Device therapy for remodeling in congestive heart failure

Benefit of stem cells and skeletal myoblast cells in dilated cardiomyopathies

Although some authors suggest that there is mitotic division in the heart, most cardiomyocytes do not have the capacity to regenerate after myocardial infarction and when this occurs there is a deterioration of contractile function, and if the area of ​​infarction is extensive ventricular remodeling may occur, leading to the development of heart failure. Cell transplantation into the myocardium with the goal of recovery of cardiac function has been extensively studied in recent years. The effects of cell therapy are based directly on the cell type used and the type of cardiac pathology. For myocardial ischemia in the hibernating myocardium, bone marrow cells have functional benefits, however these results in transmural fibrosis are not evident. In these cases there is a benefit of implantation with skeletal myoblasts, for treating the underlying cause of disease, the loss of cell contractility.

Strategies to attenuate pathological remodeling in heart failure

PURPOSE OF REVIEW

The incidence of heart failure is increasing due to an aging population and improved management of diseases that are precursors to ventricular dysfunction. The success of therapeutic advances has created a challenge for the next generation of investigational heart failure treatments because the mortality rate has decreased to such a degree that larger trials will be needed to demonstrate mortality advantage. Prior work has linked favorable changes in ventricular geometry to improved survival, suggesting that remodeling may be a suitable surrogate endpoint.

RECENT FINDINGS

In addition to the established benefits of neurohormonal blockade, new mechanical and electrical therapies are proving beneficial in heart failure. Passive cardiac support devices and cardiac resynchronization therapy have been recently demonstrated to induce reverse remodeling of the left ventricle and may improve outcomes, including quality of life, functional status, and mortality.

SUMMARY

Ventricular remodeling is strongly correlated with improvement in other heart failure outcomes. Early phase trials of novel therapeutics should carefully examine remodeling to obtain an efficacy signal. Larger clinical investigations should include remodeling metrics as endpoints and consider their use in a composite primary endpoint to reduce trial size.