What's New in Heart Failure? November 2024

In this column, we want to provide clinicians and researchers with short and concise summaries of recently published studies in the European Journal of Heart Failure that we think are of particular relevance to heart failure specialists (Figure 1). One study highlights the prognostic role of baseline right ventricular dysfunction (RVD) after transcatheter aortic valve implantation (TAVI) in patients with paradoxical low-flow, low-gradient aortic stenosis (pLFLG AS). Another describes the so-called cardio-ocular syndrome, a reversible change in the retinal microvasculature in acute decompensated heart failure (ADHF). Further, a EUROMACS analysis of the association between caseload volume and outcomes in the implantation of left ventricular assist devices (LVADs) is presented. Finally, results from a retrospective analysis highlight the prognostic role of improved tricuspid regurgitation (TR) after decongestion in patients hospitalized with ADHF. Patients with pLFLG AS constitute a diagnostic challenge as pLFLG AS is generally associated with an adverse prognosis.1 Nies and colleagues investigated the prognostic role of baseline RVD following TAVI in this collective.2 The single-centre retrospective study from Germany included 114 patients with pLFLG AS. RVD, as indicated by a fractional area change (FAC) of ≤35% and/or a tricuspid annular plane systolic excursion (TAPSE) of <18 mm, was present in 50% of the cohort. A New York Heart Association functional class improvement was observed in close to three quarters of the cohort after TAVI. However, all-cause mortality remained high with a 2-year survival rate of 67.3% and 5-year survival rate of 31.0%. Survival was significantly lower in patients with RVD. Patients with an FAC ≤35% had the lowest 2- and 5-year survival rates. After adjustment for relevant confounders, FAC, systolic pulmonary artery pressure (sPAP), TAPSE/sPAP ratio, right atrial area, right ventricular diameter and tricuspid regurgitation emerged as independent predictors of all-cause mortality in patients suffering from pLFLG AS who underwent TAVI. Venous congestion is the leading cause of hospitalization for ADHF.3 The associated volume overload leads to impaired organ perfusion due to increased venous pressure. Consecutively, organ dysfunction, especially of the kidney, the liver, the intestines and the brain linked to ADHF has been described but more comprehensive data are missing.4 Abdin et al.5 were now able to show that the eyes are also affected during episodes of ADHF. They described the so-called cardio-ocular syndrome. In 40 patients with acute ADHF and after recompensation functional and morphological choroidal and retinal changes utilizing optical coherence tomography (OCT) and OCT angiography were analysed and compared to 40 healthy controls. Compared to the control group, patients with ADHF showed impaired visual acuity (0.15 ± 0.1 vs. 0.35 ± 0.1 logMAR, p < 0.001), reduced macular vessel density (18.0 ± 1.9 vs. 14.3 ± 3.6 mm/mm2, p < 0.001) and perfusion density (42.6 ± 3.2 vs. 35.2 ± 9.7%, p < 0.001) on admission. After recompensation, the mean overall vessel density and mean overall perfusion density were markedly increased at discharge (14.3 ± 3.6 vs. 19.7 ± 2.6 mm/mm2, p = 0.001, and 35.2 ± 9.7 vs. 39.2 ± 6.5%, p = 0.005, respectively). The mean diameter of the superior temporal retinal vein at admission was significantly larger compared to the control group (136 ± 19 vs. 124 ± 22 μm, p = 0.008) and decreased significantly to 122 ± 15 μm at discharge (p < 0.001). These results revealed remarkable reversible changes in retinal microvasculature in ADHF. The global prevalence of heart failure has been rising with an increase of nearly 30% between the years 2010 and 2019.6 Survival is improving thanks to medical progress.7, 8 LVADs are an established therapy option for advanced and end-stage heart failure patients.9-11 While interdisciplinary care of these patients by selected heart failure specialists is essential, most recommendations and guidelines are based on studies dominated by high caseload volume centres.9, 12 Two US studies have reported conflicting results on the relationship between centre volume and survival in LVAD patients.13, 14 The study by Mihalj and colleagues addresses the question of whether there is an association between the caseload and clinical outcomes in LVAD patients in Europe. They conducted a Europe-wide retrospective