scholarly journals A case report of advanced heart failure refractory to pharmacological therapy who was successfully recovered by combinatory usage of cardiac resynchronizing therapy, Impella and MitraClip

2020 ◽  
Author(s):  
Mitsuo Sobajima ◽  
Nobuyuki Fukuda ◽  
Hiroshi Ueno ◽  
Koichiro Kinugawa
Keyword(s):  
Heart Failure ◽  
Cardiac Resynchronization Therapy ◽  
Therapeutic Option ◽  
Bed Rest ◽  
Pharmacological Therapy ◽  
Advanced Heart Failure ◽  
Cardiac Resynchronization ◽  
Functional Mitral Regurgitation ◽  
Resynchronization Therapy ◽  
Qrs Duration

Abstract Background  The safety and efficacy of MitraClip for advanced heart failure (HF) patients who are inotrope-dependent or mechanically supported are unknown. Case summary  The patient was a 71-year-old man diagnosed as dilated cardiomyopathy in 2003. He was admitted due to worsening HF in January 2019 and became dependent upon intravenous infusion of inotropes. During the 8-month hospitalization, his haemodynamics were relatively static with bed rest and continuous inotropes, but he was definitely dependent on them. Our multidisciplinary team decided to perform both cardiac resynchronization therapy (CRT) and MitraClip under Impella support. First, Impella was inserted from left subclavian artery. After a week, CRT was implanted from right subclavian vein, and the QRS duration of electrocardiogram became remarkably narrow. MitraClip was performed 2 weeks after Impella, and functional mitral regurgitation improved from severe to mild, and Impella was removed on the same day. Inotropes could be ceased, and he was discharged 2 months after MitraClip. Discussion  During inotrope-dependent status, there was a risk that HF would worsen with haemodynamic collapse when performing CRT implantation, and we firstly supported his haemodynamics by Impella. Cardiac resynchronization therapy implantation before MitraClip seemed to be crucial. In fact, the mitral valve morphology before Impella insertion had very poor coaptation of the anterior and posterior leaflets that was not optimal for MitraClip procedure. But the Impella support and correction of dyssynchrony by CRT markedly improved the coaptation of those leaflets. The combination therapy of CRT and MitraClip unloading with Impella maybe a new therapeutic option for advanced HF.

scholarly journals Predictors of Positive Response to Resynchronization Therapy in Patients with Recurrent Episodes of Acutely Decompensated Advanced Heart Failure

2018 ◽  
Vol 4 (1) ◽  
pp. 24-31
Author(s):  
Anca Găitan ◽  
Cristian Stătescu ◽  
Radu Sascau ◽  
Mircea Balasanian ◽  
Cătălina Arsenescu Georgescu
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Cardiac Resynchronization Therapy ◽  
Positive Response ◽  
Chronic Renal Disease ◽  
Therapeutic Option ◽  
Biventricular Pacing ◽  
Advanced Heart Failure ◽  
Cardiac Resynchronization ◽  
Resynchronization Therapy

Abstract Background: In just a few years, cardiac resynchronization therapy (CRT) has emerged as a key player in the treatment of advanced heart failure (HF). However, approximately 30% of patients with CRT device implantation do not achieve a favorable response. The purpose of the present study was to identify clinical, electrocardiographic, and echocardiographic predictors of a positive response to biventricular pacing in patients with advanced decompensated HF. Methods: This prospective, observational study involved 42 consecutive patients admitted in emergency settings in our clinic with HF in New York Heart Association (NYHA) functional class III/IV, with QRS duration ≥120 ms and left ventricle ejection fraction (LVEF) ≤35%, who underwent cardiac resynchronization therapy (CRT-P or CRT-D) between January 2010 and July 2014. Statistical analysis was performed using IBM SPSS statistical software. Results: The clinical response (improvement in NYHA class) was recorded in 6 patients (14.3%), while echocardiographic response (change in ejection fraction and/or in endsystolic or end-diastolic volumes) was recorded in 10 patients (23.8%). The most frequently observed type of response to CRT was the double (clinical plus echocardiographic) response, recorded in 23 out of 42 patients (54.8%). ROC analysis identified the absence of chronic renal disease and the duration from onset of symptoms to CRT implantation as good predictors for clinical improvement after CRT (AUC = 0.625, 95% CI: 0.400–0.850 for absence of renal failure and AUC = 0.516, 95% CI: 0.369–0.853 for symptoms duration). However, gender, age, duration from symptom onset, and comorbidities were not good predictors for the echocardiographic response (AUC <0.600). Conclusions: CRT represents an important therapeutic option for selected patents with advanced decompensated HF and prolonged QRS interval; however, only some of the commonly used criteria can predict a favorable outcome in patients undergoing CRT.

