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Thompson N, Ravagli E, Mastitskaya S, Challita R, Hadaya J, Iacoviello F, Idil AS, Shearing PR, Ajijola OA, Ardell JL, Shivkumar K, Holder D, Aristovich K. Towards spatially selective efferent neuromodulation: anatomical and functional organization of cardiac fibres in the porcine cervical vagus nerve. J Physiol 2024. [PMID: 39183636 DOI: 10.1113/jp286494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 08/09/2024] [Indexed: 08/27/2024] Open
Abstract
Spatially selective vagus nerve stimulation (sVNS) offers a promising approach for addressing heart disease with enhanced precision. Despite its therapeutic potential, VNS is limited by off-target effects and the need for time-consuming titration. Our research aimed to determine the spatial organization of cardiac afferent and efferent fibres within the vagus nerve of pigs to achieve targeted neuromodulation. Using trial-and-error sVNS in vivo and ex vivo micro-computed tomography fascicle tracing, we found significant spatial separation between cardiac afferent and cardiac efferent fibres at the mid-cervical level and they were localized on average on opposite sides of the nerve cross-section. This was consistent between both in vivo and ex vivo methods. Specifically, cardiac afferent fibres were located near pulmonary fibres, consistent with findings of cardiopulmonary convergent circuits and, notably, cardiac efferent fascicles were exclusive. These cardiac efferent regions were located in close proximity to the recurrent laryngeal regions. This is consistent with the roughly equitable spread across the nerve of the afferent and efferent fibres. Our study demonstrated that targeted neuromodulation via sVNS could achieve scalable heart rate decreases without eliciting cardiac afferent-related reflexes; this is desirable for reducing sympathetic overactivation associated with heart disease. These findings indicate that understanding the spatial organization of cardiac-related fibres within the vagus nerve can lead to more precise and effective VNS therapy, minimizing off-target effects and potentially mitigating the need for titration. KEY POINTS: Spatially selective vagus nerve stimulation (sVNS) presents a promising approach for addressing chronic heart disease with enhanced precision. Our study reveals significant spatial separation between cardiac afferent and efferent fibres in the vagus nerve, particularly at the mid-cervical level. Utilizing trial-and-error sVNS in vivo and micro-computed tomography fascicle tracing, we demonstrate the potential for targeted neuromodulation, achieving therapeutic effects such as scalable heart rate decrease without stimulating cardiac afferent-related reflexes. This spatial understanding opens avenues for more effective VNS therapy, minimizing off-target effects and potentially eliminating the need for titration, thereby expediting therapeutic outcomes in myocardial infarction and related conditions.
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Affiliation(s)
- Nicole Thompson
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Enrico Ravagli
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Svetlana Mastitskaya
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Ronald Challita
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Joseph Hadaya
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Francesco Iacoviello
- Electrochemical Innovation Lab, Department of Chemical Engineering, University College London, London, UK
| | - Ahmad Shah Idil
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Paul R Shearing
- Electrochemical Innovation Lab, Department of Chemical Engineering, University College London, London, UK
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jeffrey L Ardell
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - David Holder
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Kirill Aristovich
- EIT and Neurophysiology Research Group, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
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Blumer V, Januzzi JL, Lindenfeld J, Solomon SD, Psotka MA, Carson PE, Bristow MR, Abraham WT, Gandotra C, Saville BR, O'Connor C, Fiuzat M. Heart Failure Drug Development Over the Eras: From the Heart Failure Collaboratory. JACC. HEART FAILURE 2024:S2213-1779(24)00416-5. [PMID: 39001743 DOI: 10.1016/j.jchf.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/02/2024] [Accepted: 03/28/2024] [Indexed: 07/15/2024]
Abstract
Over the past decade, the field of heart failure (HF) has witnessed remarkable progress in drug development, resulting in the approval of numerous groundbreaking drugs by the U.S. Food and Drug Administration. To address some of these challenges, the U.S. Food and Drug Administration has issued guidance documents that have been critical in contemporary HF drug development; however, there are still many challenges in need of investigation. This article leverages efforts of the Heart Failure Collaboratory and the scientific community to discuss the critical need for innovative trial designs, important concepts in clinical trials in the modern era, and the utilization of big data to accelerate HF drug development. At this inflection point in HF drug development, it is imperative that, as a global scientific community, we foster increased collaboration among researchers, clinicians, patients, and regulatory bodies. Only through such unified efforts can we navigate the complexities of HF, accelerate the development process, and ultimately deliver effective therapies that transform patient outcomes.
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Affiliation(s)
- Vanessa Blumer
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA.
| | - James L Januzzi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Michael R Bristow
- Division of Cardiology, University of Colorado Anschutz Medial Campus, Aurora, Colorado, USA
| | - William T Abraham
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University College of Medicine/Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Charu Gandotra
- Office of New Drugs, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Springs, Maryland, USA
| | | | - Christopher O'Connor
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA; Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
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Owens MM, Dalal S, Radovic A, Fernandes L, Syed H, Herndon MK, Cooper C, Singh K, Beaumont E. Vagus nerve stimulation alleviates cardiac dysfunction and inflammatory markers during heart failure in rats. Auton Neurosci 2024; 253:103162. [PMID: 38513382 PMCID: PMC11318104 DOI: 10.1016/j.autneu.2024.103162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 02/21/2024] [Accepted: 02/28/2024] [Indexed: 03/23/2024]
Abstract
Vagus nerve stimulation (VNS) is under clinical investigation as a therapy for heart failure with reduced ejection fraction (HFrEF). This study aimed to investigate its therapeutic effects on three main components of heart failure: cardiac function, cardiac remodeling and central neuroinflammation using a pressure overload (PO) rat model. Male Sprague-Dawley rats were divided into four groups: PO, PO + VNS, PO + VNS sham, and controls. All rats, except controls, underwent a PO surgery to constrict the thoracic aorta (~50 %) to induce HFrEF. Open loop VNS therapy was continuously administered to PO + VNS rats at 20 Hz, 1.0 mA for 60 days. Evaluation of cardiac function and structure via echocardiograms showed decreases in stroke volume and relative ejection fraction and increases in the internal diameter of the left ventricle during systole and diastole in PO rats (p < 0.05). However, these PO-induced adverse changes were alleviated with VNS therapy. Additionally, PO rats exhibited significant increases in myocyte cross sectional areas indicating hypertrophy, along with significant increases in myocardial fibrosis and apoptosis, all of which were reversed by VNS therapy (p < 0.05). Furthermore, VNS mitigated microglial activation in two central autonomic nuclei: the paraventricular nucleus of the hypothalamus and locus coeruleus. These findings demonstrate that when VNS therapy is initiated at an early stage of HFrEF progression (<10 % reduction in relative ejection fraction), the supplementation of vagal activity is effective in restoring multi organ homeostasis in a PO model.
