically appealing. So far, such targeted therapies have mostly failed to show significant positive effects in patients with PH-LHD, in contrast to their proven efficacy in other forms of pre-capillary PH. Whether such therapies may benefit some specific subgroups of patients (HFrEF, HFpEF) with specific hemodynamic phenotypes (post- or pre-capillary PH) and various degrees of RV dysfunction still needs to be addressed.
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Affiliation(s)
- Zied Ltaief
- Service of Adult Intensive Care Medicine, University Hospital, 1011 Lausanne, Switzerland;
| | - Patrick Yerly
- Service of Cardiology, University Hospital, 1011 Lausanne, Switzerland;
| | - Lucas Liaudet
- Service of Adult Intensive Care Medicine, University Hospital, 1011 Lausanne, Switzerland;
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39
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Gard EK, Beale AL, Telles F, Silvestry FE, Hanff T, Hummel SL, Litwin SE, Petrie MC, Shah SJ, Borlaug BA, Burkhoff D, Komtebedde J, Kaye DM, Nanayakkara S. Left atrial enlargement is associated with pulmonary vascular disease in heart failure with preserved ejection fraction. Eur J Heart Fail 2023; 25:806-814. [PMID: 36847073 PMCID: PMC10625803 DOI: 10.1002/ejhf.2805] [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: 10/12/2022] [Revised: 01/22/2023] [Accepted: 02/17/2023] [Indexed: 03/01/2023] Open
Abstract
AIMS Elevated left atrial (LA) pressure is a pathophysiologic hallmark of heart failure with preserved ejection fraction (HFpEF). Chronically elevated LA pressure leads to LA enlargement, which may impair LA function and increase pulmonary pressures. We sought to evaluate the relationship between LA volume and pulmonary arterial haemodynamics in patients with HFpEF. METHODS AND RESULTS Data from 85 patients (aged 69 ± 8 years) who underwent exercise right heart catheterization and echocardiography were retrospectively analysed. All had symptoms of heart failure, left ventricular ejection fraction ≥50% and haemodynamic features of HFpEF. Patients were divided into LA volume index-based tertiles (≤34 ml/m2 , >34 to ≤45 ml/m2 , >45 ml/m2 ). A subgroup analysis was performed in patients with recorded LA global reservoir strain (n = 60), with reduced strain defined as ≤24%. Age, sex, body surface area and left ventricular ejection fraction were similar between volume groups. LA volume was associated with blunted increases in cardiac output with exercise (padjusted <0.001), higher resting mean pulmonary artery pressure (padjusted = 0.003), with similar wedge pressure (padjusted = 1). Pulmonary vascular resistance (PVR) increased with increasing LA volume (padjusted <0.001). Larger LA volumes featured reduced LA strain (padjusted <0.001), with reduced strain associated with reduced PVR-compliance time (0.34 [0.28-0.40] vs. 0.38 [0.33-0.43], p = 0.03). CONCLUSION Increasing LA volume may be associated with more advanced pulmonary vascular disease in HFpEF, featuring higher PVR and pulmonary pressures. Reduced LA function, worse at increasing LA volumes, is associated with a disrupted PVR-compliance relationship, further augmenting impaired pulmonary haemodynamics.
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Affiliation(s)
| | | | - Fernando Telles
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Thomas Hanff
- Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Scott L. Hummel
- University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | | | | | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Dan Burkhoff
- Cardiovascular Research Foundation, New York, NY, USA
| | | | - David M. Kaye
- Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Shane Nanayakkara
- Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart & Diabetes Institute, Melbourne, Victoria, Australia
- Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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40
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Mohan RC, Litwin SE. The Intriguing Links Among Patent Foramen Ovale, Patent Foramen Ovale Closure, and the Risk for Heart Failure. J Am Soc Echocardiogr 2023:S0894-7317(23)00204-3. [PMID: 37204391 DOI: 10.1016/j.echo.2023.04.012] [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: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Rajeev C Mohan
- Division of Cardiology, Scripps Clinic, La Jolla, California
| | - Sheldon E Litwin
- Division of Cardiology, Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Regional Health Network, Charleston, South Carolina.
