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Challenging cases in heart failure

Clinical pathway

Heart Failure

This well attended session on Saturday morning started with a talk by Prof. G. Filippatos (Athens, Greece), chair-elect of the European Heart Failure Association who gave an excellent overview of the new 2012 ESC guidelines on heart failure.  He started by highlighting the importance of non-invasive cardiac imaging for the diagnosis of heart failure and the pivotal role of left ventricular ejection fraction (LVEF) measurements in daily practice.
Important changes in recommendations for pharmacological treatment in patients with heart failure with reduced ejection fraction (HFREF) include the extended use of mineralocorticoid receptor blockers in patients who remain symptomatic under treatment with ACE/ARB and beta-blockers. Also, ivabradine should be considered to reduce the risk of heart failure hospitalization in patients in sinus rhythm with an LVEF≤35%, a heart rate remaining ≥ 70 beats per minute, and persisting symptoms (NYHA class II-IV) despite optimal medical treatment including beta-blockers (Class IIa, level of evidence B).  In patients who are unable to tolerate a beta-blocker, it may be considered to reduce the risk of heart failure hospitalisations in patients in sinus rhythm, with an LVEF≤35% and a heart rate remaining ≥ 70 beats per minute (Class IIb, level of evidence C). For patients with heart failure with preserved ejection fraction (HFPEF), however, randomized clinical trials were all neutral, and thus, no formal recommendations for pharmacological treatment are given for these patients. 
Prof. Filippatos also gave a concise overview of the different indications for device therapy and also discussed the recently presented BLOCK-HF trial (cardiac resynchronization therapy (CRT) versus right ventricular pacing in patients with LV dysfunction and atrio-ventricular block). He concluded his talk with the management of acute heart failure and discussed the important results of the just published Relax-AHF trial (Teerlink et al Lancet  2012 Nov 6, epub ahead of print. doi:pii: S0140-6736(12)61855-8. 10.1016/S0140-6736(12)61855-8.)
Prof O. Breithardt (Leipzig, Germany) subsequently presented a case of HFREF and secondary mitral regurgitation (MR) that was treated with CRT. After reviewing the mechanisms of secondary MR, he discussed the role of echocardiography in these patients, not only for the evaluation of dyssynchrony, but also for the evaluation of tethering and closing forces on the mitral valve. For the evaluation of closing forces, non-invasive evaluation of LV dp/dt by continuous wave Doppler may be helpful, although the values obtained are not directly comparable to dp/dt values measured invasively. Also after CRT implantation, echocardiography is important as a monitoring tool, since, for example, the improvement in MR severity is closely related to the improvement of systolic function. Prof. Breithardt concluded his talk by showing some promising new approaches to secondary MR including mitral valve annuloplasty in combination with chordal cutting.
The next case was presented by Prof. CM Yu (Hong Kong). He presented the case of a 56 year old woman with heart failure and reduced ejection fraction (LVEF 20%), QRS 130 ms and borderline dyssynchrony measurements who remained seriously symptomatic and also showing no significant improvement in systolic function after CRT-D treatment. This patient was subsequently treated with Cardiac Contractility Modulation (CMM) therapy. This device-based therapy enhances intrinsic contractility of intrinsic heart beats (during sinus rhythm) by applying large amplitude electrical current during late systole. To apply this current, the device uses 1 right atrial lead and 2 leads in the interventricular septum. After CMM treatment, the patient improved significantly regarding symptoms and LVEF (increase to LVEF 30%), but 3 years later the effect was abruptly lost with the occurrence of atrial fibrillation. Only after ablation therapy was persistent sinus rhythm obtained and the device could be switched on again resulting in fast improvement of symptoms and LVEF.
After this case presentation, Prof. Yu briefly discussed the results of clinical trials that evaluated CCM (including the FIX-CHF-4 and FIX-CHF-5 trials). Pooled results of these trials suggest an improvement of symptoms and quality of life, but no significant effect on hard cardiac endpoints has yet been shown.
Finally, Prof. G. Di Salvo (Riyadh, SA) gave an extensive overview of the use of different echocardiography parameters (including conventional parameters, tissue Doppler imaging, strain/strain rate and speckle tracking) for the evaluation of diastolic function in HFPEF patients. He also illustrated the application of these parameters in more complex clinical situations such as the prediction of pulmonary congestion after atrial septal defect closure and mitral stenosis.




Challenging cases in heart failure

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

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