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Objectives To compare the relationship between the third heart sound (S3) measured by implantable cardiac devices (devS3) and auscultation (ausS3) and evaluate their prognostic power for predicting heart failure events (HFEs). Methods In the MultiSENSE study, devS3 was measured daily with continuous values while ausS3 was assessed at study visits with discrete grades. They were compared between patients with and without HFEs at baseline and against each other directly. Cox proportional hazard models were developed between follow-up visits (FUs) and over the whole study. Simulations were performed on devS3 to match limitations of auscultation. Results Nine hundred patients were studied, of whom 106 patients experienced 192 HFEs. Two S3 sensing modalities correlated with each other but at baseline only devS3 differentiated patients with or without HFEs (p Conclusions S3 measured from implantable cardiac devices has stronger prognostic power to predict episodes of future HF events than that of auscultation.

Background N-terminal pro-B-type natriuretic peptide (NT-proBNP), a non-active fragment of the prohormone proBNP, is produced by the heart and released in response to volume or pressure overload. NT-proBNP has proven to be a valuable biomarker in the diagnosis and prognosis of heart failure (HF), and NT-proBNP concentrations rise with worsening HF. HeartLogic, a multi-sensor composite index and alert algorithm, aggregates multiple physiologic trends associated with HF status, and proactively provides alerts for worsening HF with high sensitivity and low alert burden. Objective To compare NT-proBNP concentrations during periods IN or OUT of an active HeartLogic alert. Methods The MultiSENSE study enrolled 900 HF patients with an implanted COGNIS CRT-D, and followed them up to 1 year. Device software was modified to permit collection of chronic trends HeartLogic leveraged (heart sounds, heart rate, thoracic impedance, respiration and activity). Clinicians were blinded to individual sensors and results of HeartLogic during the study. Optional NT-proBNP tests were conducted when clinically needed (e.g., patients hospitalized with HF symptoms). HeartLogic index of the day before each of the NT-proBNP test dates was extracted. Based on HeartLogic alert state (i.e., IN alert vs OUT of alert), NT-proBNP concentrations were divided into two groups and compared using a one-way ANOVA. Results Of a total of 855 valid NT-proBNP tests in 741 patients with valid associated HeartLogic index, 180 NT-proBNP concentrations were measured in 150 patients while the HeartLogic alert state was IN alert, and 675 were measured in 616 patients while HeartLogic was OUT of alert. Figure 1 shows when HeartLogic was IN alert, the NT-proBNP concentrations (6957.9±10398.0 pg/ml) were significantly higher than those when HeartLogic was OUT of alert (1675.5±4403.1 pg/ml) (p Conclusion HF patients’ NT-proBNP concentrations were significantly elevated when HeartLogic was IN alert status, consistent with the HeartLogic algorithm capturing clinical worsening of HF status.

Heart failure (HF) is a clinical syndrome characterized by reduced exercise tolerance, dyspnoea and peripheral oedema, which is confirmed with imaging evidence of ventricular dysfunction and, if available, cardiac biomarkers. HF is one of the major cardiovascular causes of morbidity and mortality worldwide. It has a prevalence of 1–2%, rising with age to >10% in those over 70 years old. Pharmacological and device-based therapy for HF with reduced ejection fraction (HFrEF) has dramatically improved over the last 30 years, resulting in significantly better outcomes for patients, in terms of improvements in quality of life, and reduction in morbidity and mortality. However, some patients remain highly symptomatic despite these measures and for a select few, advanced therapies (e.g. mechanical circulatory support devices and cardiac transplantation) might be suitable. This article provides an overview of contemporary management of patients with HFrEF.

Heart failure (HF) is a clinical syndrome characterized by dyspnoea, fatigue and fluid retention accompanied by objective evidence of cardiac dysfunction. The syndrome affects around 2% of the general population, affecting men more commonly than women (under the age of 80), with incidence and prevalence rising steeply with age. HF causes substantial morbidity and reduced life expectancy, and coronary artery disease accounts for two-thirds of cases in developed countries. Investigation is important to ascertain the diagnosis, identify the aetiology (which might be reversible) and give some indication of prognosis. Currently, more than 40% of people die within 18 months of a new diagnosis of HF. Treatment has been revolutionized by large randomized-controlled clinical trials studying the effects of antagonism of the renin–angiotensin–aldosterone and sympathetic nervous systems, and, more recently, the effects of device therapy. Cardiac transplantation remains an option for patients who are severely symptomatic (and at high risk) despite optimal medical and appropriate device therapy.

We review the journey to myocardial and neurologic recovery of a 42-year-old mother with severe acute cardiogenic shock and multiorgan failure after extensive subarachnoid hemorrhage, who was salvaged successfully using a CentriMag short-term biventricular assist device.