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Affiliation(s)
- Misty M Owens
- Department of Biomedical Sciences, East Tennessee State University, Stanton-Gerber Hall, 178 Maple Ave., P.O. Box 70582, Mountain Home, TN, 37684, United States of America
| | - Suman Dalal
- Department of Health Sciences, East Tennessee State University, 248 Lamb Hall, PO Box 70673, Johnson City, TN, 37614, United States of America; Center of Excellence in Inflammation, Infectious Disease and Immunity, East Tennessee State University, 1276 Gilbreath Dr., Box 70300, Johnson City, TN 37614, United States of America
| | - Aleksandra Radovic
- Department of Biomedical Sciences, East Tennessee State University, Stanton-Gerber Hall, 178 Maple Ave., P.O. Box 70582, Mountain Home, TN, 37684, United States of America
| | - Luciano Fernandes
- Department of Biomedical Sciences, East Tennessee State University, Stanton-Gerber Hall, 178 Maple Ave., P.O. Box 70582, Mountain Home, TN, 37684, United States of America
| | - Hassan Syed
- Department of Biomedical Sciences, East Tennessee State University, Stanton-Gerber Hall, 178 Maple Ave., P.O. Box 70582, Mountain Home, TN, 37684, United States of America
| | - Mary-Katherine Herndon
- Department of Biomedical Sciences, East Tennessee State University, Stanton-Gerber Hall, 178 Maple Ave., P.O. Box 70582, Mountain Home, TN, 37684, United States of America
| | - Coty Cooper
- Department of Biomedical Sciences, East Tennessee State University, Stanton-Gerber Hall, 178 Maple Ave., P.O. Box 70582, Mountain Home, TN, 37684, United States of America
| | - Krishna Singh
- Department of Biomedical Sciences, East Tennessee State University, Stanton-Gerber Hall, 178 Maple Ave., P.O. Box 70582, Mountain Home, TN, 37684, United States of America; Center of Excellence in Inflammation, Infectious Disease and Immunity, East Tennessee State University, 1276 Gilbreath Dr., Box 70300, Johnson City, TN 37614, United States of America; James H. Quillen Veterans Affairs Medical Center, Lamont St & Veterans Way, Johnson City, TN 37604, United States of America
| | - Eric Beaumont
- Department of Biomedical Sciences, East Tennessee State University, Stanton-Gerber Hall, 178 Maple Ave., P.O. Box 70582, Mountain Home, TN, 37684, United States of America; Center of Excellence in Inflammation, Infectious Disease and Immunity, East Tennessee State University, 1276 Gilbreath Dr., Box 70300, Johnson City, TN 37614, United States of America.
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Wernisch L, Edwards T, Berthon A, Tessier-Lariviere O, Sarkans E, Stoukidi M, Fortier-Poisson P, Pinkney M, Thornton M, Hanley C, Lee S, Jennings J, Appleton B, Garsed P, Patterson B, Buttinger W, Gonshaw S, Jakopec M, Shunmugam S, Mamen J, Tukiainen A, Lajoie G, Armitage O, Hewage E. Online Bayesian optimization of vagus nerve stimulation. J Neural Eng 2024; 21:026019. [PMID: 38479016 DOI: 10.1088/1741-2552/ad33ae] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/13/2024] [Indexed: 04/04/2024]
Abstract
Objective.In bioelectronic medicine, neuromodulation therapies induce neural signals to the brain or organs, modifying their function. Stimulation devices capable of triggering exogenous neural signals using electrical waveforms require a complex and multi-dimensional parameter space to control such waveforms. Determining the best combination of parameters (waveform optimization or dosing) for treating a particular patient's illness is therefore challenging. Comprehensive parameter searching for an optimal stimulation effect is often infeasible in a clinical setting due to the size of the parameter space. Restricting this space, however, may lead to suboptimal therapeutic results, reduced responder rates, and adverse effects.Approach. As an alternative to a full parameter search, we present a flexible machine learning, data acquisition, and processing framework for optimizing neural stimulation parameters, requiring as few steps as possible using Bayesian optimization. This optimization builds a model of the neural and physiological responses to stimulations, enabling it to optimize stimulation parameters and provide estimates of the accuracy of the response model. The vagus nerve (VN) innervates, among other thoracic and visceral organs, the heart, thus controlling heart rate (HR), making it an ideal candidate for demonstrating the effectiveness of our approach.Main results.The efficacy of our optimization approach was first evaluated on simulated neural responses, then applied to VN stimulation intraoperatively in porcine subjects. Optimization converged quickly on parameters achieving target HRs and optimizing neural B-fiber activations despite high intersubject variability.Significance.An optimized stimulation waveform was achieved in real time with far fewer stimulations than required by alternative optimization strategies, thus minimizing exposure to side effects. Uncertainty estimates helped avoiding stimulations outside a safe range. Our approach shows that a complex set of neural stimulation parameters can be optimized in real-time for a patient to achieve a personalized precision dosing.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Guillaume Lajoie
- Université de Montréal and Mila-Quebec AI Institute, Montréal, Canada
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Zile MR, Lindenfeld J, Weaver FA, Zannad F, Galle E, Rogers T, Abraham WT. Baroreflex activation therapy in patients with heart failure and a reduced ejection fraction: Long-term outcomes. Eur J Heart Fail 2024; 26:1051-1061. [PMID: 38606555 DOI: 10.1002/ejhf.3232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/21/2024] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
AIMS Carotid baroreflex activation therapy (BAT) restores baroreflex sensitivity and modulates the imbalance in cardiac autonomic function in patients with heart failure with reduced ejection fraction (HFrEF). We tested the hypothesis that treatment with BAT significantly reduces cardiovascular mortality and heart failure morbidity and provides long-term safety and sustainable symptomatic improvement. METHODS AND RESULTS BeAT-HF was a prospective, multicentre, randomized, two-arm, parallel-group, open-label, non-implanted control trial. New York Heart Association (NYHA) class III subjects, ejection fraction ≤35%, previous heart failure hospitalization or N-terminal pro-B-type natriuretic peptide (NT-proBNP) >400 pg/ml, no class I indication for cardiac resynchronization therapy and NT-proBNP <1600 pg/ml were randomized to BAT plus optimal medical management (BAT group) or optimal medical management alone (control). The primary endpoint was cardiovascular mortality and HF morbidity; additional pre-specified endpoints included durability of safety, quality of life (QOL), exercise capacity (6-min hall walk distance [6MHWD]), functional status (NYHA class), hierarchical composite win ratio, freedom from all-cause death, left ventricular assists device (LVAD) implantation, heart transplant. Overall, 323 patients had 332 primary events, median follow-up was 3.6 years/patient. Both primary endpoint (rate ratio 0.94, 95% confidence interval [CI] 0.57-1.57; p = 0.82) and components of the primary endpoints were not significantly different between BAT and control. The system- and procedure-related major adverse neurological and cardiovascular event-free rate remained 97% throughout the trial. Symptom improvement (QOL, 6MHWD, NYHA class, all nominal p < 0.001) in the BAT group was durable in time, sustainable in extent. Win ratio (1.26, 95% CI 1.02-1.58) and freedom from all-cause death, LVAD implantation, heart transplant (hazard ratio 0.66, 95% CI 0.43-1.01) favoured the BAT group but did not reach statistical significance. CONCLUSION The BeAT-HF primary endpoint was neutral; however, BAT provided safe, effective, and sustainable improvements in HFrEF patient's functional status, 6MHWD and QOL.
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Affiliation(s)
- Michael R Zile
- Medical University of South Carolina, Charleston, South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, SC, USA
| | | | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm Centre d'Investigation, CHU de Nancy, Institute Lorrain du Coeur et des Vaisseaux, Nancy, France
| | | | | | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
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6
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Rajendran PS, Hadaya J, Khalsa SS, Yu C, Chang R, Shivkumar K. The vagus nerve in cardiovascular physiology and pathophysiology: From evolutionary insights to clinical medicine. Semin Cell Dev Biol 2024; 156:190-200. [PMID: 36641366 PMCID: PMC10336178 DOI: 10.1016/j.semcdb.2023.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/01/2023] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
The parasympathetic nervous system via the vagus nerve exerts profound influence over the heart. Together with the sympathetic nervous system, the parasympathetic nervous system is responsible for fine-tuned regulation of all aspects of cardiovascular function, including heart rate, rhythm, contractility, and blood pressure. In this review, we highlight vagal efferent and afferent innervation of the heart, with a focus on insights from comparative biology and advances in understanding the molecular and genetic diversity of vagal neurons, as well as interoception, parasympathetic dysfunction in heart disease, and the therapeutic potential of targeting the parasympathetic nervous system in cardiovascular disease.
