Resolution of cheyne-stokes respiration after treatment of heart failure with Sacubitril/Valsartan

Sleep-disordered breathing (SDB) is highly prevalent in patients with heart failure (HF), and is known to be associated with a worse prognosis. The severity of central sleep apnea is thought to mirror cardiac dysfunction. The novel angiotensin receptor-neprilysin inhibitor (ARNi) sacubitril has been shown to improve HF, but a relationship between treatment with ARNi and the severity of SDB has not yet been investigated. We report the case of a 71-year-old male with HF and SDB. Treatment with sacubitril/valsartan was associated with improved cardiac function, as shown by a reduction in the level of N-terminal prohormone of brain natriuretic peptide from 3,249 to 1,720 pg/mL, and an improvement in left-ventricular ejection fraction from 30 to 35%. This was accompanied by a marked reduction in the apnea-hypopnea index (from 41 to 19/h). To the best of our knowledge, this is the first case to document parallel improvements in HF and SDB after the initiation of ARNi treatment

Automatic positive airway pressure for obstructive sleep apnea in heart failure with reduced ejection fraction

$\bf Background$ Moderate-to-severe obstructive sleep apnea (OSA) is highly prevalent in heart failure patients with reduced left ventricular ejection fraction (HFrEF), and is associated with worsening cardiac function and increased mortality. $\bf Objectives$ The automatic positive airway pressure (APAP) trial tested the impact of APAP treatment on changes for the pre-specified endpoints: changes in peak oxygen uptake (peak VO$_2$), percent-predicted peak VO$_2$ and oxygen uptake at anaerobic threshold (VO$_2$-AT). $\bf Methods$ This randomized, controlled pilot study included patients with chronic, stable HFrEF who had moderate-to-severe OSA. Patients were randomized 1:1 to either APAP (AutoSet™, ResMed) or nasal strips (control) for 6 months. $\bf Results$ 76 patients have been randomized and 58 had complete data for final analysis. There was a statistically significant change in the APAP intervention arm for the primary endpoint percent-predicted peak VO$_2$ in comparison to control (67 $\pm$ 17 to 73 $\pm$ 19%; $\it p$ = 0.01). Additional primary endpoints peak VO$_2$ and VO$_2$-AT showed a trend in increase in the APAP group. Moreover, there were significant improvements within the APAP group for hypoxemia, left ventricular function and quality of life from baseline to 6 months, but not within the control group ($\it p$ = 0.001 and $\it p$ = 0.037, respectively). $\bf Conclusion$ APAP intervention was shown to significantly improve outcome compared to control group, represented in percent-predicted peak VO$_2$, an established surrogate marker for cardiovascular prognosis in HFrEF. APAP has additional beneficial effects on hypoxemia, cardiac function and quality of life

Addition of Levosimendan to overcome acute cardiogenic shock

Treatment of refractory cardiogenic shock has poor outcome. Levosimendan addition may help to achieve hemodynamic stabilization and improve conditions to where further treatment options such as listing for heart transplantation may become possible

Phrenic nerve stimulation improves physical performance and hypoxemia in heart failure patients with central sleep apnea

Background: Central sleep apnea (CSA) is a common comorbidity in patients with heart failure (HF) and has been linked to increased morbidity and mortality risk. In addition, CSA is associated with impaired quality of life, reduced physical performance capacity, and hypoxemia. Phrenic nerve stimulation (PNS) is a novel approach to the treatment of CSA and has been shown to be safe and effective in this indication. However, there are currently no data on the effects of PNS on physical performance and hypoxia in CSA HF patients, both of which have been shown to be linked to mortality in HF. Methods: This prospective study enrolled patients with HF and CSA diagnosed using polysomnography. All were implanted with a PNS system (remedē® system, Respicardia Inc., Minnetonka, MN, USA) for the treatment of CSA. Examinations included polysomnography (to determine hypoxemic burden), echocardiography and a standardized 6-min walk test prior to device implantation (baseline) and after 6 months of follow-up. Results: A total of 24 patients were enrolled (mean age 67.1 $\pm$ 11.2 years, 88% male). The 6-min walk distance was 369.5 $\pm$ 163.5 m at baseline and significantly improved during follow-up (to 410 $\pm$ 169.7 m; $\it p$ = 0.035). Hypoxemic burden, determined based on time with oxygen saturation < 90% improved from 81 $\pm$ 55.8 min at baseline to 27.9 $\pm$ 42.8 min during PNS therapy ($\it p$ < 0.01). Conclusion: In addition to safely and effectively treating CSA, PNS is also associated with improved physical performance capacity and reduced hypoxemic burden in patients with HF

First-in-human high-density epicardial mapping and ablation through a left anterior minithoracotomy in an LVAD patient presenting in electrical storm

