164 Effect of cardiac contractility modulation therapy on myocardial work in patients with heart failure with reduced ejection fraction

Aims Cardiac contractility modulation therapy (CCMT) has been shown to reduce hospitalizations and to improve quality of life in heart failure patients with reduced ejection fraction (HFrEF) who remain symptomatic despite disease-modifying therapies. Strain imaging derived myocardial work (MW) is an emerging tool for evaluating left ventricular mechanics by incorporating systolic deformation and afterload burden in the analysis. To evaluate prospectively the impact of CCMT in HFrEF patients on MW derived parameters in relation to standard echocardiographic indices. Methods and results We recruited 12 HFrEF patients with indications to CCMT according to current clinical practice. A comprehensive echo-Doppler evaluation, including speckle tracking derived assessment of global longitudinal strain (GLS), was performed before and after three months from the CCM device implantation. Parameters of MW such as global work index (GWI), global constructive work (GCW) global wasted work (GWW), and global work efficiency (GWE) were calculated according to standardized procedures. Median values (interquartile range) were compared for all those parameters from baseline and 3-month follow-up with Wilcoxon Rank Sum test for continuous variables. At three months from CCM implant an improvement of LVEF [from 32% (27–34) to 36% (29–39), P < 0.05], GLS [from 7.4% (6.2–11.2) to 9.9% (7.5–9.4), P < 0.05], GWI [from 461 mmHg (372–613) to 589 mmHg (413–696), P < 0.05], GCW [from 800 mmHg (620–930) to 970 mmHg (644–1009), P = 0.236], and GWE [from 73% (65–78) to 85% (78–87), P < 0.05] was observed, with a consistent reduction of GWW [from 161 mmHg (148–227) to 125 mmHg (101–188), P < 0.05]. We also found a positive correlation between the magnitude of LVEF improvement and the baseline values of GCW (r = 0.727, P = 0.011). Conclusions At 3 months, CCMT significantly improves standard and advanced left ventricular systolic function indices. This improvement is due to the increase of constructive work and a reduction of wasted work. In addition, the increase of left ventricular ejection fraction can be predicted by the global constructive work levels at baseline.

49 A case report of cardiac contractility modulation therapy for heart failure treatment in patient with amyloidosis: is to be considered a valid therapeutic option?

Aims Cardiac amyloidosis (CA) is primarily associated with fibril deposits in many cardiac structures, causing biventricular wall thickness and stiffness. CA may result in arrhythmias and particularly in an aggressive form of heart failure (HF). Cardiac contractility modulation (CCM) showed to be a concrete therapeutic option in patients with symptomatic HF despite optimal medical therapy (OMT), with Left Ventricular Ejection Fraction (LVEF) between 25% and 45%, with narrow QRS complex (<130 ms). This case aims to further explore the effectiveness of CCM therapy in a patient affected by concomitant ischaemic cardiomyopathy and CA. Methods and results A 42-year-old man with Chronic HF secondary to both post-ischaemic due to spontaneous coronary artery dissection (SCAD) and post alcoholic dilated cardiomyopathy was hospitalized at our department in February 2020 due to worsening HF (3rd HF hospitalization in the same year). The patient was a NYHA class III, with chronic kidney failure, a narrow QRS complex (100 ms) and a LVEF of 27% with familiar history of sudden death, already implanted with ICD. The patient resulted untreatable with sacubitril/valsartan, as it elicited strong hypotension. During current hospitalization the BNP value was 942.60 pg/ml, and the Quality of Life (QoL) evaluated from Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was 72 points. Moreover, the patient underwent umbilical biopsy that confirmed the presence of amyloidosis. Thus, the CCM therapy device (Optimizer® Smart, Impulse Dynamics) was implanted to try to reduce HF symptoms and hospitalizations. The therapy was programmed for 10 h per day, with delivery of CCM from both septal leads with amplitude of 6.5 V at 20.56 ms pulses duration. Figure 1A and B shows the septal position of leads and a surface ECG with the CCM therapy spike after QRS. The patient significantly improved as early as the first period after implantation. The 10-month in-office FU performed on December 2020 revealed in addition to the absence of new HF hospitalizations, a significant improvement in QoL and HF-symptoms, with a MLWHFQ score of 42, an enhancement to NHYA class II, and even a slight decrease of BNP of 767 pg/ml. The echo exam revealed no significant changes in the EF, with an improvement of global longitudinal strain and no worsening of other haemodynamic parameters. A further FU performed in June 2021 showed continuous improvement of QoL with a MLWHFQ score of 25 e no HF hospitalizations. Conclusions In this patient affected by multiple cardiomyopathies, including CA, CCM therapy proved to improve its QoL with no HF hospital admissions since the implantation. The absence of significant echocardiographic worsening is a positive aspect, considering the patient’s status, the concomitant aetiologies, and the presence of amyloidosis, given its progressive and infiltrative nature.