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Affiliation(s)
| | - Joseph Hadaya
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA Molecular, Cellular, and Integrative Physiology Program, Los Angeles, CA, USA
| | - Sahib S Khalsa
- Laureate Institute for Brain Research, Tulsa, Ok, USA; Oxley College of Health Sciences, University of Tulsa, Tulsa, Ok, USA
| | - Chuyue Yu
- Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA; Department of Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT, USA
| | - Rui Chang
- Department of Neuroscience, Yale University School of Medicine, New Haven, CT, USA; Department of Cellular and Molecular Physiology, Yale University School of Medicine, New Haven, CT, USA
| | - Kalyanam Shivkumar
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; UCLA Molecular, Cellular, and Integrative Physiology Program, Los Angeles, CA, USA.
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7
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Alpenglow JK, Bunsawat K, Francisco MA, Craig JC, Iacovelli JJ, Ryan JJ, Wray DW. Impaired cardiopulmonary baroreflex function and altered cardiovascular responses to hypovolemia in patients with heart failure with preserved ejection fraction. J Appl Physiol (1985) 2024; 136:525-534. [PMID: 38174372 PMCID: PMC11212821 DOI: 10.1152/japplphysiol.00510.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/05/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is associated with autonomic dysregulation, which may be related to baroreflex dysfunction. Thus, we tested the hypothesis that cardiac and peripheral vascular responses to baroreflex activation via lower-body negative pressure (LBNP; -10, -20, -30, -40 mmHg) would be diminished in patients with HFpEF (n = 10, 71 ± 7 yr) compared with healthy controls (CON, n = 9, 69 ± 5 yr). Changes in heart rate (HR), mean arterial pressure (MAP, Finapres), forearm blood flow (FBF, ultrasound Doppler), and thoracic impedance (Z) were determined. Mild levels of LBNP (-10 and -20 mmHg) were used to specifically assess the cardiopulmonary baroreflex, whereas responses across the greater levels of LBNP represented an integrated baroreflex response. LBNP significantly increased in HR in CON subjects at -30 and -40 mmHg (+3 ± 3 and +6 ± 5 beats/min, P < 0.01), but was unchanged in patients with HFpEF across all LBNP levels. LBNP provoked progressive peripheral vasoconstriction, as quantified by changes in forearm vascular conductance (FVC), in both groups. However, a marked (40%-60%) attenuation in FVC responses was observed in patients with HFpEF (-6 ± 8, -15 ± 6, -16 ± 5, and -19 ± 7 mL/min/mmHg at -10, -20, -30, and -40 mmHg, respectively) compared with controls (-15 ± 10, -22 ± 6, -25 ± 10, and -28 ± 10 mL/min/mmHg, P < 0.01). MAP was unchanged in both groups. Together, these data provide new evidence for impairments in cardiopulmonary baroreflex function and diminished cardiovascular responsiveness during hypovolemia in patients with HFpEF, which may be an important aspect of the disease-related changes in autonomic cardiovascular control in this patient group.NEW & NOTEWORTHY Data from the current study demonstrate diminished cardiovascular responsiveness during hypovolemia induced by incremental lower-body negative pressure in patients with heart failure with preserved ejection fraction (HFpEF). These diminished responses imply impaired cardiopulmonary baroreflex function and altered autonomic cardiovascular regulation which may represent an important aspect of HFpEF pathophysiology.
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Affiliation(s)
- Jeremy K Alpenglow
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- George E. Wahlen Department of Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, United States
| | - Michael A Francisco
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- George E. Wahlen Department of Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, United States
| | - Jesse C Craig
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- George E. Wahlen Department of Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, United States
| | - Jarred J Iacovelli
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
| | - D Walter Wray
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah, United States
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States
- George E. Wahlen Department of Veterans Affairs Medical Center, Geriatric Research, Education, and Clinical Center, Salt Lake City, Utah, United States
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Kellett DO, Aziz Q, Humphries JD, Korsak A, Braga A, Gutierrez Del Arroyo A, Crescente M, Tinker A, Ackland GL, Gourine AV. Transcriptional response of the heart to vagus nerve stimulation. Physiol Genomics 2024; 56:167-178. [PMID: 38047311 PMCID: PMC11281814 DOI: 10.1152/physiolgenomics.00095.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023] Open
Abstract
Heart failure is a major clinical problem, with treatments involving medication, devices, and emerging neuromodulation therapies such as vagus nerve stimulation (VNS). Considering the ongoing interest in using VNS to treat cardiovascular disease, it is important to understand the genetic and molecular changes developing in the heart in response to this form of autonomic neuromodulation. This experimental animal (rat) study investigated the immediate transcriptional response of the ventricular myocardium to selective stimulation of vagal efferent activity using an optogenetic approach. Vagal preganglionic neurons in the dorsal motor nucleus of the vagus nerve were genetically targeted to express light-sensitive chimeric channelrhodopsin variant ChIEF and stimulated using light. RNA sequencing of the left ventricular myocardium identified 294 differentially expressed genes (false discovery rate < 0.05). Qiagen Ingenuity Pathway Analysis (IPA) highlighted 118 canonical pathways that were significantly modulated by vagal activity, of which 14 had a z score of ≥2/≤-2, including EIF-2, IL-2, integrin, and NFAT-regulated cardiac hypertrophy. IPA revealed the effect of efferent vagus stimulation on protein synthesis, autophagy, fibrosis, autonomic signaling, inflammation, and hypertrophy. IPA further predicted that the identified differentially expressed genes were the targets of 50 upstream regulators, including transcription factors (e.g., MYC and NRF1) and microRNAs (e.g., miR-335-3p and miR-338-3p). These data demonstrate that the vagus nerve has a major impact on the myocardial expression of genes involved in the regulation of key biological pathways. The transcriptional response of the ventricular myocardium induced by stimulation of vagal efferents is consistent with the beneficial effect of maintained/increased vagal activity on the heart.NEW & NOTEWORTHY This experimental animal study investigated the immediate transcriptional response of the ventricular myocardium to selective stimulation of vagal efferent activity. Vagal stimulation induced significant transcriptional changes in the heart involving the pathways controlling autonomic signaling, inflammation, fibrosis, and hypertrophy. This study provides the first direct evidence that myocardial gene expression is modulated by the activity of the autonomic nervous system.
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Affiliation(s)
- Daniel O Kellett
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Qadeer Aziz
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Jonathan D Humphries
- Department of Life Sciences, Manchester Metropolitan University, Manchester, United Kingdom
| | - Alla Korsak
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Alice Braga
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Ana Gutierrez Del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Marilena Crescente
- Department of Life Sciences, Manchester Metropolitan University, Manchester, United Kingdom
| | - Andrew Tinker
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Alexander V Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
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9
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Abdin A, Lauder L, Fudim M, Abraham WT, Anker SD, Böhm M, Mahfoud F. Neuromodulation interventions in the management of heart failure. Eur J Heart Fail 2024; 26:502-510. [PMID: 38247193 DOI: 10.1002/ejhf.3147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Despite remarkable improvements in the management of heart failure (HF), HF remains one of the most rapidly growing cardiovascular condition resulting in a substantial burden on healthcare systems worldwide. In clinical practice, however, a relevant proportion of patients are treated with suboptimal combinations and doses lower than those recommended in the current guidelines. Against this background, it remains important to identify new targets and investigate additional therapeutic options to alleviate symptoms and potentially improve prognosis in HF. Therefore, non-pharmacological interventions targeting autonomic imbalance in HF have been evaluated. This paper aims to review the physiology, available clinical data, and potential therapeutic role of device-based neuromodulation in HF.