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41
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Borlaug BA, Sharma K, Shah SJ, Ho JE. Heart Failure With Preserved Ejection Fraction: JACC Scientific Statement. J Am Coll Cardiol 2023; 81:1810-1834. [PMID: 37137592 DOI: 10.1016/j.jacc.2023.01.049] [Citation(s) in RCA: 88] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/27/2023] [Accepted: 01/30/2023] [Indexed: 05/05/2023]
Abstract
The incidence and prevalence of heart failure with preserved ejection fraction (HFpEF) continue to rise in tandem with the increasing age and burdens of obesity, sedentariness, and cardiometabolic disorders. Despite recent advances in the understanding of its pathophysiological effects on the heart, lungs, and extracardiac tissues, and introduction of new, easily implemented approaches to diagnosis, HFpEF remains under-recognized in everyday practice. This under-recognition presents an even greater concern given the recent identification of highly effective pharmacologic-based and lifestyle-based treatments that can improve clinical status and reduce morbidity and mortality. HFpEF is a heterogenous syndrome and recent studies have suggested an important role for careful, pathophysiological-based phenotyping to improve patient characterization and to better individualize treatment. In this JACC Scientific Statement, we provide an in-depth and updated examination of the epidemiology, pathophysiology, diagnosis, and treatment of HFpEF.
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Affiliation(s)
- Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Kavita Sharma
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jennifer E Ho
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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42
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Stencel J, Alai HR, Dhore-Patil A, Urina-Jassir D, Le Jemtel TH. Obesity, Preserved Ejection Fraction Heart Failure, and Left Ventricular Remodeling. J Clin Med 2023; 12:jcm12093341. [PMID: 37176781 PMCID: PMC10179420 DOI: 10.3390/jcm12093341] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 04/30/2023] [Accepted: 05/06/2023] [Indexed: 05/15/2023] Open
Abstract
Owing to the overwhelming obesity epidemic, preserved ejection fraction heart failure commonly ensues in patients with severe obesity and the obese phenotype of preserved ejection fraction heart failure is now commonplace in clinical practice. Severe obesity and preserved ejection fraction heart failure share congruent cardiovascular, immune, and renal derangements that make it difficult to ascertain whether the obese phenotype of preserved ejection fraction heart failure is the convergence of two highly prevalent conditions or severe obesity enables the development and progression of the syndrome of preserved ejection fraction heart failure. Nevertheless, the obese phenotype of preserved ejection fraction heart failure provides a unique opportunity to assess whether sustained and sizeable loss of excess body weight via metabolic bariatric surgery reverses the concentric left ventricular remodeling that patients with preserved ejection fraction heart failure commonly display.
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Affiliation(s)
- Jason Stencel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, Tulane University Heart and Vascular Institute, New Orleans, LA 70112, USA
| | - Hamid R Alai
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, Tulane University Heart and Vascular Institute, New Orleans, LA 70112, USA
- Southeast Louisiana VA Healthcare System (SLVHCS), New Orleans, LA 70119, USA
| | - Aneesh Dhore-Patil
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, Tulane University Heart and Vascular Institute, New Orleans, LA 70112, USA
| | - Daniela Urina-Jassir
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, Tulane University Heart and Vascular Institute, New Orleans, LA 70112, USA
| | - Thierry H Le Jemtel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, Tulane University Heart and Vascular Institute, New Orleans, LA 70112, USA
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43
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Sachdev V, Sharma K, Keteyian SJ, Alcain CF, Desvigne-Nickens P, Fleg JL, Florea VG, Franklin BA, Guglin M, Halle M, Leifer ES, Panjrath G, Tinsley EA, Wong RP, Kitzman DW. Supervised Exercise Training for Chronic Heart Failure With Preserved Ejection Fraction: A Scientific Statement From the American Heart Association and American College of Cardiology. J Am Coll Cardiol 2023; 81:1524-1542. [PMID: 36958952 DOI: 10.1016/j.jacc.2023.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is one of the most common forms of heart failure; its prevalence is increasing, and outcomes are worsening. Affected patients often experience severe exertional dyspnea and debilitating fatigue, as well as poor quality of life, frequent hospitalizations, and a high mortality rate. Until recently, most pharmacological intervention trials for HFpEF yielded neutral primary outcomes. In contrast, trials of exercise-based interventions have consistently demonstrated large, significant, clinically meaningful improvements in symptoms, objectively determined exercise capacity, and usually quality of life. This success may be attributed, at least in part, to the pleiotropic effects of exercise, which may favorably affect the full range of abnormalities-peripheral vascular, skeletal muscle, and cardiovascular-that contribute to exercise intolerance in HFpEF. Accordingly, this scientific statement critically examines the currently available literature on the effects of exercise-based therapies for chronic stable HFpEF, potential mechanisms for improvement of exercise capacity and symptoms, and how these data compare with exercise therapy for other cardiovascular conditions. Specifically, data reviewed herein demonstrate a comparable or larger magnitude of improvement in exercise capacity from supervised exercise training in patients with chronic HFpEF compared with those with heart failure with reduced ejection fraction, although Medicare reimbursement is available only for the latter group. Finally, critical gaps in implementation of exercise-based therapies for patients with HFpEF, including exercise setting, training modalities, combinations with other strategies such as diet and medications, long-term adherence, incorporation of innovative and more accessible delivery methods, and management of recently hospitalized patients are highlighted to provide guidance for future research.
