ESC Congress 2017 In Review -- Main Edition - 23

ESC Congress 2017

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In Review

A Look Ahead in the Treatment of
Heart Failure
Written by Brian Hoyle

Table 1. Eligibility Criteria for Implantation of LVADs
Patients with > 2 months of severe symptoms despite optimal
medical and device therapy and more than one of the following:
LVEF < 25% and, if measered, peak VO2 < 12 mL/kg/min.
≥ 3 HF hospitalisations in previous 12 months without an obvious precipitating
cause.
Dependence on intravenous inotropic therapy.
Progressive end-organ dysfunction (worsening renal and/or hepatic function)
due to reduced perfusion and not to inadequate ventricular filling pressure
(PCWP ≥ 20 mm Hg and SBP ≤ 80-90 mm Hg or CI ≤ 2 L/min/m2).
Absence of severe right ventricular dysfunction together with severe tricuspid regurgitation.
CI, cardiac index; LVEF, left ventricular ejection fraction; HF, heart failure; PCWP,
pulmonary capillary wedge pressure; SPB, systolic blood pressure; VO2, volume
of oxygen.
Reprinted from Ponikowski P, Voors AA et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;37:2129-
2200. doi:10.1093/eurheartj/ehw128. By permission of Oxford University Press
on behalf of the European Society of Cardiology.

Refinements of LVADs and the repertoire of devices
have led to their increasing use. Devices capable of providing continuous flow are available. Immediate installation of an LVAD improves the patient's condition. But,
the immediate short-term benefit should not obscure the
reality that complications like infection, stroke, and major
bleeding frequently occur and need to be handled immediately by a multidisciplinary care team. Patients need to

be educated concerning the possibility of setbacks and
the ongoing need for care.
Right ventricular dysfunction can develop following
installation of a LVAD. A very recent systematic review
and meta-analysis clarified the predictive factors of
right ventricular problems [Bellavia D et al. Eur J Heart
Fail. 2017].
Patient-driven future developments in LVADs include
devices that automatically adapt to the changing cardiac
demands of exercise and a fully implantable device that
would enable a person to swim.
The DOSE-AHF [Felker GM et al. N Engl J Med. 2011]
and CARRESS-HF [Bart BA et al. N Engl J Med. 2012]
clinical trials highlighted that the outcome of acute HF
(AHF) continues to be poor. In DOSE-AHF and CARRESSHF, 40% of patients were hospitalised or had died by
60 days following treatment randomisation, according
to Gerasimos Filippatose, MD, PhD, Athens University
Hospital Attikon, Greece.
Improving the outlook calls for better diagnosis and
classification, increased knowledge of the disease epidemiology and pathophysiology, and better disease
management. In terms of classification, the 2016 ESC
guidelines for the diagnosis and treatment of HF
[Ponikowski P et al. Eur Heart J. 2016] stratified HF into
categories of reduced, mid-range, and preserved ejection fraction (Figure 1).
Figure 1. European Society of Cardiology Classification of Heart Failure
Heart Failure With Preserved, Mid-range, and Reduced EF
Type of HF

Criteria

According to Alexandre Mebazaa, MD, PhD, FESC, Hôpitaux
Universitaires Saint Louis-Lariboisière, Paris, France,
mechanical circulatory support devices continue to
improve in design and performance, and are leading to
more prolonged survival in advanced heart failure (HF).
However, left ventricular assisted devices (LVADs) remain
burdened by postimplantation complications.
Advanced HF patients who are stable but require assistance in weakening or strengthening the force of muscular contractions in the heart can benefit, in some cases, from cardiac resynchronisation in case of large QRS
[Milliez P et al. Eur J Heart Fail. 2008].
LVADs can be considered in patients with end-stage HF
with reduced ejection fraction (HRrEF) who have received
appropriate medical/device therapy, either as a bridge to
heart transplantation or, in those not eligible for a transplant, to reduce the risk of premature death. There are a
number of eligibility criteria (Table 1) [Ponikowski P et al.
Eur J Heart Fail. 2016].

HFrEF

HFmrEF

HFpEF

Symptoms ± Signs

LVEF < 40%

LVEF 40-49%

LVEF ≥ 50%

1. Elevated levels of
natriuretic peptides,
2. At least one additinal
criterion:
a. relevant structural
heart disease (LVH
and/or LAE),
b. diastolic dysfunction.

HF, heart failure; HFrEF, heart failure with reduced ejection fraction; HFmrEF,
heart failure with mid-range ejection fraction; HFpEF, heart failure with preserved ejection fraction; LAE, left atrial enlargement; LVEF, left ventricular ejection fraction; LVH, left ventricular hypertrophy.
Reprinted from Ponikowski P, Voors AA et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2016;37:2129-
2200. doi:10.1093/eurheartj/ehw128. By permission of Oxford University Press
on behalf of the European Society of Cardiology.

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