Use of Cardiac Contractility Modulation in an Older Patient with Non-Ischemic Dilated Cardiomyopathy: A Case Report

Cardiac contractility modulation (CCM) is a novel device-based therapy used in patients with HFrEF. CCM therapy is associated with an improvement in exercise tolerance, increased quality of life, reduced HF hospitalizations, and reverse remodelling of the left ventricle in patients with HFrEF. In this case, we report the clinical benefit of CCM in an older patient with advanced HFrEF due to ischemic dilated cardiomyopathy with frequent heart failure-related hospitalizations and poor quality of life despite optimal medical therapy.

The assessment of left ventricular myocardial work in patients with chronic heart failure receiving cardiac contractility modulation therapy

Introduction A new non-invasive technology for the assessment of left ventricular myocardial work (LVMW) is based on speckle-tracking echocardiography and considers LV pressure. Changes in LVMW are described in patients with different cardiovascular diseases. In patients with chronic heart failure (CHF), LVMW is associated with long-term prognosis and favorable response to cardiac resynchronization therapy. Purpose To study echocardiographic parameters, including LVMW, in patients with CHF receiving cardiac contractility modulation therapy. Methods The study included 40 patients (31 men and 7 women) aged 60.5 [55.0; 66.0] years with heart failure with reduced ejection fraction (NYHA class II or III) in combination with atrial fibrillation. Before implantation of cardiac contractility modulation (CCM) device and 2, 6 and 12 months after, the patients underwent transthoracic echocardiography with an assessment of the main structural and functional parameters. Also, initially and after 12 months of CCM therapy, an assessment of global longitudinal strain (GLS) and LVMW was performed (global work index (GWI), global constructive work (GCW), global wasted work, global work efficiency (GWE)). Results Initially, the patients included in the study had enlarged left heart chambers and decreased left ventricular ejection fraction (LVEF). CCM therapy was accompanied by significant increase in LVEF from 30.0 [26.5; 37.0]% before device implantation up to 34.4 [27.0; 40.0]% (p=0.016) after 2 months and up to 38.0 [30.5; 42.0]% (p<0.01) after 6 months of treatment. One year after device implantation, a significant increase in LVEF was maintained as compared with initial data (39 [31; 45]%, p<0.01). We also analyzed the dynamics of echocardiographic parameters depending on etiology of CHF (ischemic and non-ischemic). As in general group of patients regardless of CHF etiology there was a significant increase in LVEF, that reached maximum values after 12 months of therapy (36 [30; 42]% in group with ischemic etiology, p<0.01 and 37 [30; 45]% in group with non-ischemic etiology, p<0.01). The assessment of GLS before and 12 months after device implantation revealed no significant dynamics (−7 [−9; −4]% and −8 [−9; −5]%, p=0.93). However, we observed significant changes in LVMW: an increase in GWI from 429 [332; 744] to 635 [401; 815] mm Hg% (p=0.01) and GWE (from 73 [68; 79] to 74 [70; 87] %, p=0.02) due to an increase in GCW (from 791 [530; 1031] to 836 [708; 1109] mm Hg%, p=0.03). Conclusions A significant increase in LVEF, GWI and GWE in patients with CHF (NYHA class II or III) receiving CCM therapy indicates an improvement in LV systolic function and the effectiveness of CCM therapy. The modern echocardiographic technologies open great opportunities for detailed assessment of the effectiveness of treatment of patients with CHF, including the use of CCM devices. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Health of Russian Federation

Cardiac Contractility Modulation Therapy for Heart Failure – First Romanian Experience

