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Left atrial to coronary sinus shunting in more advanced heart failure with preserved ejection fraction
Ryan J Tedford1, Brian A Houston1, JoAnn Lindenfeld2
1Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.
Insights
A novel left atrial to coronary sinus shunt improved quality of life and heart function in heart failure patients with high natriuretic peptide levels. This inter-atrial shunt device shows promise for severe heart failure cases.
Area of Science:
- Cardiology
- Medical Devices
- Heart Failure Research
Background:
- Inter-atrial shunt device therapy for heart failure has yielded variable results.
- Patients with advanced heart failure, often indicated by high natriuretic peptide (NP) levels, are typically 'non-responders'.
- Novel device placement strategies are needed to improve outcomes in severe heart failure.
Purpose of the Study:
- To evaluate the haemodynamic and clinical response to a novel left atrial to coronary sinus (LA-CS) shunt.
- To analyze the efficacy of the LA-CS shunt in patients with elevated natriuretic peptide (NP) levels, indicating severe heart failure.
- To assess the impact of the LA-CS shunt on quality of life, functional class, and right heart function.
Main Methods:
- Analysis of 95 patients from the ALT-FLOW early feasibility study with preserved left ventricular ejection fraction (>40%) and 1-year follow-up.
- Patients were stratified into low and high subgroups based on baseline natriuretic peptide levels (BNP and NT-proBNP).
- Haemodynamic parameters, clinical outcomes (KCCQ-OSS, NYHA class), and right heart function were assessed pre- and post-implantation.
Main Results:
- The high NP subgroup, indicative of more advanced disease, showed significant improvements in quality of life (KCCQ-OSS) and NYHA functional class.
- Workload-adjusted pulmonary artery wedge pressure at peak exercise significantly declined in both high and low NP subgroups post-implantation.
- Cardiac index and right ventricular structure/function were preserved through 6 months and 1 year, respectively, in both NP subgroups.
Conclusions:
- The LA-CS shunt provided consistent improvements in quality of life, haemodynamics, and functional class, even in patients with the highest NP levels.
- Right heart function remained stable post-intervention in all patient groups.
- The study suggests that the specific shunt location (LA-CS) may positively influence outcomes in symptomatic heart failure patients, including those with severe disease.
Aims:
Inter-atrial shunt device therapy has shown mixed results in clinical trials, with clinical 'non-responders' typically showing features of more advanced heart failure. We aimed to analyse the haemodynamic and clinical response of a novel left atrial to coronary sinus (LA-CS) shunt device in patients with higher natriuretic peptide (NP) levels, a marker of disease severity.
Methods And Results:
An analysis population (n = 95) of patients from the ALT-FLOW early feasibility study with left ventricular ejection fraction >40% and 1-year follow up was analysed. The cohort was divided into low and high subgroups based on NP levels [b-type natriuretic peptide (BNP) and n-terminal pro BNP (NT-proBNP)]. The mean BNP and NT-proBNP levels for low versus high subgroups were 64.2 ± 34.3 versus 261 ± 103 and 322 ± 269 versus 2050 ± 1070 pg/mL, respectively. Patients in the high NP subgroup had evidence of more advanced disease including worse haemodynamic profiles, lower estimated glomerular filtration rate, and higher percentages of atrial fibrillation. The high NP subgroup experienced significant improvements in KCCQ-OSS and NYHA functional class (P < 0.0001 and P < 0.001, respectively) and to a similar magnitude compared with the low NP subgroup. Compared with pre-implant baseline, workload adjusted pulmonary artery wedge pressure at peak exercise declined in the high NP subgroup (PCWL, 164.1 vs. 96.0 mmHg/W/kg at 6 months, P < 0.003) as well as the low NP subgroup (115.9 vs. 65.9 mmHg/W/keg at 6 months, P < 0.001). Importantly, in both NP subgroups, there was preservation of cardiac index through 6 months as well as right ventricular structure (right ventricular diastolic dimension) and function (tricuspid annular systolic plane excursion) through 1 year.
Conclusions:
The quality-of-life, haemodynamic, and functional class improvements along with stable right heart function seen in ALT-FLOW study of LA-CS shunt remain consistent in the subgroup with highest NP levels. This suggests that shunting location could influence outcomes in symptomatic heart failure patients.
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