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44
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Saito Y, Obokata M, Harada T, Kagami K, Sorimachi H, Yuasa N, Kato T, Wada N, Okumura Y, Ishii H. Disproportionate exercise-induced pulmonary hypertension in relation to cardiac output in heart failure with preserved ejection fraction: a non-invasive echocardiographic study. Eur J Heart Fail 2023. [PMID: 36915276 DOI: 10.1002/ejhf.2821] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 01/22/2023] [Accepted: 02/26/2023] [Indexed: 03/16/2023] Open
Abstract
AIMS Pulmonary hypertension (PH) and pulmonary vascular remodelling are common in patients with heart failure with preserved ejection fraction (HFpEF). Many patients with HFpEF demonstrate an abnormal pulmonary haemodynamic response to exercise that is not identifiable at rest. This can be estimated non-invasively by the mean pulmonary artery pressure-cardiac output relationship (mPAP/CO slope). We sought to characterize the pathophysiology of disproportionate exercise-induced PH in relation to CO (DEi-PH) and its prognostic impact in patients with HFpEF. METHODS AND RESULTS A total of 345 patients (166 HFpEF and 179 controls) underwent ergometry exercise stress echocardiography with simultaneous expired gas analysis. DEi-PH was defined as the mPAP/CO slope >5.2 mmHg/L/min (median value). At rest, there were no differences in right ventricular (RV) function and severity of PH between HFpEF patients with and without DEi-PH. Compared with controls (n = 179) and HFpEF without DEi-PH (n = 83), HFpEF with DEi-PH (n = 83) demonstrated worse exercise capacity (lower peak oxygen consumption), depressed RV systolic function, impaired RV-pulmonary artery coupling, limitation in CO augmentation, more right-sided congestion, and worse ventilatory efficiency (higher minute ventilation vs. carbon dioxide volume) during peak exercise. Kaplan-Meier analyses showed that HFpEF patients with DEi-PH had higher rates of composite outcomes of all-cause mortality or heart failure events than those without (log-rank p = 0.0002). CONCLUSION Patients with HFpEF and DEi-PH demonstrated distinct pathophysiologic features that become apparent only during exercise. These data suggest that DEi-PH is a pathophysiologic phenotype of HFpEF and reinforce the importance of exercise stress echocardiography for detailed characterization of HFpEF.
