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Device therapy for severe heart failure (HF) has shown efficacy both in acute and chronic settings. Recent percutaneous device innovations have pioneered a field known as interventional HF, providing clinicians with a variety of options for acute decompensated HF that are centered on nonsurgical mechanical circulatory support. Other structural-based therapies are aimed at the pathophysiology of chronic HF and target the underlying etiologies such as functional mitral regurgitation, ischemic cardiomyopathy, and increased neurohumoral activity. Remote hemodynamic monitoring devices have also been shown to be efficacious for the ambulatory management of HF. We review the current data on devices and investigational therapies for HF management whereby pharmacotherapy falls short.

Late right heart failure (RHF) is increasingly recognized in patients with long-term left ventricular assist device (LVAD) support and is associated with decreased survival and increased incidence of adverse events such as gastrointestinal bleeding and stroke. Progression of right ventricular (RV) dysfunction to clinical syndrome of late RHF in patients supported with LVAD is dependent on the severity of pre-existing RV dysfunction, persistent or worsening left- or right-sided valvular heart disease, pulmonary hypertension, inadequate or excessive left ventricular unloading, and/or progression of the underlying cardiac disease. RHF likely represents a continuum of risk with early presentation and progression to late RHF. However, de novo RHF develops in a subset of patients leading to increased diuretic requirement, arrhythmias, renal and hepatic dysfunction, and heart failure hospitalizations. The distinction between isolated late RHF and RHF due to left-sided contributions is lacking in registry studies and should be the focus of future registry data collection. Potential management strategies include optimization of RV preload and afterload, neurohormonal blockade, LVAD speed optimization, and treatment of concomitant valvular disease. In this review, the authors discuss definition, pathophysiology, prevention, and management of late RHF.

Background:Studies have shown that hemodynamic LVAD ramp studies can be used to optimize speeds and improve clinical outcomes, yet these studies lack external validation.Methods:470 LVAD patients, including 3 LVAD subtypes, were retrospectively analyzed and 53 ramp studies were identified. Measurements (RA, mean PA, PCWP, and CI) were taken at speeds +/- 20% of the manufacturer recommended set speed for HM2, HM3, and HVAD devices. Primary outcomes were all-cause and heart failure (HF) hospitalizations in the 6-month period pre- and post-ramp study. Secondary outcomes included final LVAD speed and hemodynamic measurements following ramp study. Time to first hospitalization and cumulative incidence rate of all-cause and HF hospitalization were reported.Results:Baseline characteristics of 53 studies included: mean age of 60.1 (+/- 10.9), 84.9% male, 56.6% ischemic etiology, 71.7% destination therapy, and average NYHA class and INTERMACS of 2.5 (+/- 0.7) and 5.9 (+/- 1), respectively. 38 of 53 studies (71.7%) showed PCWP decompression >20%, with average PCWP decompression of 51.2% (+/- 21.0%), and CI increase of 22.5% (+/- 18.7%). Optimal LVAD speeds were chosen to maintain CI > 2.2, PCWP < 15 and minimize RAP, in the absence of suction events. 31 (58.5%) of studies resulted in an LVAD speed change and 16 (30.2%) of studies resulted in diuretic change. All-cause and HF hospitalizations were significantly decreased in the 6-months following ramp studies compared the 6-months pre-ramp (total days hospitalized for all causes: 12.0 vs 26.6, p=0.0002; total days hospitalized for HF, 4.8 vs 22.1, p=0.00003). Speed changes were associated with a nonsignificant improvement in time to first hospitalization.Conclusion:This externally validates previous data suggesting that LVAD hemodynamic ramp studies decrease hospitalizations. Larger, prospective studies may elucidate specific hemodynamic targets to improve mortality and reduce rehospitalizations.