Lars H. Lund

Patient selection for left ventricular assist devices

Heart transplantation (HTx) improves symptoms and prolongs life in advanced heart failure (HF), but organ supply is limited. In recent years, mechanical circulatory support and specifically implantable left ventricular assist devices (LVADs) have undergone technical improvements, and outcomes have improved dramatically. Left ventricular assist devices are now viable options for patients with severe HF as bridge to transplantation, destination therapy, or as bridge to recovery. Many believe that LVADs may soon provide outcomes similar to, or better than, HTx, launching a new era of end‐stage HF management. The key to improving outcomes is patient selection, but the field is changing rapidly and guidelines and consensus are limited. This review summarizes recent reports of predictors of poor outcomes and provides an overview of selection for LVAD therapy.

Selecting patients for heart transplantation: comparison of the Heart Failure Survival Score (HFSS) and the Seattle heart failure model (SHFM).

BACKGROUND The Heart Failure Survival Score (HFSS) risk-stratifies patients with chronic heart failure (CHF) referred for heart transplantation using 7 parameters, including peak VO₂. The Seattle Heart Failure Model (SHFM) is a 20-variable model that combines clinical, laboratory and therapeutic data. Although both models have excellent accuracy, only the HFSS was derived and validated in patients referred for transplantation, and the HFSS and SHFM have not been directly compared. METHODS We tested the accuracy of the SHFM and compared the HFSS and SHFM in 715 patients referred for heart transplantation. RESULTS Over a follow-up of 962 ± 912 days, 354 patients died or received an urgent heart transplantation or a ventricular assist device. One-year event-free survival was 89%, 72% and 60%, respectively, for the low-, medium- and high-risk HFSS strata, and 93%, 76%, and 58%, respectively, for the low-, medium- and high-risk SHFM strata. The HFSS and SHFM were modestly correlated (R = -0.48, p < 0.001). In receiver operating characteristic curve analysis, areas under the curves (AUCs) for the HFSS and SHFM were comparable (1 year: 0.72 vs 0.73; 2-year: 0.70 vs 0.74, respectively) and incremental to New York Heart Association class. The 1- and 2-year combined HFSS+SHFM AUCs were 0.77 and 0.76, respectively, significantly better than the HFSS or SHFM alone. CONCLUSIONS The HFSS and SHFM provide accurate and comparable risk stratification in CHF patients referred for transplantation. Combining the HFSS and SHFM improves predictive ability.

The Heart Failure Survival Score outperforms the peak oxygen consumption for heart transplantation selection in the era of device therapy.

BACKGROUND The peak oxygen consumption (VO(2)) and the Heart Failure Survival Score (HFSS) risk stratify patients with chronic heart failure (CHF) referred for heart transplantation. However, these tools were developed before widespread use of implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT). The prognostic accuracy of these tools in patients with ICD and/or CRT is unknown. METHODS Cardiopulmonary exercise testing with measurement of peak VO(2) and calculation of the HFSS was done in 715 CHF patients (54 ± 12 years; ICD, 244; CRT, 30; CRT-D, 108; none, 333) referred for heart transplantation. RESULTS During an average follow-up of 962 ± 912 days, 354 patients died or received urgent heart transplant or left ventricular assist device. By Cox hazard analysis, both peak VO(2) and HFSS were powerful independent prognostic markers. By Kaplan-Meier analysis, the HFSS was effective in discriminating patients into low-, medium-, and high-risk groups in all device groups. In contrast, the peak VO(2) did not discriminate between low (>14 ml/min/kg) and medium (10.1 to 14 ml/min/kg) risk in device patients. By area under the receiver operating characteristic curve, the HFSS performed better than the peak VO(2) (1-year in total cohort; 0.72 vs. 0.65; p < 0.001; 1-year in device patients; 0.69 vs. 0.65; p < 0.001). CONCLUSION The HFSS outperforms the peak VO(2) in risk stratification for CHF in the presence of an ICD and/or CRT. Furthermore, a peak VO(2) ≤ 10 ml/kg/min rather than the traditional cutoff value ≤ 14 ml/min/kg may be more useful for risk stratification in the device era.