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Affiliation(s)
- Amr Abdin
- Internal Medicine Clinic III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
| | - Lucas Lauder
- Internal Medicine Clinic III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
| | - Marat Fudim
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Michael Böhm
- Internal Medicine Clinic III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
| | - Felix Mahfoud
- Internal Medicine Clinic III, Cardiology, Angiology and Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
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Chouairi F, Levin A, Biegus J, Fudim M. Emerging devices for heart failure management. Prog Cardiovasc Dis 2024; 82:125-134. [PMID: 38242194 DOI: 10.1016/j.pcad.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/21/2024]
Abstract
There have been significant advances in the treatment of heart failure (HF) in recent years, driven by significant strides in guideline-directed medical therapy (GDMT). Despite this, HF is still associated with high levels of morbidity and mortality, and most patients do not receive optimal medical therapy. In conjunction with the improvement of GDMT, novel device therapies have been developed to better treat HF. These devices include technology capable of remotely monitoring HF physiology, devices that modulate the autonomic nervous system, and those that structurally change the heart with the ultimate aim of addressing the root causes of HF physiology As these device therapies gradually integrate into the fabric of HF patient care, it becomes increasingly important for modern cardiologists to become familiar with them. Hence, the objective of this review is to shed light on currently emerging devices for the treatment of HF.
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Affiliation(s)
- Fouad Chouairi
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Allison Levin
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Duke Clinical Research Institute, Durham, NC, USA.
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11
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Filippini FB, Ribeiro HB, Bocchi E, Bacal F, Marcondes-Braga FG, Avila MS, Sturmer JD, Marchi MFDS, Kanhouche G, Freire AF, Cassar R, Abizaid AA, de Brito FS. Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure. Arq Bras Cardiol 2023; 120:e20220496. [PMID: 38126512 PMCID: PMC10773459 DOI: 10.36660/abc.20220496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 04/05/2023] [Accepted: 05/17/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Central Illustration : Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure Transcatheter devices for monitoring and treating advanced chronic heart failure patients. PA: pulmonary artery; LA: left atrium; AFR: atrial flow regulator; TASS: Transcatheter Atrial Shunt System; VNS: vagus nerve stimulation; BAT: baroreceptor activation therapy; RDN: renal sympathetic denervation; F: approval by the American regulatory agency (FDA); E: approval by the European regulatory agency (CE Mark). BACKGROUND Innovations in devices during the last decade contributed to enhanced diagnosis and treatment of patients with cardiac insufficiency. These tools progressively adapted to minimally invasive strategies with rapid, widespread use. The present article focuses on actual and future directions of device-related diagnosis and treatment of chronic heart failure.
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Affiliation(s)
- Filippe Barcellos Filippini
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Alemão Oswaldo CruzSão PauloSPBrasil Hospital Alemão Oswaldo Cruz , São Paulo , SP – Brasil
| | - Henrique Barbosa Ribeiro
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Edimar Bocchi
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Fernando Bacal
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Fabiana G. Marcondes-Braga
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Monica S. Avila
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Janine Daiana Sturmer
- Hospital Alemão Oswaldo CruzSão PauloSPBrasil Hospital Alemão Oswaldo Cruz , São Paulo , SP – Brasil
| | - Mauricio Felippi de Sá Marchi
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Gabriel Kanhouche
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Antônio Fernando Freire
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Renata Cassar
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Alexandre A. Abizaid
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Fábio Sândoli de Brito
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
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Pahuja M, Akhtar KH, Krishan S, Nasir YM, Généreux P, Stavrakis S, Dasari TW. Neuromodulation Therapies in Heart Failure: A State-of-the-Art Review. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101199. [PMID: 39131073 PMCID: PMC11307467 DOI: 10.1016/j.jscai.2023.101199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 08/13/2024]
Abstract
Heart failure (HF) continues to impact the population globally with increasing prevalence. While the pathophysiology of HF is quite complex, the dysregulation of the autonomic nervous system, as evident in heightened sympathetic activity, serves as an attractive pathophysiological target for newer therapies and HF. The degree of neurohormonal activation has been found to correlate to the severity of symptoms, decline in functional capacity, and mortality. Neuromodulation of the autonomic nervous system aims to restore the balance between sympathetic nervous system and the parasympathetic nervous system. Given that autonomic dysregulation plays a major role in the development and progression of HF, restoring this balance may potentially have an impact on the core pathophysiological mechanisms and various HF syndromes. Autonomic modulation has been proposed as a potential therapeutic strategy aimed at reduction of systemic inflammation. Such therapies, complementary to drug and device-based therapies may lead to improved patient outcomes and reduce disease burden. Most professional societies currently do not provide a clear recommendation on the use of neuromodulation techniques in HF. These include direct and indirect vagal nerve stimulation, spinal cord stimulation, baroreflex activation therapy, carotid sinus stimulation, aortic arch stimulation, splanchnic nerve modulation, cardiopulmonary nerve stimulation, and renal sympathetic nerve denervation. In this review, we provide a comprehensive overview of neuromodulation in HF.
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Affiliation(s)
- Mohit Pahuja
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Khawaja Hassan Akhtar
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Satyam Krishan
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Yusra Minahil Nasir
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Philippe Généreux
- Department of Medicine, Section of Cardiovascular Medicine, Morristown Medical Center, Morristown, New Jersey
| | - Stavros Stavrakis
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Heart Rhythm Institute, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Tarun W. Dasari
- Department of Medicine, Section of Cardiovascular Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
- Heart Rhythm Institute, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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13
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Zhang J, Saju C. A systematic review of randomised controlled trials with adaptive and traditional group sequential designs - applications in cardiovascular clinical trials. BMC Med Res Methodol 2023; 23:200. [PMID: 37679710 PMCID: PMC10483862 DOI: 10.1186/s12874-023-02024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Trial design plays a key role in clinical trials. Traditional group sequential design has been used in cardiovascular clinical trials over decades as the trials can potentially be stopped early, therefore, it can reduce pre-planned sample size and trial resources. In contrast, trials with adoptive designs provide greater flexibility and are more efficient due to the ability to modify trial design according to the interim analysis results. In this systematic review, we aim to explore characteristics of adaptive and traditional group sequential trials in practice and to gain an understanding how these trial designs are currently being reported in cardiology. METHODS PubMed, Embase and Cochrane Central Register of Controlled Trials database were searched from January 1980 to June 2022. Randomised controlled phase 2/3 trials with either adaptive or traditional group sequential design in patients with cardiovascular disease were included. Descriptive statistics were used to present the collected data. RESULTS Of 456 articles found in the initial search, 56 were identified including 43 (76.8%) trials with traditional group sequential design and 13 (23.2%) with adaptive. Most trials were large, multicentre, led by the USA (50%) and Europe (28.6%), and were funded by companies (78.6%). For trials with group sequential design, frequency of interim analyses was determined mainly by the number of events (47%). 67% of the trials stopped early, in which 14 (32.6%) were due to efficacy, and 5 (11.6%) for futility. The commonly used stopping rule to terminate trials was O'Brien- Fleming-type alpha spending function (10 (23.3%)). For trials with adaptive designs, 54% of the trials stopped early, in which 4 (30.8%) were due to futility, and 2 (15.4%) for efficacy. Sample size re-estimation was commonly used (8 (61.5%)). In 69% of the trials, simulation including Bayesian approach was used to define the statistical stopping rules. The adaptive designs have been increasingly used (from 0 to 1999 to 38.6% after 2015 amongst adaptive trials). 25% of the trials reported "adaptive" in abstract or title of the studies. CONCLUSIONS The application of adaptive trials is increasingly popular in cardiovascular clinical trials. The reporting of adaptive design needs improving.
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Affiliation(s)
- Jufen Zhang
- School of Medicine, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, CM1 1SQ, U.K..