analysis of all primary LVAD implantations between 2011 and 2020 as listed in the EUROMACS registry.15 A total of 4802 patients from 35 participating centres were included and divided into two groups based on the annual caseload of the treating centre. Centers were divided into higher-volume centres (>30 cases per year; implanted 62% of the patients) and lower-volume centres (≤30 cases per year; implanted 38% of the patients). The primary endpoint was 1-year survival. Secondary endpoints were an analysis of overall survival, device-related adverse events (e.g. stroke, pump thrombosis, etc.) and readmissions. Cumulative follow-up was 10 003 patient-years with a median follow-up of 1.54 years. There was no significant difference in 1-year survival between patients implanted at lower-volume centres and those implanted at higher-volume centres. Regarding overall survival, patients in centres with higher annual case numbers had a higher mortality risk compared to patients in lower volume centres. Additionally, patients at high-volume centres had a significantly higher risk of adverse events such as pump thrombosis or outflow graft obstruction (adjusted subdistribution hazard ratio [HR] 1.76, 95% confidence interval [CI] 1.18–2.62, p = 0.005) compared to lower-volume centres, but a lower risk of adverse events other than pump thrombosis or stroke. Patients admitted to high-volume centres tended to be sicker, with a higher prevalence of INTERMACS profiles 1 and 2 and a greater need for intravenous inotropic support. Although the results of this analysis were adjusted for various confounders, the presence of residual confounding is likely. In summary, annual case volume was not associated with 1-year survival. Quality improvement in centres of all sizes is needed to improve patient outcomes. Future analyses should include the experience of the teams involved, which is not necessarily derived from the annual caseload, as well as the complexity of each case and comorbidities. Despite many recent advances in the treatment of heart failure, ADHF still remains a major contributor to hospitalizations.16 Patients with ADHF typically present with symptoms of congestion, that is, pulmonary venous congestion or oedema, pleural effusion, and in the case of right ventricular failure splanchnic congestion and peripheral oedema. A significant proportion of these patients suffer from TR mostly due to annulus dilatation secondary to volume overload.17 Decongestion leads to a rapid loss of volume, concomitant with reduced annulus dilatation and improved coaptation of tricuspid leaflets.18, 19 To this point, the evolution of TR during recompensation and its prognostic value to predict future cardiovascular outcomes have not been sufficiently studied. To address this question, Zocca et al.20 performed a retrospective single-centre cohort study using patients enrolled in the TRI-AHF registry.21 The primary endpoint was a composite of 5-year all-cause mortality and heart failure hospitalization (HFH). Approximately 1000 patients admitted to hospital with ADHF and at least two consecutive echocardiographic examinations before and after decongestion were analysed, 30% of whom had moderate or severe TR at admission. Before discharge, half of them had improved TR. Baseline characteristics associated with a lower probability of TR improvement included atrial fibrillation (odds ratio [OR] 2.237, 95% CI 1.063–4.710, p = 0.034), chronic heart failure (OR 2.402, 95% CI 1.049–5.499, p = 0.038) and high dose of oral diuretics (>50 mg/day furosemide equivalent; OR 2.493, 95% CI 1.058–5.872, p = 0.037). Improved TR patients showed larger reductions in E/E' and sPAP and were more likely to receive guideline-directed medical therapy. At multivariable Cox regression analysis, improved TR compared with persistent moderate/severe TR was associated with a significantly lower risk of 5-year all-cause mortality/HFH (HR 0.524, 95% CI 0.326–0.842, p = 0.008) and of 5-year all-cause mortality (HR 0.461, 95% CI 0.251–0.846, p = 0.012). The main limitation of the present study is its retrospective design. However, among patients with ADHF it seems prudent to determine TR severity prior to discharge to confirm effective decongestion. Patients with high-grade residual TR are at increased risk and should therefore be monitored closely. Valve interventions such as tricuspid transcatheter edge-to-edge repair should be additionally considered to improve cardiovascular outcomes.