scholarly journals Analysis of Risk Factors for Acute Heart Failure in Patients with Dilated Cardiomyopathy and Persistent Severe Functional Mitral Regurgitation Despite Cardiac Resynchronization Therapy

2020 ◽  
pp. 35-39
Author(s):  
R. V. Buriak ◽  
K. V. Rudenko ◽  
O. A. Krykunov
Keyword(s):  
Risk Factors ◽  
Heart Failure ◽  
Mitral Regurgitation ◽  
Cardiac Resynchronization Therapy ◽  
Dilated Cardiomyopathy ◽  
Left Ventricular ◽  
Cardiac Resynchronization ◽  
Functional Mitral Regurgitation ◽  
Reverse Remodeling ◽  
Resynchronization Therapy

Congestive heart failure resulting from non-ischemic dilated cardiomyopathy (DCM) with secondary functional mitral regurgitation (FMR) is associated with poor prognosis. Medical treatment results in a 1-year survival of 52% to 87% and a 5-year survival of 22% to 54%, with highest survivals observed in more recent years, probably reflecting improvements in medical therapy. Non-surgical interventions involve cardiac resynchronization therapy. In addition to medical treatment, cardiac resynchronization therapy (CRT) should be considered in patients with New York Heart Association (NYHA) class II– IV HF, left ventricular ejection fraction (LVEF) =35%, normal sinus rhythm and left bundle branch block with QRS >150 ms. In these patients, CRT can also facilitate left ventricular (LV) reverse remodeling and reduce associated FMR. The aim of this study was to investigate the features of symptomatology and to analyze the risk factors for acute heart failure (AHF) in patients with DCM and persistent severe functional mitral regurgitation despite CRT and optimal guideline-directed medical therapy (GDMT). Materials and methods. After providing informed consent, 144 patients with severe FMR were involved in the study. Concomitant tricuspid valve regurgitation was registered in 142 (98.6%) cases. The median LVEF was 27.0 (23.0-31.6)%. 40 (27.8%) patients had a permanent form of atrial fibrillation, and 24 (16.7%) patients had a first-degree atrioventricular node block. The median NT-proBNP was 2600 (2133-3200) pg/ml, indicating the presence of severe chronic heart failure. Results. The median term after CRT device implantation was 36 (3.5-60) months. A comparative analysis between DCM patients with and without CRT revealed statistically significant differences between clinical characteristics, namely: age (p=0.020), lower heart rate (p=0.004), lower hemoglobin (p=0.017), higher erythrocyte sedimentation rate (ESR) (p=0.000) and more frequent AHF at the hospital stage (p=0.030). The incidence of AHF at the hospital stage was 13.8% in patients with CRT and 3.5% in those without CRT. The calculated odds ratio of AHF was 4.44 (95% confidence interval (CI) 1.039-18.971), and the relative risk of AHF was 3.966 (95% CI 1.054-14.915). Discussion. FMR has been reported to persist in about 20% to 25% of CRT patients and, in an additional 10% to 15%, it may actually worsen after CRT. In this subset of CRT non-responders, reduced reverse remodeling, increased morbidity, and increased mortality have been reported compared with CRT patients in whom FMR was significantly reduced or abolished. Conclusions. The results of our study demonstrate that severe functional mitral regurgitation despite cardiac resynchronization therapy in patients with dilated cardiomyopathy is a significant risk factor for AHF and subsequent hospitalizations for heart failure.

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