Non-ischaemic cardiomyopathy (NICM) is a common cause of heart failure. If no cause is identified it is termed idiopathic dilated cardiomyopathy (IDCM). Guideline-recommended therapy can improve left ventricular systolic function (LVSF). Although criteria for defining myocardial recovery exist, its

Although peripartum cardiomyopathy (PPCM) is associated with mortality and morbidity, improvement in cardiac function – termed myocardial recovery – can occur. No study has systematically reviewed myocardial recovery in PPCM and its independent predictors. A systematic review was performed of

Background The third heart sound (S3) is regarded as one of the earliest signs of heart failure (HF) and is typically assessed via auscultation clinically. The embedded accelerometer sensor in implantable devices can pick up the mechanical vibration caused by S3. We compared the device-measured S3 amplitude (devS3) to auscultated S3 volume grades (audS3). Methods In the MultiSENSE study, ambulatory HF patients implanted with a CRT-D were enrolled and followed up for 1 year. DevS3 amplitude was trended daily. Clinicians were asked to auscultate for S3 intensity on a graded scale (None/Low/Moderate/Loud) at baseline and each regular follow-up. Clinicians were blinded to the devS3 data at the time of assessment. We compared devS3 on the day of assessment in patients with different level of audS3 intensity. ANOVA test was used to compare the mean S3 amplitudes among groups and unpaired t-tests for between-group comparison. Conclusion This demonstrates that device-measured S3 amplitude reflects auscultated S3 heart sound volume grades. Since device-measured S3 is an objective measure on a continuous scale as opposed to auscultation which is subjectively categorized, it could avoid inter-observer auscultation variability and enables monitoring of this clinical variables in ambulatory HF patients. Result A total of 5211 auscultation reports were obtained from the 900 patients in the study. AudS3 intensity was None in 4709, Low in 391, Moderate in 108, and Loud in 3 reports (moderate and loud were combined for this analysis). Figure represents the devS3 amplitude (mean ± standard error) on the day of the follow-up as a function of the audS3 grades reported, the mean devS3 values for None, Low, and Moderate/Loud audS3 was 0.96 ± 0.01 mG, 1.02 ± 0.02 mG, and 1.27± 0.06 mG respectively. Both ANOVA test and unpaired tests between groups were significant and remained significant after adjusting for repeated measures.

Heart failure (HF) is a clinical syndrome characterized by dyspnoea, fatigue and fluid retention accompanied by objective evidence of cardiac dysfunction. The syndrome affects around 2% of the general population, affecting men more commonly than women (under the age of 80), with incidence and prevalence rising steeply with age. HF causes substantial morbidity and reduced life expectancy, and coronary artery disease accounts for two-thirds of cases in developed countries. Investigation is important to ascertain the diagnosis, identify the aetiology (which might be reversible) and give some indication of prognosis. Currently, more than 40% of people die within 18 months of a new diagnosis of HF. Treatment has been revolutionized by large randomized-controlled clinical trials studying the effects of antagonism of the renin–angiotensin–aldosterone and sympathetic nervous systems, and, more recently, the effects of device therapy. Cardiac transplantation remains an option for patients who are severely symptomatic (and at high risk) despite optimal medical and appropriate device therapy.

Background A multisensor algorithm has been demonstrated to predict heart failure (HF) events in patients with implanted devices with high sensitivity and low false positive rate. However, it is not known how the individual sensors change from hospital admission to discharge and whether it can be indicative of readmissions or death within 30 days. Methods The MultiSENSE study followed 900 HF patients with CRT-D for up to 1 year. Devices were modified to enable the collection of first (S1) and third (S3) heart sounds, thoracic impedance (TI), respiratory rate (RR), rapid shallow breathing index (RSBI), night heart rate (nHR), and activity. All hospitalizations were adjudicated by an independent committee. Hospitalizations with HF as a primary cause (HFH) were identified. HFH with an admission outside of the customized data collection were excluded due to lack of sensor data. Each HFH was classified as unresolved if it was followed by all-cause hospitalization or death within 30 days of discharge; otherwise, it was classified as resolved. For each type of HFH, daily sensor values on the day before admission and the day before discharge were compared with a pairwise t-test. The changes in each sensor were compared between the resolved and the unresolved group via t-test. Significant difference in comparisons was defined as that with p Results Out of 149 HFHs, 109 were determined as resolved and 40 as unresolved. Additional HFHs were excluded if sensor data at admission or discharge was not available (see Figure). Admission-to-discharge differences for resolved HFHs showed improvement in S3, S1, TI, and RR; no change in RSBI and nHR, and reduction in activity. Admission-to-discharge differences for unresolved HFHs showed improvement in TI; no change in S3, S1, RR, nHR; worsening in RSBI, and reduction in activity. Changes in RSBI were significantly different between the two groups of HFHs. Conclusions Worsening in RSBI during hospitalization identified a group of patients with either early HF readmissions or death.

