Pomeranian atRial flOw reguLatOr iN conGestive hEart failuRe (PROLONGER): Study protocol

Advances in device-based treatment of heart failure with preserved ejection fraction: evidence from clinical trials

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.

Unveiling the Hidden Chamber: Exploring the Importance of Left Atrial Function and Filling Pressure in Cardiovascular Health

The left atrium (LA) is a vital component of the cardiovascular system, playing a crucial role in cardiac function. It acts as a reservoir, conduit, and contractile chamber, contributing to optimal left ventricle (LV) filling and cardiac output. Abnormalities in LA function have been associated with various cardiovascular conditions, including heart failure, atrial fibrillation, valvular heart disease, and hypertension. Elevated left ventricular filling pressures resulting from impaired LA function can lead to diastolic dysfunction and increase the risk of adverse cardiovascular events. Understanding the relationship between LA function and LV filling pressures is crucial for comprehending the pathophysiology of cardiovascular diseases and guiding clinical management strategies. This article provides an overview of the anatomy and physiology of the LA, discusses the role of LA mechanics in maintaining normal cardiac function, highlights the clinical implications of elevated filling pressures, and explores diagnostic methods for assessing LA function and filling pressures. Furthermore, it discusses the prognostic implications and potential therapeutic approaches for managing patients with abnormal LA function and elevated filling pressure. Continued research and clinical focus on left atrial function are necessary to improve diagnostic accuracy, prognostic assessment, and treatment strategies in cardiovascular diseases. It will explore the importance of assessing LA function as a marker of cardiac performance and evaluate its implications for clinical practice. In accordance with rigorous scientific methodology, our search encompassed PubMed database. We selected articles deemed pertinent to our subject matter. Subsequently, we extracted and synthesized the salient contents, capturing the essence of each selected article.

Left atrium decompression devices across the spectrum of ejection fraction in heart failure: an updated systematic review and meta-regression analysis

BACKGROUND

In patients affected by heart failure (HF) with reduced ejection fraction (HFrEF), pharmacological treatments have been proven to alleviate symptoms and improve prognosis, while no treatment other than sodium-glucose co-transporter-2 inhibitors have demonstrated significant effects in HF with preserved ejection fraction (HFpEF). Left atrium decompression devices (LADd) have been recently investigated as a new interventional approach in patients with HFpEF.

OBJECTIVES

To assess the efficacy of LADd on soft endpoints in HF patients across the spectrum of ejection fraction.

METHODS

PubMed and Web of Science were searched without restrictions from inception to 28 May 2022 to identify valuable articles. The studies that met the inclusion criteria were analyzed. The prespecified main outcomes were the change from baseline in 6-min walking distance (6MWD), NYHA class and health-related quality of life (HRQoL). Secondary outcomes were reduction in HF hospitalizations, echocardiographic, and hemodynamic parameters.

RESULTS

Eleven studies, with a total of 547 patients, were included. LADd significantly improved 6MWD by 43.95 m (95% CI 29.64-58.26 m), decreased NYHA class by 0.93 (95% CI 1.20-0.67), and improved HRQoL questionnaire by 20.45 points (95% CI 13.77-27.14) with better results for all outcomes in patients with lower EFs.

CONCLUSION

The present meta-analysis suggests that LADd are favorable in improving 6MWD, NYHA class, and HRQoL in HF across a wide spectrum of ejection fraction, with better outcomes in patients with lower EFs.

TRIAL REGISTRATION

CRD42022336077, URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=336077 .

Device-based percutaneous treatments to decompress the left atrium in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for more than half of heart failure hospital admissions in the last years and is burdened by high mortality and poor quality of life. Providing effective management for HFpEF patients is a major unmet clinical need. Increase in left atrial pressure is the key determinant of pulmonary congestion, with consequent dyspnoea and exercise limitation. Evidence on benefits of medical treatment in HFpEF patients is limited. Thus, alternative strategies, including devices able to reduce left atrial pressure, through an interatrial communication determining a left-right shunt, were developed. This review aims to summarize evidence regarding the use of percutaneous interatrial shunting devices. These devices are safe and effective in improving hemodynamic and clinical parameters, including pulmonary capillary wedge pressure, 6-min walking distance, and New York Heart Association functional class. Data on cardiovascular mortality and re-hospitalization for heart failure are still scarce.