Epidemiology and one-year outcomes in patients with chronic heart failure and preserved, mid-range and reduced ejection fraction: an analysis of the ESC Heart Failure Long-Term Registry

The objectives of the present study were to describe epidemiology and outcomes in ambulatory heart failure (HF) patients stratified by left ventricular ejection fraction (LVEF) and to identify predictors for mortality at 1 year in each group.

Rationale and design of the Karolinska-Rennes (KaRen) prospective study of dyssynchrony in heart failure with preserved ejection fraction.

Heart failure with preserved ejection fraction (HFPEF) is common but not well understood. Electrical dyssynchrony in systolic heart failure is harmful. Little is known about the prevalence and the prognostic impact of dyssynchrony in HFPEF.

First Annual IMACS Report: A global International Society for Heart and Lung Transplantation Registry for Mechanical Circulatory Support.

The first annual report of the International Society for Heart and Lung Transplantation (ISHLT) Mechanically Assisted Circulatory Support (IMACS) registry provides global data on 5,942 patients from 31 countries. This initial report focuses on patient demographics, survival, device types, adverse events, competing outcomes, and a risk factor analysis.

Global Public Health Burden of Heart Failure

Heart failure (HF) is a global pandemic affecting at least 26 million people worldwide and is increasing in prevalence. HF health expenditures are considerable and will increase dramatically with an ageing population. Despite the significant advances in therapies and prevention, mortality and morbidity are still high and quality of life poor. The prevalence, incidence, mortality and morbidity rates reported show geographic variations, depending on the different aetiologies and clinical characteristics observed among patients with HF. In this review we focus on the global epidemiology of HF, providing data about prevalence, incidence, mortality and morbidity worldwide.

Associations with and prognostic impact of chronic kidney disease in heart failure with preserved, mid-range, and reduced ejection fraction

As the role of chronic kidney disease (CKD) in different types of heart failure (HF) is poorly understood, our aim was to compare CKD in HF with preserved (HFpEF), mid‐range (HFmrEF), and reduced ejection fraction (HFrEF) with regard to prevalence, associations and prognostic role.

New echocardiographic predictors of clinical outcome in patients presenting with heart failure and a preserved left ventricular ejection fraction: a subanalysis of the Ka (Karolinska) Ren (Rennes) Study

To identify electrocardiographic and echocardiographic predictors of mortality and hospitalizations for heart failure (HF) in the KaRen study.

Association of Spironolactone Use With All-Cause Mortality in Heart Failure A Propensity Scored Cohort Study

Background—In 3 randomized controlled trials in heart failure (HF), mineralocorticoid receptor antagonists reduced mortality. The net benefit from randomized controlled trials may not be generalizable, and eplerenone was, but spironolactone was not, studied in mild HF. We tested the hypothesis that spironolactone is associated with reduced mortality also in a broad unselected contemporary population with HF and reduced ejection fraction, in particular New York Heart Association (NYHA) I–II. Methods and Results—We prospectively studied 18 852 patients (age 71±12 years; 28% women) with NYHA I–IV and ejection fraction <40% who were registered in the Swedish Heart Failure Registry between 2000 and 2012 and who were (n=6551) or were not (n=12 301) treated with spironolactone. We derived propensity scores for spironolactone treatment based on 41 covariates. We assessed survival by Cox regression with adjustment for propensity scores and with matching based on propensity score. We performed sensitivity and residual confounding analyses and analyzed the NYHA I–II and III–IV subgroups separately. One-year survival was 83% versus 84% in treated versus untreated patients (log rank P<0.001). After adjustment for propensity scores, the hazard ratio for spironolactone was 1.05 (95% confidence interval, 1.00–1.11; P=0.054). Spironolactone interacted with NYHA (P<0.001). In the NYHA I–II subgroup, after adjustment for propensity scores, the hazard ratio for spironolactone was 1.11 (95% confidence interval, 1.02–1.21; P=0.019). Conclusions—In an unselected contemporary population of HF with reduced ejection fraction, spironolactone was not associated with reduced mortality. The net benefits of spironolactone may be lower outside the clinical trial setting and in milder HF.