Background Respiratory distress is common in heart failure (HF) and a primary driver for HF hospitalizations. Minute Ventilation (MV), a product of respiratory rate and tidal volume, is known to be elevated in HF patients due to ventilation/perfusion (V/Q) mismatch. However, it is not known if changes in MV accurately reflect emergence of rapid shallow breathing patterns in ambulatory patients preceding a HF event. Methods The MultiSENSE trial enrolled 900 patients implanted with a COGNIS CRT-D and followed them up to 1 year. Device software was modified to permit collection of chronic diagnostic sensor data including impedance based respiration rate (RR) and tidal volume (TV), which was used to compute MV (= RR*TV) and Rapid Shallow Breathing Index (RSBI = RR/TV), and activity (XL). Daily averages were separately computed over entire 24 hours as well as during resting epochs. HF events (HFEs) were independently adjudicated and defined as HF admissions or unscheduled visits with intravenous HF treatment. Relative changes preceding HFEs were computed between a baseline 30–60 days prior to HFEs (BL) and 3-day pre-HFE (ST) as (ST-BL)/BLx100% and reported as mean +/- SEM. Significance was tested using Wilcoxon signed-rank test. Results 900 patients followed for a year experienced 192 HFEs. Using 24-hour averages, significant changes were observed in RR, TV and RSBI indicating the emergence of rapid shallow breathing pattern leading up to HFE. MV average over 24 hours showed nonsignificant decrease coincident with decreased patient activity but showed no change when daily averaging was limited to resting epochs. In contrast, RR, TV and RSBI were significantly changed even at rest in directions consistent with the emergence of rapid shallow breathing pattern. Conclusion Device measured rapid shallow breathing is significantly elevated in the three day epoch preceding HFEs, whereas minute ventilation is not, in both 24-hour as well as resting period daily averages. Automatic ambulatory longitudinal monitoring of changes in rapid shallow breathing patterns may enable better monitoring for emerging respiratory distress in HF patients.

Chronic heart failure (CHF) is a clinical syndrome defined by the presence of symptoms (primarily breathlessness, fatigue and fluid retention), objective evidence of cardiac dysfunction, and in cases where the diagnosis is in doubt, a response to treatment directed towards it. It is not only important to investigate to ascertain the diagnosis, but also to identify the aetiology (as this might be reversible) and to give some indication of the prognosis of the condition. The treatment of CHF has been revolutionalized by large randomized controlled clinical trials studying the effects of antagonism of the renin-angiotensin-aldosterone and sympathetic nervous systems, as well as more recently, device therapy. These therapies now form the cornerstones in the management of the condition, and prognosis for this syndrome has improved as a result. However, cardiac transplantation remains an option for patients who remain severely symptomatic, and at high risk, despite optimal medical and appropriate device therapy.

Background Right heart catheterization long has been a routine investigation in advanced heart failure, and its measurements have been linked variably to prognosis. However, in the modern era, newer potential markers of prognosis are coming to light. This study reconsiders the use of right heart catheterization data and compares their use to that of N-terminal pro-brain natriuretic peptide (NT-proBNP), a neurohormone linked with prognosis in chronic heart failure. Methods We assessed prospectively the prognostic potential of baseline right heart catheterization data in 97 consecutive patients with advanced heart failure referred to the Scottish Cardiopulmonary Transplant Unit for consideration of cardiac transplantation. Patients underwent baseline routine investigation, including right heart catheterization and blood draws for NT-proBNP analysis. Patients were observed for a median of 370 days. Results The primary end-point of all-cause mortality was reached in 17 patients (17.5%), and the secondary end-point of all-cause mortality or urgent cardiac transplantation was reached in 21 (21.6%) patients. Univariate predictors of all-cause mortality included pulmonary artery systolic pressure (PASP), pulmonary artery wedge pressure (PAWP), and NT-proBNP concentration greater than their median values. Univariate predictors of the secondary end-point included right atrial pressure, PASP, PAWP, and NT-proBNP concentration greater than their median values, and left ventricular ejection fraction, cardiac output, and cardiac index less than their median values. In multivariate analyses, however, only NT-proBNP concentration remained an independent predictor of all-cause mortality. Both NT-proBNP concentration and PAWP were independent predictors of all-cause mortality and of the need for urgent cardiac transplantation. Conclusion Baseline data from routine right heart catheterization are of limited prognostic use in advanced heart failure. A baseline NT-proBNP concentration is a superior, non-invasive method of risk stratification in this era of measuring neurohormones.

It has been noted recently, initially in pathological specimens, that infarcted myocardium can be infiltrated by adipose cells, known as lipomatous metaplasia (LM). It has been suggested that the presence of myocardial fat may interfere with the conduction system of the heart, perhaps providing a

Device-Measured Rapid Shallow Breathing With Exertion Worsens Prior to Heart Failure Decompensation Seth Rials, Bela Merkely, Roy Gardner, Viktoria Averina, Robert Sweeney, Yi Zhang, Qi An, John Boehmer; Grant Medical Center, OhioHealth, Columbus, OH; Semmelweis University Heart Center, Budapest, Hungary; Golden Jubilee National Hospital, Glasgow, United Kingdom; Boston Scientific, St. Paul, MN; Penn State Milton S. Hershey Medical Center, Hershey, PA

Six dogs were subjected to arterialization of the left anterior descending vein (LADV). Tests showed that the predominant flow through these vessels did perfuse the myocardium: Lowering of oxygen content of the perfusing blood and myocardial uptake of macroaggregate albumin 131I were noted. The possibility of small atrioventricular (A-V) shunts was not excluded.