The Evaluation of the Heart Failure Patient by Echocardiography: Time to go beyond the Ejection Fraction

Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. The echocardiogram is the single most performed and useful study in these patients. This article reviews the role of the echocardiogram in the evaluation of the heart failure patient, without focusing on the left ventricle. The discussion includes the use of the echocardiogram in the assessment of the right ventricle and diastolic function and in detecting hemodynamic and morphologic changes in heart failure over a period of time. In addition, we highlight some of the limitations of echocardiography in the assessment of these patients

Continuous Flow Left Ventricular Assist Device Therapy: A Focused Review on Optimal Patient Selection and Long-Term Follow-up Using Echocardiography

Despite widespread awareness and use of scientifically proven life-prolonging medical and device-based therapies over the last two decades, heart failure remains a leading cause of morbidity, mortality, and health care expenditure in the United States. Mechanical circulatory support with a continuous-flow left ventricular assist device (CF-LVAD), either as a bridge to heart transplantation or as destination therapy, is an increasingly used treatment modality for patients with advanced heart failure syndromes that worsen despite their receiving standard therapies. CF-LVAD support creates unique hemodynamic alterations that must be understood to provide appropriate care for these patients before and after implantation. Echocardiography is essential in the evaluation of patients who are being considered for or are mechanically supported by CF-LVADs. Here we provide a focused clinical review on the use of echocardiography in two main aspects of the evaluation of these patients: (a) optimal patient selection for CF-LVAD support and (b) follow-up assessment of optimal pump function

Mesenchymal Precursor Cells as Adjunctive Therapy in Recipients of Contemporary Left Ventricular Assist Devices

BACKGROUND: Allogeneic mesenchymal precursor cells (MPC) injected during left ventricular assist device (LVAD) implantation may contribute to myocardial recovery. This trial explores the safety and efficacy of this strategy. METHODS AND RESULTS: In this multi-center, double-blind, sham-procedure controlled trial, 30 patients were randomized (2:1) to intramyocardial injection of 25M MPCs or medium during LVAD implantation. The primary safety endpoint was incidence of infectious myocarditis, myocardial rupture, neoplasm, hypersensitivity reaction, and immune sensitization (90 days post-randomization). Key efficacy endpoints were functional status and ventricular function, while temporarily weaned from LVAD support (90 days post-randomization). Patients were followed until transplant or 12 months post-randomization, whichever came first. Mean age was 57.4 (±13.6) years, mean LVEF 18.1%, and 66.7% were destination therapy LVADs. No safety events were observed. Successful temporary LVAD weaning was achieved in 50% of MPC and 20% of control patients at 90 days (p=0.24); the posterior probability that MPCs increased the likelihood of successful weaning is 93%. At 90 days, 3 deaths occurred in control and none in MPC patients. Mean LVEF following successful wean was 24.0% (MPC=10) and 22.5% (Control=2) (p=0.56). At 12 months, 30% of MPC and 40% of control patients were successfully temporarily weaned from LVAD support (p=0.69) and 6 deaths occurred in MPC patients. Donor-specific HLA sensitization developed in 2 MPC and 3 control patients and resolved by 12 months. CONCLUSIONS: In this preliminary trial, administration of MPCs appeared to be safe and there was a potential signal of efficacy. Future studies will evaluate the potential for higher or additional doses to enhance the ability to wean LVAD recipients off support. CLINICAL TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov. Identifier: NCT01442129