Critical care


Anker also draws attention to the IRONMAN clinical trial currently being carried out by the University of Glasgow, which is investigating whether intravenous iron can improve life expectancy in patients with heart failure. Results of the five-year trial, which began in 2016, are expected shortly.


Heart pumps are more durable For patients with advanced heart failure, clinicians have long used implantable devices. The main one is a heart pump, known as a left ventricular assist device (LVAD). Fitting the patient with an LVAD is a highly invasive procedure involving opening up the chest and inserting the pump, which, as Bitar explains, “will suck the blood from the left lower chamber of the heart and then pump it into the aorta, so it takes over the function of the left side of the heart.” Because the pump needs a source of power, a cord goes through the individual's skin and is linked to a controller (a small computer) connected to batteries.


The technology has improved a great deal in the past two decades, Bitar says, pumps are more durable and reliable. The newest model, Abbott’s HeartMate 3, has reduced the risk of thrombosis inside the pump to “close to zero”, he explains, while the risk of stroke “has dropped significantly compared to previous pump generations”. Patients who have a pump fitted usually also take aspirin to reduce thrombosis risk, but there is concern that this may increase bleeding risk. A multinational trial, known as the ARIES study, which is due to complete in 2023, is investigating whether the aspirin is necessary with the HeartMate 3. Eventually, Bitar believes, the pump will be “totally internal”, and the lack of a cord coming through the skin will mitigate any risk of infection. “That’s a few years down the road,” he adds. Remote monitoring is another recent innovation. The CardioMEMS HF sensor, which has been on the market for about seven years, is used with patients recently hospitalised with later-stage HFrEF and HFpEF. Implanted into the pulmonary artery, it monitors changes in pulmonary artery pressure and transmits the reading wirelessly into the cloud. “The physician can access that from their office, see what’s going on and make some adjustments to the medication,” says Bitar.


The Guide HF study conducted to evaluate the efficacy of the CardioMEMS HF sensor was complicated by the onset of the Covid-19 pandemic, which reduced rates of hospitalisation for heart failure. But an analysis of the pre-Covid data found a 28% reduction in heart failure hospitalisations, which was enough for the FDA to expand its use to earlier-stage heart failure and late-stage heart failure without a previous hospitalisation – a decision it made in February 2022. The device has


Practical Patient Care / www.practical-patient-care.com


been shown to be successful in reducing rates of death and hospitalisation.


Removing the need for open heart surgery


In advanced cases of heart failure, treatment may involve open heart surgery. But new developments could see minimally invasive techniques used instead, greatly reducing the associated risks. For example, currently patients who have a leaky mitral valve may have surgery to insert a mitral clip. Researchers are now investigating whether they can “replace the mitral valve altogether without having to open up the chest”, says Bitar. This involves making an incision just below the left breast, puncturing the heart muscle and then using a catheter to deploy the valve. We will know the results in a couple of years. Similarly, he says, in cases where the tricuspid valve is treated, it is traditionally replaced with an artificial valve. There are now studies under way to assess whether a clip can be inserted via a catheter into the tricuspid valve. The Occlutech atrial flow regulator, another minimally invasive device, is being investigated for use with both HFpEF and HFrEF patients. Implanted into the interatrial septum of the heart, the device has a predetermined diameter allowing for controlled blood flow from the left to the right atrium, enabling the left atrium to decompress and lower left atrial pressure. Both Anker and Bitar point out that for many years treatment for heart failure remained fairly static, but that in a short space of time there have been major steps forward. Bitar is optimistic about the future, pointing out that in the past five or six years, we have seen the advent of both ARN inhibitors and SGL2 inhibitors, and that we are likely to see the omecamtiv mecarbil and solval granulate cyclase stimulator being adopted in the near future. “In terms of advanced heart failure, I think five or ten years from now, we’re going to have a totally implantable LVAD,” he says. When it comes to valve procedures, he adds: “Most of them will be done with minimally invasive procedures without having to open up a chest like we’ve done for decades. I think that’s where we’re heading.” 


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Abbott’s CardioMEMS system is placed in the pulmonary artery using a selective catheter angiogram procedure.


Abbott


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