- School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, U.K..
| | - Christy Saju
- School of Medicine, Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Bishop Hall Lane, Chelmsford, CM1 1SQ, U.K
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Hadaya J, Dajani AH, Cha S, Hanna P, Challita R, Hoover DB, Ajijola OA, Shivkumar K, Ardell JL. Vagal Nerve Stimulation Reduces Ventricular Arrhythmias and Mitigates Adverse Neural Cardiac Remodeling Post-Myocardial Infarction. JACC Basic Transl Sci 2023; 8:1100-1118. [PMID: 37791302 PMCID: PMC10543930 DOI: 10.1016/j.jacbts.2023.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/29/2023] [Accepted: 03/29/2023] [Indexed: 10/05/2023]
Abstract
This study sought to evaluate the impact of chronic vagal nerve stimulation (cVNS) on cardiac and extracardiac neural structure/function after myocardial infarction (MI). Groups were control, MI, and MI + cVNS; cVNS was started 2 days post-MI. Terminal experiments were performed 6 weeks post-MI. MI impaired left ventricular mechanical function, evoked anisotropic electrical conduction, increased susceptibility to ventricular tachycardia and fibrillation, and altered neuronal and glial phenotypes in the stellate and dorsal root ganglia, including glial activation. cVNS improved cardiac mechanical function and reduced ventricular tachycardia/ventricular fibrillation post-MI, partly by stabilizing activation/repolarization in the border zone. MI-associated extracardiac neural remodeling, particularly glial activation, was mitigated with cVNS.
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Affiliation(s)
- Joseph Hadaya
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Al-Hassan Dajani
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Steven Cha
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Peter Hanna
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Ronald Challita
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Donald B. Hoover
- Department of Biomedical Sciences, Quillen College of Medicine, East Tennessee State University, Johnson City, Tennessee, USA
- Center of Excellence in Inflammation, Infectious Disease and Immunity, East Tennessee State University, Johnson City, Tennessee, USA
| | - Olujimi A. Ajijola
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
| | - Jeffrey L. Ardell
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Molecular, Cellular, and Integrative Physiology Program, University of California, Los Angeles, Los Angeles, California, USA
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15
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Salah HM, Fudim M, Burkhoff D. Device Interventions for Heart Failure. JACC. HEART FAILURE 2023; 11:1039-1054. [PMID: 37611987 DOI: 10.1016/j.jchf.2023.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 08/25/2023]
Abstract
Despite remarkable advances in drug therapy for heart failure (HF), the residual HF-related morbidity, mortality, and hospitalizations remain substantial across all HF phenotypes, and significant proportions of patients with HF remain symptomatic despite optimal drug therapy. Driven by these unmet clinical needs, the exponential growth of transcatheter interventions, and a recent shift in the regulatory landscape of device-based therapies, novel device-based interventions have emerged as a potential therapy for various phenotypes of HF. Device-based interventions can overcome some of the limitations of drug therapy (eg, intolerance, nonadherence, inconsistent delivery, and recurrent and long-term cost) and can target some HF-related pathophysiologic pathways more effectively than drug therapy. This paper reviews the current evolving landscape of device-based interventions in HF and highlights critical points related to implementation of these therapies in the current workflow of HF management.
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Affiliation(s)
- Husam M Salah
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York, New York, USA.
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16
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Wu Z, Liao J, Liu Q, Zhou S, Chen M. Chronic vagus nerve stimulation in patients with heart failure: challenge or failed translation? Front Cardiovasc Med 2023; 10:1052471. [PMID: 37534273 PMCID: PMC10390725 DOI: 10.3389/fcvm.2023.1052471] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 05/31/2023] [Indexed: 08/04/2023] Open
Abstract
Autonomic imbalance between the sympathetic and parasympathetic nervous systems contributes to the progression of chronic heart failure (HF). Preclinical studies have demonstrated that various neuromodulation strategies may exert beneficial cardioprotective effects in preclinical models of HF. Based on these encouraging experimental data, vagus nerve stimulation (VNS) has been assessed in patients with HF with a reduced ejection fraction. Nevertheless, the main trials conducted thus far have yielded conflicting findings, questioning the clinical efficacy of VNS in this context. This review will therefore focus on the role of the autonomic nervous system in HF pathophysiology and VNS therapy, highlighting the potential reasons behind the discrepancy between preclinical and clinical studies.
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Affiliation(s)
- Zhihong Wu
- Department of Cardiovascular, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Jiaying Liao
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Qiming Liu
- Department of Cardiovascular, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shenghua Zhou
- Department of Cardiovascular, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Mingxian Chen
- Department of Cardiovascular, The Second Xiangya Hospital of Central South University, Changsha, China
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17
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Elia A, Fossati S. Autonomic nervous system and cardiac neuro-signaling pathway modulation in cardiovascular disorders and Alzheimer's disease. Front Physiol 2023; 14:1060666. [PMID: 36798942 PMCID: PMC9926972 DOI: 10.3389/fphys.2023.1060666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
The heart is a functional syncytium controlled by a delicate and sophisticated balance ensured by the tight coordination of its several cell subpopulations. Accordingly, cardiomyocytes together with the surrounding microenvironment participate in the heart tissue homeostasis. In the right atrium, the sinoatrial nodal cells regulate the cardiac impulse propagation through cardiomyocytes, thus ensuring the maintenance of the electric network in the heart tissue. Notably, the central nervous system (CNS) modulates the cardiac rhythm through the two limbs of the autonomic nervous system (ANS): the parasympathetic and sympathetic compartments. The autonomic nervous system exerts non-voluntary effects on different peripheral organs. The main neuromodulator of the Sympathetic Nervous System (SNS) is norepinephrine, while the principal neurotransmitter of the Parasympathetic Nervous System (PNS) is acetylcholine. Through these two main neurohormones, the ANS can gradually regulate cardiac, vascular, visceral, and glandular functions by turning on one of its two branches (adrenergic and/or cholinergic), which exert opposite effects on targeted organs. Besides these neuromodulators, the cardiac nervous system is ruled by specific neuropeptides (neurotrophic factors) that help to preserve innervation homeostasis through the myocardial layers (from epicardium to endocardium). Interestingly, the dysregulation of this neuro-signaling pathway may expose the cardiac tissue to severe disorders of different etiology and nature. Specifically, a maladaptive remodeling of the cardiac nervous system may culminate in a progressive loss of neurotrophins, thus leading to severe myocardial denervation, as observed in different cardiometabolic and neurodegenerative diseases (myocardial infarction, heart failure, Alzheimer's disease). This review analyzes the current knowledge on the pathophysiological processes involved in cardiac nervous system impairment from the perspectives of both cardiac disorders and a widely diffused and devastating neurodegenerative disorder, Alzheimer's disease, proposing a relationship between neurodegeneration, loss of neurotrophic factors, and cardiac nervous system impairment. This overview is conducive to a more comprehensive understanding of the process of cardiac neuro-signaling dysfunction, while bringing to light potential therapeutic scenarios to correct or delay the adverse cardiovascular remodeling, thus improving the cardiac prognosis and quality of life in patients with heart or neurodegenerative disorders.