$\bf Background$ Despite substantial technical improvements in long-term mechanical circulatory support, ventricular tachycardia (VT) remains a major challenge in left ventricular assist device (LVAD) patients. Recurrent VTs in LVAD patients are not only associated with limited quality of life, but also increased mortality. Although LVAD therapy improves VT tolerance of the left ventricle, haemodynamical deterioration of the right ventricle is the limiting factor in these patients. $\textbf {Case summary}$ We present a case report of a hybrid epicardial VT ablation of incessant VTs in a 53-year-old man with advanced heart failure and St.p. LVAD implantation. With this unique clinical case report, we describe an epicardial VT ablation using secondary surgical open-heart access in a patient with therapy-refractory VTs combing left-sided minithoracotomy with high-density (HD) mapping and catheter ablation. $\bf Discussion$ To the best of our knowledge, the presented approach is the first interdisciplinary case of epicardial VT ablation using secondary surgical open-heart access in an LVAD patient with therapy-refractory VTs. By combing left-sided minithoracotomy with HD mapping and catheter ablation, we could to demonstrate that even in these complex patients epicardial VT ablations can be performed safely and improve quality of life of LVAD patients with recurrent implantable cardioverter-defibrillator shock therapies

Non-invasive assessment of central venous pressure in heart failure

Assessing hemodynamics, especially central venous pressure (CVP), is essential in heart failure (HF). Right heart catheterization (RHC) is the gold-standard, but non-invasive methods are also needed. However, the role of 2-dimensional echocardiography (2DE) remains uncertain, and 3-dimensional echocardiography (3DE) is not always available. This study investigated standardized and breathing-corrected assessment of inferior vena cava (IVC) volume using echocardiography (2DE and 3DE) versus CVP determined invasively using RHC. Sixty consecutive HF patients were included (82% male, age 54 $\pm$ 11 years, New York Heart Association class 2.23 $\pm$ 0.8, ejection fraction 46 $\pm$ 18.4%, brain natriuretic peptide 696.93 $\pm$ 773.53 pg/mL). All patients underwent Swan-Ganz RHC followed by 2DE and 3DE, and IVC volume assessment. On 2DE, mean IVC size was 18.3 $\pm$ 5.5 mm and 13.8 $\pm$ 6 mm in the largest deflection and shortest distention, respectively. Mean CVP from RHC was 9.3 $\pm$ 5.3 mmHg. Neither 2DE nor 3DE showed acceptable correlation with invasively measured CVP; IVC volume acquisition showed optimal correlation with RHC CVP (0.64; 95% confidence interval 0.46–0.77), with better correlation when mitral valve early diastole E wave and right ventricular end-diastolic diameter were added. Using a CVP cut-point of 10 mmHg, receiver operating characteristic curve showed true positivity (specificity) of 0.90 and sensitivity of 62% for predicting CVP. A validation study confirmed these findings and verified the high predictive value of IVC volume assessment. Neither 2DE nor 3DE alone can reliably mirror CVP, but IVC volume acquisition using echocardiography allows non-invasive and adequate approximation of CVP. Correlation with invasively measured pressure was strongest when CVP is > 10 mmHg

Respiratory effects of adaptive servoventilation therapy in patients with heart failure and Cheyne-Stokes respiration compared to healthy volunteers

$\textbf {Background:}$ Nocturnal adaptive servoventilation (ASV) therapy is now frequently used to treat Cheyne-Stokes respiration (CSR), which is highly prevalent in patients with moderate-to-severe heart failure (HF) and characterized by periodical breathing (hyperventilation). $\textbf {Objectives:}$ This study analyzed and compared the acute effects of a novel ASV device on carbon dioxide pressure $(pCO_{2})$ and oxygen saturation $(SaO_{2})$ in HF patients with CSR and healthy volunteers. The influence of being asleep or awake on the ASV algorithm was also determined. $\textbf {Methods:}$ All subjects underwent ASV ($PaceWave^{TM}$, ResMed) for 1 h. Transcutaneous $pCO_{2}$ $(PtcCO_{2})$ and $SaO_{2}$ were assessed transcutaneously, while wakefulness was analyzed using EEG recordings. Assessments were made 30 min before and after ASV, and during 1 h of ASV. $\textbf {Results:}$ Twenty HF patients (19 male; age 79 $\pm$ 12 years) and 15 volunteers (13 male, age 25 $\pm$ 4 years) were included. When awake, ASV was associated with a trend towards a decrease in $PtcCO_{2}$ and an increase in $SaO_{2}$ versus baseline in HF patients (34.4 $\pm$ 3.2 to 33.7 $\pm$ 3.8 mm Hg and 93.8 $\pm$ 2.6 to 94.9 $\pm$ 2.6%, respectively) and volunteers (39.5 $\pm$ 3.0 to 38.2 $\pm$ 3.8 mm Hg and 96.9 $\pm$ 1.3 to 97.8 $\pm$ 0.9%). While asleep during ASV, $PtcCO_{2}$ increased to 36.3 $\pm$ 3.8 mm Hg and $SaO_{2}$ decreased to 93.8 $\pm$ 2.6% in HF patients, with similar changes in volunteers ($PtcCO_{2}$ 41.7 $\pm$ 3.0 mm Hg, $SaO_{2}$ 97.1 $\pm$ 1.2). All comparisons were statistically significant (p $\leq$ 0.05, except the PtcCO2 decrease in both groups when awake). $\textbf {Conclusions:}$ ASV therapy might result in hyperventilation when subjects are awake, but while asleep, $PtcCO_{2}$ increased to mid-normal values, effects that would be favorable in HF patients with CSR

