Update on Devices for Diastolic Dysfunction: Options for a No Option Condition?

This article provides an update on percutaneous devices to treat diastolic dysfunction, current clinical experience, and actively enrolling trials. We also discuss potential complications and limitations of devices.

Exertional symptoms including exertional dyspnea and exercise intolerance are common features of heart failure that are driven by left ventricular and left atrial non-compliance that results in pulmonary vascular congestion. Multiple studies that have shown that reducing total body volume and intravascular pressure, using pharmacologic therapies, are associated with improved outcomes among patients who have heart failure with reduced ejection fraction (HFrEF) (ejection fraction [EF] < 40%), but not heart failure with preserved ejection fraction (HFpEF) (EF > 55%).This is related to the fact that HFpEF is associated with altered diastolic compliance but not volume overload, which presents as exertional increases in left atrial pressure. Exercise assessment of LA and pulmonary pressures are not commonly assessed today in the clinic or in the catheterization laboratory. As elevated left atrial pressure mediates these symptoms, selective reduction in left atrial pressure may provide improvement in symptoms without complications of pharmacologic therapy such as diuresis and aggressive blood pressure reduction. Mechanical devices that aim to reduce left atrial pressure have been developed and evaluated in HFpEF and HFrEF patients. The current data from the small number of patients who have undergone treatment with left atrial decompression devices indicate that they have a high rate of success and may improve patient's exercise capacity. Larger, controlled trials are underway to better understand the role of these devices in patients with diastolic dysfunction.