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18
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Verkerk AO, Doszpod IJ, Mengarelli I, Magyar T, Polyák A, Pászti B, Efimov IR, Wilders R, Koncz I. Acetylcholine Reduces L-Type Calcium Current without Major Changes in Repolarization of Canine and Human Purkinje and Ventricular Tissue. Biomedicines 2022; 10:biomedicines10112987. [PMID: 36428555 PMCID: PMC9687254 DOI: 10.3390/biomedicines10112987] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 11/24/2022] Open
Abstract
Vagal nerve stimulation (VNS) holds a strong basis as a potentially effective treatment modality for chronic heart failure, which explains why a multicenter VNS study in heart failure with reduced ejection fraction is ongoing. However, more detailed information is required on the effect of acetylcholine (ACh) on repolarization in Purkinje and ventricular cardiac preparations to identify the advantages, risks, and underlying cellular mechanisms of VNS. Here, we studied the effect of ACh on the action potential (AP) of canine Purkinje fibers (PFs) and several human ventricular preparations. In addition, we characterized the effects of ACh on the L-type Ca2+ current (ICaL) and AP of human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) and performed computer simulations to explain the observed effects. Using microelectrode recordings, we found a small but significant AP prolongation in canine PFs. In the human myocardium, ACh slightly prolonged the AP in the midmyocardium but resulted in minor AP shortening in subepicardial tissue. Perforated patch-clamp experiments on hiPSC-CMs demonstrated that 5 µM ACh caused an ≈15% decrease in ICaL density without changes in gating properties. Using dynamic clamp, we found that under blocked K+ currents, 5 µM ACh resulted in an ≈23% decrease in AP duration at 90% of repolarization in hiPSC-CMs. Computer simulations using the O'Hara-Rudy human ventricular cell model revealed that the overall effect of ACh on AP duration is a tight interplay between the ACh-induced reduction in ICaL and ACh-induced changes in K+ currents. In conclusion, ACh results in minor changes in AP repolarization and duration of canine PFs and human ventricular myocardium due to the concomitant inhibition of inward ICaL and outward K+ currents, which limits changes in net repolarizing current and thus prevents major changes in AP repolarization.
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Affiliation(s)
- Arie O. Verkerk
- Department of Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Illés J. Doszpod
- Department of Pharmacology and Pharmacotherapy, Albert Szent-Györgyi Medical School, University of Szeged, 6721 Szeged, Hungary
| | - Isabella Mengarelli
- Department of Experimental Cardiology, Heart Center, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Tibor Magyar
- Department of Pharmacology and Pharmacotherapy, Albert Szent-Györgyi Medical School, University of Szeged, 6721 Szeged, Hungary
| | - Alexandra Polyák
- Department of Pharmacology and Pharmacotherapy, Albert Szent-Györgyi Medical School, University of Szeged, 6721 Szeged, Hungary
| | - Bence Pászti
- Department of Pharmacology and Pharmacotherapy, Albert Szent-Györgyi Medical School, University of Szeged, 6721 Szeged, Hungary
| | - Igor R. Efimov
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
- Department of Biomedical Engineering, Northwestern University, Chicago, IL 60611, USA
- Department of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Ronald Wilders
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
- Correspondence: (R.W.); (I.K.)
| | - István Koncz
- Department of Pharmacology and Pharmacotherapy, Albert Szent-Györgyi Medical School, University of Szeged, 6721 Szeged, Hungary
- Department of Biomedical Engineering, The George Washington University, Washington, DC 20052, USA
- Correspondence: (R.W.); (I.K.)
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19
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Abstract
Autonomic imbalance with a sympathetic dominance is acknowledged to be a critical determinant of the pathophysiology of chronic heart failure with reduced ejection fraction (HFrEF), regardless of the etiology. Consequently, therapeutic interventions directly targeting the cardiac autonomic nervous system, generally referred to as neuromodulation strategies, have gained increasing interest and have been intensively studied at both the pre-clinical level and the clinical level. This review will focus on device-based neuromodulation in the setting of HFrEF. It will first provide some general principles about electrical neuromodulation and discuss specifically the complex issue of dose-response with this therapeutic approach. The paper will thereafter summarize the rationale, the pre-clinical and the clinical data, as well as the future prospectives of the three most studied form of device-based neuromodulation in HFrEF. These include cervical vagal nerve stimulation (cVNS), baroreflex activation therapy (BAT), and spinal cord stimulation (SCS). BAT has been approved by the Food and Drug Administration for use in patients with HfrEF, while the other two approaches are still considered investigational; VNS is currently being investigated in a large phase III Study.
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Affiliation(s)
- Veronica Dusi
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin , Corso Bramante 88, 10126 Turin , Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin , Corso Bramante 88, 10126 Turin , Italy
| | - Michael R Zile
- Division of Cardiology, Department of Medicine, Medical University of South Carolina and RHJ Department of Veteran's Affairs Medical Center , Charleston, SC , USA
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza, University of Turin , Corso Bramante 88, 10126 Turin , Italy
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Ryan CT, Ghanta RK. Commentary: Stimulating new options for heart failure management. JTCVS Tech 2022; 14:99-100. [PMID: 35967197 PMCID: PMC9366527 DOI: 10.1016/j.xjtc.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 12/05/2022] Open
Affiliation(s)
- Christopher T. Ryan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Ravi K. Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
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21
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McBeath KCC, Angermann CE, Cowie MR. Digital Technologies to Support Better Outcome and Experience of Care in Patients with Heart Failure. Curr Heart Fail Rep 2022; 19:75-108. [PMID: 35486314 PMCID: PMC9051015 DOI: 10.1007/s11897-022-00548-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW In this article, we review a range of digital technologies for possible application in heart failure patients, with a focus on lessons learned. We also discuss a future model of heart failure management, as digital technologies continue to become part of standard care. RECENT FINDINGS Digital technologies are increasingly used by healthcare professionals and those living with heart failure to support more personalised and timely shared decision-making, earlier identification of problems, and an improved experience of care. The COVID-19 pandemic has accelerated the acceptability and implementation of a range of digital technologies, including remote monitoring and health tracking, mobile health (wearable technology and smartphone-based applications), and the use of machine learning to augment data interpretation and decision-making. Much has been learned over recent decades on the challenges and opportunities of technology development, including how best to evaluate the impact of digital health interventions on health and healthcare, the human factors involved in implementation and how best to integrate dataflows into the clinical pathway. Supporting patients with heart failure as well as healthcare professionals (both with a broad range of health and digital literacy skills) is crucial to success. Access to digital technologies and the internet remains a challenge for some patients. The aim should be to identify the right technology for the right patient at the right time, in a process of co-design and co-implementation with patients.
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Affiliation(s)
- K C C McBeath
- Royal Brompton Hospital (Guy's & St Thomas' NHS Foundation Trust), Sydney Street, London, SW3 6NP, UK
| | - C E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Würzburg, Germany
| | - M R Cowie
- Royal Brompton Hospital (Guy's & St Thomas' NHS Foundation Trust), Sydney Street, London, SW3 6NP, UK.
- School of Cardiovascular Medicine, Faculty of Medicine & Lifesciences, King's College London, London, UK.
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22
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Konstam MA, Mann DL, Udelson JJE, Ardell JL, De Ferrari GM, Cowie MR, Klein HU, Gregory DD, Massaro JM, Libbus I, DiCarlo LA, Butler J, Parker JD, Teerlink JR. Advances in Our Clinical Understanding of Autonomic Regulation Therapy Using Vagal Nerve Stimulation in Patients Living With Heart Failure. Front Physiol 2022; 13:857538. [PMID: 35530511 PMCID: PMC9068946 DOI: 10.3389/fphys.2022.857538] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/21/2022] [Indexed: 11/17/2022] Open
Abstract
The ANTHEM-HF, INOVATE-HF, and NECTAR-HF clinical studies of autonomic regulation therapy (ART) using vagus nerve stimulation (VNS) systems have collectively provided dose-ranging information enabling the development of several working hypotheses on how stimulation frequency can be utilized during VNS for tolerability and improving cardiovascular outcomes in patients living with heart failure (HF) and reduced ejection fraction (HFrEF). Changes in heart rate dynamics, comprising reduced heart rate (HR) and increased HR variability, are a biomarker of autonomic nerve system engagement and cardiac control, and appear to be sensitive to VNS that is delivered using a stimulation frequency that is similar to the natural operating frequency of the vagus nerve. Among prior studies, the ANTHEM-HF Pilot Study has provided the clearest evidence of autonomic engagement with VNS that was delivered using a stimulation frequency that was within the operating range of the vagus nerve. Achieving autonomic engagement was accompanied by improvement from baseline in six-minute walk duration (6MWD), health-related quality of life, and left ventricular EF (LVEF), over and above those achieved by concomitant guideline-directed medical therapy (GDMT) administered to counteract harmful neurohormonal activation, with relative freedom from deleterious effects. Autonomic engagement and positive directional changes have persisted over time, and an exploratory analysis suggests that improvement in autonomic tone, symptoms, and physical capacity may be independent of baseline NT-proBNP values. Based upon these encouraging observations, prospective, randomized controlled trials examining the effects on symptoms and cardiac function as well as natural history have been warranted. A multi-national, large-scale, randomized, controlled trial is well underway to determine the outcomes associated with ART using autonomic nervous system engagement as a guide for VNS delivery.