Impact of sleep-disordered breathing treatment on ventricular tachycardia in patients with heart failure

Background: Sleep-disordered breathing (SDB) is a highly common comorbidity in patients with heart failure (HF), and a known risk factor for ventricular tachycardia (VT) development. However, little is known about the impact of SDB treatment on VT burden in HF patients to date. Therefore, this study investigated VT burden, as well as implantable cardioverter-defibrillator (ICD) therapies in HF patients with SDB treatment, in comparison to untreated SDB HF patients. Methods: This retrospective study analyzed VT burden, rate of antitachycardia pacing (ATP), and the number of shocks delivered in a propensity score-matched patient cohort of patients with SDB treatment or control. Patients had moderate or severe SDB (n = 73 per each group; standardized mean difference of 0.08) and were followed for a minimum of one year. In addition, survival over 4 years was assessed. Results: Mean patient age was 67.67 $\pm$ 10.78 and 67.2 $\pm$ 10.10, respectively, with 15.06% and 10.95% of the patients, respectively, being female. Regarding SDB subtypes in the control and SDB treatment group, central sleep apnea was present in 42.46% and 41.09% of the patients, respectively, and obstructive sleep apnea was present in 26.02% and 31.50% of the patients, respectively. Mixed type sleep disorder was present in 31.50% and 27.40% of cases. Among the SDB treatment group, a significantly lower number of VTs (28.8% vs. 68.5%; $\it p$ = 0.01), ATP (21.9% vs. 50.7%; $\it p$ = 0.02), as well as a lower shock rate (5.5% vs. 31.5%; p$\it p$ < 0.01), was observed compared to the control group. Furthermore, the VT burden was significantly lower in the SDB treatment group when compared to the time prior to SDB treatment ($\it p$ = 0.02). Event-free survival was significantly higher in the SDB treatment group (Log-rank $\it p$ < 0.01). Conclusion: SDB treatment in HF patients with ICD leads to significant improvements in VT burden, ATP and shock therapy, and may even affect survival. Thus, HF patients should be generously screened for SDB and treated appropriately

Dynamics of cognitive function in patients with heart failure following transcatheter mitral valve repair

Aims: Interventional transcatheter edge-to-edge mitral valve repair (TMVR) is an established treatment option for patients with severe mitral regurgitation (MR) and high operative risk. Cognitive impairment is one of the most common conditions among often extensive comorbidities in these patients. The specific patterns of cognitive decline and particularly the effect of TMVR are not well described. Thus, this study aimed to investigate into the impact of TMVR on cognitive impairment, exercise capacity, and quality of life. Methods: Cognitive function (executive, naming, memory, attention, language, abstraction, and orientation) was assessed with the standardized Montreal Cognitive Assessment test (MoCA; range between 0 and 30 points) before and 3 months after TMVR in 72 consecutive patients alongside echocardiographic examination and assessment of exercise capacity (six-minute walk test) as well as quality-of-life questionnaires (Minnesota living with heart failure questionnaire, MLHF-Q). Results: Patients’ median age was 81 [76.0; 84.5] years, 39.7% were female with a median EuroScore II of 4.4% [2.9; 7.7]. The assessment of cognitive function showed a significant improvement of the cumulative MoCA-Test result (from 22.0 [19.0; 24.5] to 24 [22.0; 26.0]; $\it p$ < 0.001) with significant changes in the subcategories executive ($\it p$ < 0.001), attention ($\it p$ < 0.001), abstraction ($\it p$ < 0.001), and memory ($\it p$ < 0.001). In addition, quality of life (from 47.5 [25.0; 69.3] to 24.0 [12.0; 40.0]; $\it p$ < 0.001) and exercise capacity (from 220.0 m [160.0; 320.0] to 280.0 m [200.0; 380.0]; $\it p$ = 0.003) increased significantly 3 months after the TMVR procedure. Conclusions: TMVR leads to a significant improvement of cognitive function, exercise capacity, and quality of life in patients with chronic heart failure in 3 months follow up and again highlights the benefit of the evermore established TMVR procedure for patients with high operative risk