Aim: The purpose of this study is to present the first Romanian case-series of patients with heart failure with reduced ejection fraction (HFrEF), supported with the newest generation of cardiac contractility modulation (CCM) device. Methods and results: 16 patients (15 men), aged 66.6±7.49 years, were supported with OPTIMIZER® smart IPG CCMX10 device and followed-up for an average duration of 385.75±326.32 days. The etiology of HF was ischemic in 13 patients (81%), 8 patients (50%) had atrial fibrillation, mean creatinine clearance value was 55.8±13.87 ml/min, and 5 patients (31,2%) had diabetes mellitus. All patients were supported with an implanted cardio verter-defibrillator (ICD), while 5 patients (31.2%) had cardiac resynchronization therapy (CRT) on top. The pharma cological treatment has been optimized in all patients. Six months after implantation, the LVEF has increased from 25.93%±6.21 to 35.5%±4.31 (p=0.00002), NYHA class improved from 3.18±0.4 to 1.83±0.38 (p<0.0001), and exercise tolerance evaluated with 6 minute walking test (6MWT) increased (from 321.87±70.63m to 521.41±86.43m; p<0,00001). Three patients (18,7%) died during the follow-up period after 48, 108 and 545 days (one non-cardiac death). Conclusions: Cardiac contractile therapy is a feasible, safe, and useful therapy for patients with HFrEF whose symptomatology is not improved with optimal standard therapy.

Dynamics of Holter electrocardiogram monitoring in patients with chronic heart failure and atrial fibrillation on the background of cardiac contractility modulation

Aim. To evaluate the dynamics of cardiac arrhythmias on the background of cardiac contractility modulation (MCC) in patients with chronic heart failure (CHF) and various forms of atrial fibrillation (AF) on the basis of daily electrocardiogram (ECG) monitoring. Materials and methods. In 100 patients with CHF and AF, the following studies were performed before implantation of the MCC device and after 12 months of follow-up: 12-channel ECG with an estimate of the width of the QRS complex, transthoracic echocardiography (EchoCG), and Holter ECG monitoring. All patients received long-term optimal drug therapy for CHF before surgery. Results. The results obtained indicate that there is no effect of MCC on the development and progression of ventricular arrhythmias in patients with CHF and AF during the year of follow-up, both extrasystole and tachyarrhythmias, regardless of the etiology and LVEF (less than 35% or more than 35%), and a decrease in the frequency of AF paroxysms in patients with CHF during treatment. These results are due to the reverse remodeling of the LV myocardium under the influence of the MCC device. Conclusion. The use of MСС in patients with CHF and AF is a safe method of therapy that does not induce cardiac arrhythmias, including ventricular extrasystole. Large-scale comparative studies are required to evaluate these results.

Four-year follow-up of a patient with mixed cardiomyopathy and an implanted cardiac contractility modulation device: a case report

The article presents a case report of a 28-year-old male patient with mixed dilated cardiomyopathy: myocardial noncompaction and chemotherapy-related cardiotoxicity, which led to severe heart failure (HF). With optimal drug therapy, the patient was implanted with a cardiac contractility modulation device in order to improve exercise tolerance, quality of life and relieve HF symptoms. Complex therapy has led to significant clinical and echocardiographic improvement. This case demonstrates a 4-year follow-up of a patient with a reduced left ventricular ejection fraction and an implanted cardiac contractility modulation device, whose condition, after several severe HF decompensations, was stabilized.

Cardiac contractility modulation therapy in elderly patients with chronic heart failure: results of the 12-month follow-up

Aim. This study aimed to evaluate the efficacy and safety of cardiac contractility modulation (CCM) therapy in elderly patients with heart failure with reduced ejection fraction (HFrEF).Methods. Sixteen patients older than 65 years old (median age 70 years) undergoing CCM Optimizer (Impulse Dynamics) device implantation due to HFrEF (NYHA class II - 9 (56%), III - 4 (25%), IV - 3 (19%)) were enrolled in this two-center observational study. Before implantation 6-minute walk test (6MWT), transthoracic echocardiography (TTE) was performed on all patients, and NTproBNP levels were assessed. The follow-up duration was 12 months with 2, 6, 12-month follow-up visits. Control 6MWT, TTE and NTproBNP tests were performed at 6-month and 12-month follow-up visits.Results. Two patients died during follow-up due to HF decompensation. The remaining patients showed a significant improvement in 6MWT (350 m vs 402.5 m, p=0,01). We also noted a tendency towards the left ventricular EF improvement (33% vs 40%, p=0,2) and lower values of NTproBNP levels (1112 pg/ml vs 527 pg/ml, p=0,19).Conclusion. CCM therapy is a safe and efficient additional treatment option to manage elderly patients with HFrEF for reducing signs and symptoms of HF.