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Affiliation(s)
- Marvin A Konstam
- The CardioVascular Center at Tufts Medical Center, Boston, MA, United States
| | - Douglas L Mann
- Center for Cardiovascular Research, Washington University School of Medicine, Saint Louis, MO, United States
| | | | - Jeffrey L Ardell
- UCLA Neurocardiology Program of Excellence, University of California, Los Angeles, Los Angeles, CA, United States
| | | | - Martin R Cowie
- School of Cardiovascular Medicine and Sciences, King's College London, London, United Kingdom
| | - Helmut U Klein
- Division of Cardiology, University of Rochester Medical Center, Rochester, NY, United States
| | - Douglas D Gregory
- Clinical Cardiovascular Science Foundation, Boston, MA, United States
| | - Joseph M Massaro
- Department of Biostatistics, School of Public Health, Boston University, Boston, MA, United States
| | - Imad Libbus
- LivaNova USA Incorporated, Houston, TX, United States
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, United States
| | - John D Parker
- University of Toronto, University Health Network, Toronto, ON, Canada
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, San Francisco, CA, United States
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23
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Libbus I, Stubbs SR, Mazar ST, Mindrebo S, KenKnight BH, DiCarlo LA. Implantable vagus nerve stimulation system performance is not affected by internal or external defibrillation shocks. J Interv Card Electrophysiol 2022; 63:555-560. [PMID: 34467496 PMCID: PMC9151504 DOI: 10.1007/s10840-021-01050-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Autonomic regulation therapy (ART) for heart failure (HF) is delivered using vagus nerve stimulation (VNS), and has been associated with improvement in cardiac function and HF symptoms. VNS is delivered using an implantable pulse generator (IPG) and a lead placed around the cervical vagus nerve. Because HF patients may receive concomitant cardiac defibrillation therapy, testing was conducted to determine the effect of defibrillation (DF) on VNS system performance. METHODS Normal swine (n = 4) with VNS system implants on the right cervical vagus nerve received sequential defibrillation shocks with three defibrillation systems: an implantable cardioverter defibrillator (ICD), a subcutaneous ICD (S-ICD), and an external cardioverter defibrillator (ECD). Each system delivered a series of bipolar high-energy shocks and reverse-polarity high-energy shocks. RESULTS The specified cardiac defibrillation shocks were delivered successfully from each of the three defibrillation systems to all animals. After each shock series, interrogation of the IPG confirmed that software and data were unchanged from pre-programmed values. After all of the defibrillation shocks were delivered, the IPGs underwent and passed comprehensive electrical testing demonstrating proper system function. No shifts in IPG parameters or ART system failures were observed, and histologic evaluation of the vagus nerve revealed no anatomic changes. CONCLUSIONS Implantable VNS systems were tested in vivo for immunity to defibrillation via ICD, S-ICD, and ECD, and were found to be unaffected by a series of high-energy defibrillation shocks. These results confirm that ART systems are capable of continuing to function after defibrillation and the cervical vagus nerve is anatomically unaffected.
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24
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Al Rameni D, Akay M, Jumean M, Al Rameeni A, Kar B, Gregoric ID. Implantation of a Vagus Nerve Stimulator for Patients with Heart Failure with Reduced Ejection Fraction: An Educational Video. JTCVS Tech 2022; 14:96-98. [PMID: 35967202 PMCID: PMC9366221 DOI: 10.1016/j.xjtc.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/30/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives Implantation and use of vagus nerve stimulation (VNS) systems is a proven treatment strategy for epilepsy and depression, and extensive research regarding vagal control of the heart has led to the idea of VNS as a potential adjunct treatment for heart failure with reduced ejection fraction (HFrEF). We describe our experience with the implantation of an investigational VNS system to manage patients living with HFrEF. Methods As part of the ongoing ANTHEM-HFrEF (Autonomic Regulation Therapy to Enhance Myocardial Function and Reduce Progression of Heart Failure with Reduced Ejection Fraction) Pivotal Study, a 67-year-old male patient with a history of ischemic cardiomyopathy was randomized to implantation of the VITARIA System (LivaNova Inc). The electrical lead requires no mapping for placement around the vagus nerve. The surgical procedure was completed uneventfully under general anesthesia, and the device was activated in the operating room after surgery. Results Following successful implantation and activation of the VNS system, the patient was discharged to home on the same day. Conclusions Current, ongoing studies, such as the ANTHEM-HFrEF Pivotal Study, are designed to determine the long-term effects of VNS on heart failure symptoms, hospitalization rates, and survival. The VNS-implantation procedure was straightforward.
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Verrier RL, Libbus I, Nearing BD, KenKnight BH. Multifactorial Benefits of Chronic Vagus Nerve Stimulation on Autonomic Function and Cardiac Electrical Stability in Heart Failure Patients With Reduced Ejection Fraction. Front Physiol 2022; 13:855756. [PMID: 35431984 PMCID: PMC9005779 DOI: 10.3389/fphys.2022.855756] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 02/21/2022] [Indexed: 12/20/2022] Open
Abstract
Heart failure with reduced left ventricular ejection fraction is a progressive disease that claims > 352,000 lives annually in the United States alone. Despite the development of an extensive array of pharmacologic and device therapies, prognosis remains poor. Disruption in autonomic balance in the form of heightened sympathetic nerve activity and reduced vagal tone have been established as major causes of heart failure progression. Interest in chronic neuromodulation mediated by vagus nerve stimulation (VNS) has intensified in recent years. This review focuses on four main goals: (1) To review the preclinical evidence that supports the concept of a cardioprotective effect of VNS on autonomic function and cardiac electrical stability along with the underlying putative mechanisms. (2) To present the initial clinical experience with chronic VNS in patients with heart failure and highlight the controversial aspects of the findings. (3) To discuss the latest findings of the multifactorial effects of VNS on autonomic tone, baroreceptor sensitivity, and cardiac electrical stability and the state-of-the-art methods employed to monitor these relationships. (4) To discuss the implications of the current findings and the gaps in knowledge that require attention in future investigations.
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Affiliation(s)
- Richard L. Verrier
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Harvard Medical School, Boston, MA, United States
- *Correspondence: Richard L. Verrier, , orcid.org/0000-0001-5602-6793
| | - Imad Libbus
- LivaNova USA, Inc., Houston, TX, United States
| | - Bruce D. Nearing
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Cardiovascular Medicine, Harvard Medical School, Boston, MA, United States
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26
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Konstam MA. Autonomic Dysregulation in Diabetes: CAN We Prevent Heart Failure? Eur J Heart Fail 2022; 24:642-644. [PMID: 35246908 DOI: 10.1002/ejhf.2476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Marvin A Konstam
- The CardioVascular Center, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
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27
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Kain V, Halade GV. Dysfunction of resolution receptor triggers cardiomyopathy of obesity and signs of non-resolving inflammation in heart failure. Mol Cell Endocrinol 2022; 542:111521. [PMID: 34843898 PMCID: PMC10515100 DOI: 10.1016/j.mce.2021.111521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/03/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) has been an emerging type of cardiac disease since the pseudo-left ventricle function is preserved; therefore, challenges in finding the target and treatment. Damage and pathogen-associated molecular patterns (DAMPs and PAMPs) are widely investigated in acute and chronic inflammation in heart failure; however, lifestyle-associated molecular patterns (LAMPs: diet, sleep, exercise), particularly in obesity, remains of interest due to the enormous increase of HFpEF patients. In this review, we covered obesity-related cardiomyopathy, LAMPs, and resolution receptor dysfunction in the context of heart failure with preserved ejection fraction.
