Left atrial pressure-assisted acute heart failure management in the cardiac intensive care unit: a proof-of-concept

A 69-year-old male patient with non-ischaemic dilated cardiomyopathy and advanced heart failure with reduced ejection fraction was admitted to cardiac intensive care unit (CICU) due to acute pulmonary oedema, anasarca, and cardiogenic shock. The echocardiogram revealed severe biventricular dysfunction, whereas lab tests documented multi-organ failure. Two years before, the patient was enrolled in VECTOR-HF trial1,2 and implanted with V-LAPTM system (Vectorious MedicalTechnologies, Tel-Aviv, Israel), an interatrial device designed to remotely monitor left atrial pressure (LAP) over time in chronic heart failure (HF) patients. A progressive increase in LAP was noted in the days preceding the decompensation event, unresponsive to the timely oral therapy optimization proposed by the HF team (Panel A). Since the admission, LAP measurements were acquired and integrated with the other haemodynamic parameters (like central venous pressure, CVP) to orient clinical management: high-dose intravenous diuretic, inotropes, and pressure support non-invasive ventilation (NIV) were initiated accordingly. During the stay in the CICU, LAP measurement decreased anticipating the clinical signs of decongestion and was paralleled by CVP reduction, supporting a progressive furosemide dose reduction. On Day 3, in the absence of clinical signs of congestion, a steep rise in LAP was noticed (Panel B), that anticipated by 12 h an episode of acute respiratory failure and sustained ventricular tachycardia, shocked by implantable cardioverter defibrillator. A new up-titration of diuretic and inotropic therapy led to prompt remission. During the following period of restored clinical stability, LAP values continued to be high, while CVP decreased (Panel C). Despite regression of overt congestion, a different strategy was adopted: a high diuretic dose was maintained, and levosimendan infusion was started. No further deterioration occurred. Only when stable LAP values normalization was observed, successful weaning from inotropes and NIV was achieved. The patient was then discharged from CICU to cardiac rehabilitation. Despite growing evidence in chronic HF management with implantable haemodynamic monitoring systems,3 little is known regarding their application in acute HF. Pulmonary artery pressure-guided therapy has been reported to be useful to direct intra-hospital diuretic and inotropic infusion.4,5 Successful strategies to improve care for HF patients should assist health care providers with rapid recognition and early aggressive treatment, ensuring a continuity of care from the chronic to the acute setting and vice versa. This critical pathway could be guided by the integration of different parameters and data sources, providing reliable documentation of treatment response. In our experience, LAP monitoring, when compared with standard, more fluctuating haemodynamic parameters provided early and reliable information on haemodynamic status, anticipating the clinical signs of congestion and adverse events. While waiting for further studies, the V-LAPTM system appears promising to master congestion during acute HF-related hospitalizations. The authors thank Dr Tommaso Sanna for his contribution to this case. All authors declare no disclosure of interest for this contribution. No data were generated or analysed for or in support of this paper.