Restructuring the Heart From Failure to Success: Role of Structural Interventions in the Realm of Heart Failure

Abstract

Heart failure through the spectrum of reduced (HFrEF), mid-range (or mildly reduced or HFmEF), and preserved ejection fraction (HFpEF), continues to plague patients' quality of life through recurrent admissions and high mortality rates. Despite tremendous innovation in medical therapy, patients continue to experience refractory congestive symptoms due to adverse left ventricular remodeling, significant functional mitral regurgitation (FMR), and right-sided failure symptoms due to significant functional tricuspid regurgitation (FTR). As most of these patients are surgically challenging for open cardiac surgery, the past decade has seen the development and evolution of different percutaneous structural interventions targeted at improving FMR and FTR. There is renewed interest in the sphere of left ventricular restorative devices to effect reverse remodeling and thereby improve effective stroke volume and patient outcomes. For patients suffering from HFpEF, there is still a paucity of disease-modifying effective medical therapies, and these patients continue to have recurrent heart failure exacerbations due to impaired left ventricular relaxation and high filling pressures. Structural therapies involving the implantation of inter-atrial shunt devices to decrease left atrial pressure and the development of implantable devices in the pulmonary artery for real-time hemodynamic monitoring would help redefine treatment and outcomes for patients with HFpEF. Lastly, there is pre-clinical data supportive of soft robotic cardiac sleeves that serve to improve cardiac function, can assist contraction as well as relaxation of the heart, and have the potential to be customized for each patient. In this review, we focus on the role of structural interventions in heart failure as it stands in current clinical practice, evaluate the evidence amassed so far, and review promising structural therapies that may transform the future of heart failure management.

The Development of a Permanent Implantable Spacer with the Function of Size Adjustability for Customized Treatment of Regurgitant Heart Valve Disease

“…The device, a Pivot-TR system, has the 3D leaflet as a coaptation enhancer. Several spacer-based devices have been developed for the treatment of tricuspid regurgitation (TR), including the Edwards Forma [ 4 ], Coramaze [ 13 ], and Croiduo valve [ 14 ]. A key distinction between these devices and the Pivot-TR system lies in their requirement for a coaxial spacer orientation, as opposed to the vertical orientation of the Pivot-TR.…”

Multimodality imaging for transcatheter tricuspid valve repair and replacement

“…The device is delivered via an 18Fr steerable catheter via femoral venous access. The Tripair device is currently in pre-clinical testing ( 91 ).…”

Structural Interventions in Heart Failure: Mending a Broken Heart

“…Heart failure with reduced ejection fraction results in progressive deleterious left ventricular remodeling leading to increased end-diastolic volumes, myocardial stress, functional mitral regurgitation, and worsening heart failure symptoms [53]. Early surgical techniques of left ventricular geometry restoration have been met with mixed results; however, this adverse remodeling of the left ventricular cavity has recently generated renewed interest as a target of percutaneous left ventricular restoration devices [54].…”

“…Results have been mixed across the PARACHUTE trials and more research is necessary to determine the safety and outcomes associated with these devices; a detailed review of the Parachute device can be found from Dhakal and Oliveira [55]. This Parachute device is not currently in use [53].…”

“…Another device currently under investigation for the reverse remodeling of altered left ventricular geometry is the AccuCinch (Ancora Heart, Inc) ventricular restoration system. This device is a nitinol anchor-based cinching cable that is percutaneously placed in the left ventricular cavity below the level of the mitral valve, functioning to reduce the size of the left ventricle [53]. Early feasibility data suggest an improvement in symptomatology and LVEDV at 12-months post-device implantation according to the manufacturer [56].…”