Neuromodulation Therapy in Heart Failure: Combined Use of Drugs and Devices

Device therapies for heart failure with reduced ejection fraction: a new era

Even with significant advancements in the treatment modalities for patients with heart failure (HF), the rates of morbidity and mortality associated with HF are still high. Various therapeutic interventions, including cardiac resynchronization therapy, Implantable Cardiovascular-Defibrillators, and left ventricular assist devices, are used for HF management. Currently, more research and developments are required to identify different treatment modalities to reduce hospitalization rates and improve the quality of life of patients with HF. In relation to this, various non-valvular catheter-based therapies have been recently developed for managing chronic HF. These devices target the pathophysiological processes involved in HF development including neurohumoral activation, congestion, and left ventricular remodeling. The present review article aimed to discuss the major transcatheter devices used in managing chronic HF. The rationale and current clinical developmental stages of these interventions will also be addressed in this review.

Neuromodulation interventions in the management of heart failure

Despite remarkable improvements in the management of heart failure (HF), HF remains one of the most rapidly growing cardiovascular condition resulting in a substantial burden on healthcare systems worldwide. In clinical practice, however, a relevant proportion of patients are treated with suboptimal combinations and doses lower than those recommended in the current guidelines. Against this background, it remains important to identify new targets and investigate additional therapeutic options to alleviate symptoms and potentially improve prognosis in HF. Therefore, non-pharmacological interventions targeting autonomic imbalance in HF have been evaluated. This paper aims to review the physiology, available clinical data, and potential therapeutic role of device-based neuromodulation in HF.

The neurometabolic axis: A novel therapeutic target in heart failure

Abnormal cardiac metabolism or cardiac metabolic remodeling is reported before the onset of heart failure with reduced ejection fraction (HFrEF) and is known to trigger and maintain the mechanical dysfunction and electrical, and structural abnormalities of the ventricle. A dysregulated cardiac autonomic tone characterized by sympathetic overdrive with blunted parasympathetic activation is another pathophysiological hallmark of HF. Emerging evidence suggests a link between autonomic nervous system activity and cardiac metabolism. Chronic β-adrenergic activation promotes maladaptive metabolic remodeling whereas cholinergic activation attenuates the metabolic aberrations through favorable modulation of key metabolic regulatory molecules. Restoration of sympathovagal balance by neuromodulation strategies is emerging as a novel nonpharmacological treatment strategy in HF. The current review attempts to evaluate the 'neuro-metabolic axis' in HFrEF and whether neuromodulation can mitigate the adverse metabolic remodeling in HFrEF.

Transcatheter interventions for heart failure

Despite significant advances in the medical management of patients living with heart failure, there continues to be significant morbidity and mortality associated with the condition. There is a growing need for research and development of additional modalities to fill the management and treatment gaps, reduce hospitalisations and improve the quality of life for patients living with heart failure. In the last decade, there has been a rapid rise in the use of non-valvular catheter-based therapies for the management of chronic heart failure to complement existing guideline-directed management. They target well-defined mechanistic and pathophysiological processes critical to the progression of heart failure including left ventricular remodelling, neurohumoral activation, and congestion. In this review, we will explore the physiology, rationale, and current stages of the clinical development of the existing procedures.

Reflecting on the advancements of HFrEF therapies over the last two decades and predicting what is yet to come

What was once considered a topic best avoided, managing heart failure with reduced ejection fraction (HFrEF) has become the focus of many drug and device therapies. While the four pillars of guideline-directed medical therapies have successfully reduced heart failure hospitalizations, and some have even impacted cardiovascular mortality in randomized controlled trials (RCTs), patient-reported outcomes have emerged as important endpoints that merit greater emphasis in future studies. The prospect of an oral inotrope seems more probable now as targets for drug therapies have moved from neurohormonal modulation to intracellular mechanisms and direct cardiac myosin stimulation. While we have come a long way in safely providing durable mechanical circulatory support to patients with advanced HFrEF, several percutaneous device therapies have emerged, and many are under investigation. Biomarkers have shown promise in not only improving our ability to diagnose incident heart failure but also our potential to implicate specific pathophysiological pathways. The once-forgotten concept of discordance between pressure and volume, the forgotten splanchnic venous and lymphatic compartments, have all emerged as promising targets for diagnosing and treating heart failure in the not-so-distant future. The increase in heart failure-related cardiogenic shock (CS) has revived interest in defining optimal perfusion targets and designing RCTs in CS. Rapid developments in remote monitoring, telemedicine, and artificial intelligence promise to change the face of heart failure care. In this state-of-the-art review, we reminisce about the past, highlight the present, and predict what might be the future of HFrEF therapies.

Modern Approaches for the Treatment of Heart Failure: Recent Advances and Future Perspectives

Heart failure (HF) is a progressively deteriorating medical condition that significantly reduces both the patients' life expectancy and quality of life. Even though real progress was made in the past decades in the discovery of novel pharmacological treatments for HF, the prevention of premature deaths has only been marginally alleviated. Despite the availability of a plethora of pharmaceutical approaches, proper management of HF is still challenging. Thus, a myriad of experimental and clinical studies focusing on the discovery of new and provocative underlying mechanisms of HF physiopathology pave the way for the development of novel HF therapeutic approaches. Furthermore, recent technological advances made possible the development of various interventional techniques and device-based approaches for the treatment of HF. Since many of these modern approaches interfere with various well-known pathological mechanisms in HF, they have a real ability to complement and or increase the efficiency of existing medications and thus improve the prognosis and survival rate of HF patients. Their promising and encouraging results reported to date compel the extension of heart failure treatment beyond the classical view. The aim of this review was to summarize modern approaches, new perspectives, and future directions for the treatment of HF.

Device Therapy in Chronic Heart Failure: JACC State-of-the-Art Review

The regulatory landscape for device-based heart failure (HF) therapies has seen a major shift in the last 7 years. In 2013, the U.S. Food and Drug Administration released guidance for early feasibility and first-in-human studies, thereby encouraging device innovation, and in 2016 the U.S. Congress authorized the Breakthrough Devices Program to expedite access for Americans to innovative devices indicated for diagnosis and treatment of serious illnesses, such as HF. Since December 2016, there has been an increase in the number of HF devices for which manufacturers are seeking approval through the breakthrough designation pathway. This has led to a rapid uptake in the development and evaluation of device-based HF therapies. This article reviews the current and future landscape of device therapies for chronic HF and associated comorbidities and the regulatory environment that is driving current and future innovation.