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Affiliation(s)
- Yuki Saito
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.,Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Masaru Obokata
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Kazuki Kagami
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan.,Division of Cardiovascular Medicine, National Defense Medical College, Tokorozawa, Japan
| | - Hidemi Sorimachi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Naoki Yuasa
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Toshimitsu Kato
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Naoki Wada
- Department of Rehabilitation Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
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45
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Abbasi MA, Borlaug BA. Pulmonary vascular disease in heart failure with preserved ejection fraction: the evidence grows. Eur J Heart Fail 2023; 25:332-334. [PMID: 36789637 DOI: 10.1002/ejhf.2800] [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: 02/07/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023] Open
Affiliation(s)
- Muhannad A Abbasi
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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46
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Schuster A, Schulz A, Lange T, Evertz R, Hartmann F, Kowallick JT, Hellenkamp K, Uecker M, Seidler T, Hasenfuß G, Backhaus SJ. Concomitant latent pulmonary vascular disease leads to impaired global cardiac performance in heart failure with preserved ejection fraction. Eur J Heart Fail 2023; 25:322-331. [PMID: 36691723 DOI: 10.1002/ejhf.2781] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/05/2023] [Accepted: 01/15/2023] [Indexed: 01/25/2023] Open
Abstract
AIMS The REDUCE-LAP II trial demonstrated adverse outcomes after interatrial shunt device (IASD) placement in heart failure with preserved ejection fraction (HFpEF) attributed to latent pulmonary vascular disease (PVD). We hypothesized that exercise stress cardiovascular magnetic resonance (CMR) imaging could provide non-invasive characterization of cardiac and pulmonary physiology for improved patient selection. METHODS AND RESULTS The HFpEF-Stress trial prospectively enrolled 75 patients with exertional dyspnoea and diastolic dysfunction. Patients underwent rest and exercise stress right heart catheterization, echocardiography and CMR imaging. Pulmonary artery and capillary wedge pressures, cardiac index (CI) and pulmonary vascular resistance (PVR) were calculated. Latent PVD was defined as increased PVR ≥ 1.74 Wood units during exercise stress. CMR assessed long-axis strains (LAS) and filling volumes of all cardiac chambers. Right ventricular (RV) function was further quantified by stroke and peak flow volumes. Patients with latent PVD (n = 24) showed lower RV function (rest tricuspid annular plane systolic excursion, p = 0.010; stress RV LAS, p < 0.001) compared to patients without (n = 43). During exercise stress, RV stroke and peak flow volumes (p < 0.001) were reduced and led to impaired left atrial filling (p = 0.040) with a strong statistical trend to impaired ventricular (LV) filling (p = 0.098). This subsequently resulted in reduced LV-CI (p < 0.001) despite preserved LV systolic function (LV LAS p ≥ 0.255). The degree of RV dysfunction during exercise stress best predicted latent PVD (RV peak flow, area under the curve at rest 0.73 vs. stress 0.89, p = 0.004). CONCLUSIONS Latent PVD is a feature of HFpEF and is associated with impaired RV functional reserve, global diastolic filling and LV-CI. This can be quantified by CMR and used to identify patients likely to benefit from IASD implantation.
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Affiliation(s)
- Andreas Schuster
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Alexander Schulz
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Torben Lange
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Ruben Evertz
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Finn Hartmann
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Johannes T Kowallick
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.,University Medical Center Göttingen (UMG), Institute for Diagnostic and Interventional Radiology, Göttingen, Germany
| | - Kristian Hellenkamp
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany
| | - Martin Uecker
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.,University Medical Center Göttingen (UMG), Institute for Diagnostic and Interventional Radiology, Göttingen, Germany.,Institute of Biomedical Imaging, Graz University of Technology, Graz, Austria
| | - Tim Seidler
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Gerd Hasenfuß
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Sören J Backhaus
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Georg-August University, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.,School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 476] [Impact Index Per Article: 476.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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48
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Caravita S, Baratto C. Understanding mechanisms of Fontan failure: exercise haemodynamics to unmask diastolic dysfunction, again! Eur J Heart Fail 2023; 25:26-29. [PMID: 36519686 DOI: 10.1002/ejhf.2756] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/04/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Sergio Caravita
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Milan, Italy.,Department of Management, Information and Production Engineering, University of Bergamo, Dalmine, Italy
| | - Claudia Baratto
- Department of Cardiology, Istituto Auxologico Italiano IRCCS, Milan, Italy
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49
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Interatrial Septal Devices for HFpEF: What We Learned from REDUCE LAP-HF. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00975-0] [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: 12/23/2022]
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50
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Omote K, Borlaug BA. Pulmonary vascular reserve with exercise in heart failure. Eur Heart J 2022; 43:4516-4517. [PMID: 36335982 DOI: 10.1093/eurheartj/ehac540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Kazunori Omote
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA.,Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55902, USA
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