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Affiliation(s)
- Vasundhara Kain
- Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, Tampa, FL, 33602, USA
| | - Ganesh V Halade
- Division of Cardiovascular Sciences, Department of Medicine, University of South Florida, Tampa, FL, 33602, USA.
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28
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Saku K, Yokota S, Nishikawa T, Kinugawa K. Interventional heart failure therapy: A new concept fighting against heart failure. J Cardiol 2021; 80:101-109. [PMID: 34924236 DOI: 10.1016/j.jjcc.2021.11.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/24/2021] [Indexed: 10/19/2022]
Abstract
Heart failure is a progressive disease that is associated with repeated exacerbations and hospitalizations. The rapid increase in the number of heart failure patients is a global health problem known as the 'heart failure pandemic'. To control the pandemic, multifaceted approaches are essential, ranging from prevention of onset to long-term disease management. Especially in patients with moderate to severe heart failure (stages C and D), surgical and catheter-based interventions are prerequisites for saving lives, preserving cardiac function, improving quality of life (QOL), and prognosis. In addition, various new medical technologies for these interventions have been clinically applied and have been shown to be effective against symptoms and improve the QOL and prognosis of patients with heart failure. Furthermore, the concept of interventional heart failure (IHF) therapy, which considers heart recovery and prevention of worsening of heart failure via multidisciplinary treatment using surgical, catheter interventions, and mechanical circulatory support devices, has been proposed worldwide. This review discusses the importance of IHF therapy in heart failure management, recent changes in interventional technologies and strategies for patients with heart failure, and worldwide education attempts for IHF specialists.
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Affiliation(s)
- Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan.
| | - Shohei Yokota
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Takuya Nishikawa
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
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29
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Abstract
Vagal nerve stimulation (VNS) has a strong pathophysiological rationale as a potentially beneficial treatment for heart failure with reduced ejection fraction. Despite several promising preclinical studies and pilot clinical studies, the two large, controlled trials—NECTAR-HF and INOVATE-HF—failed to demonstrate the expected benefit. It is likely that clinical application of VNS in phase III studies was performed before a sufficient degree of understanding of the complex pathophysiology of autonomic electrical modulation had been achieved, therefore leading to an underestimation of its potential benefit. More knowledge on the complex dose–response issue of VNS (i.e., pulse amplitude, frequency, duration and duty cycle) has been gathered since these trials and a new randomized study is currently underway with an adaptive design and a refined approach in an attempt to deliver the proper dose to a more selected group of patients.
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Affiliation(s)
- Veronica Dusi
- Division of Cardiology, Department of Medical Sciences, Citta della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy.
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, Citta della Salute e della Scienza Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
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30
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Verrier RL, Nearing BD, D'Avila A. Spectrum of clinical applications of interlead ECG heterogeneity assessment: From myocardial ischemia detection to sudden cardiac death risk stratification. Ann Noninvasive Electrocardiol 2021; 26:e12894. [PMID: 34592018 PMCID: PMC8588374 DOI: 10.1111/anec.12894] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 08/23/2021] [Accepted: 09/03/2021] [Indexed: 12/11/2022] Open
Abstract
Heterogeneity in depolarization and repolarization among regions of cardiac cells has long been recognized as a major factor in cardiac arrhythmogenesis. This fundamental principle has motivated development of noninvasive techniques for quantification of heterogeneity using the surface electrocardiogram (ECG). The initial approaches focused on interval analysis such as interlead QT dispersion and Tpeak -Tend difference. However, because of inherent difficulties in measuring the termination point of the T wave and commonly encountered irregularities in the apex of the T wave, additional techniques have been pursued. The newer methods incorporate assessment of the entire morphology of the T wave and in some cases of the R wave as well. This goal has been accomplished using a number of promising vectorial approaches with the resting 12-lead ECG. An important limitation of vectorcardiographic analyses is that they require exquisite stability of the recordings and are not inherently suitable for use in exercise tolerance testing (ETT) and/or ambulatory ECG monitoring for provocative stress testing or evaluation of the influence of daily activities on cardiac electrical instability. The objectives of the present review are to describe a technique that has been under clinical evaluation for nearly a decade, termed "interlead ECG heterogeneity." Preclinical testing data will be briefly reviewed. We will discuss the main clinical findings with regard to sudden cardiac death risk stratification, heart failure evaluation, and myocardial ischemia detection using standard recording platforms including resting 12-lead ECG, ambulatory ECG monitoring, ETT, and pharmacologic stress testing in conjunction with single-photon emission computed tomography myocardial perfusion imaging.
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Affiliation(s)
- Richard L Verrier
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce D Nearing
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andre D'Avila
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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31
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Fudim M, Abraham WT, von Bardeleben RS, Lindenfeld J, Ponikowski PP, Salah HM, Khan MS, Sievert H, Stone GW, Anker SD, Butler J. Device Therapy in Chronic Heart Failure: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 78:931-956. [PMID: 34446165 PMCID: PMC9941752 DOI: 10.1016/j.jacc.2021.06.040] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/21/2021] [Indexed: 12/12/2022]
Abstract
The regulatory landscape for device-based heart failure (HF) therapies has seen a major shift in the last 7 years. In 2013, the U.S. Food and Drug Administration released guidance for early feasibility and first-in-human studies, thereby encouraging device innovation, and in 2016 the U.S. Congress authorized the Breakthrough Devices Program to expedite access for Americans to innovative devices indicated for diagnosis and treatment of serious illnesses, such as HF. Since December 2016, there has been an increase in the number of HF devices for which manufacturers are seeking approval through the breakthrough designation pathway. This has led to a rapid uptake in the development and evaluation of device-based HF therapies. This article reviews the current and future landscape of device therapies for chronic HF and associated comorbidities and the regulatory environment that is driving current and future innovation.
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Affiliation(s)
- Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - William T. Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Ralph Stephan von Bardeleben
- Medizinische Klinik - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsmedizin Mainz, Mainz, Germany
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Piotr P. Ponikowski
- Centre for Heart Diseases, University Hospital, Wroclaw, Poland,Department of Heart Diseases, Medical University, Wroclaw, Poland
| | - Husam M. Salah
- Department of Medicine, University of Arkansas for Medical Sciences, AR, USA
| | - Muhammad Shahzeb Khan
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Horst Sievert
- CardioVascular Center Frankfurt, Frankfurt, Germany,Anglia Ruskin University, Chelmsford, United Kingdom
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, and the Cardiovascular Research Foundation, New York, NY, USA
| | - Stefan D. Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA.
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32
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Mandrola J, Althouse AD, Foy A, Bhatt DL. Adaptive Trials in Cardiology: Some Considerations and Examples. Can J Cardiol 2021; 37:1428-1437. [PMID: 34252567 DOI: 10.1016/j.cjca.2021.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/29/2021] [Accepted: 06/29/2021] [Indexed: 12/15/2022] Open
Abstract
Adaptive trials hold great promise to enhance the evidence base supporting medical interventions. In this review, we will describe the basic principles of an adaptive trial and the different types of adaptive trials, show examples of adaptive trials, and conclude with the advantages and challenges of different types of adaptive trials. While regulatory bodies have expressed a desire to see more adaptive trials, resistance in the community remains. We hope that this review helps to build greater acceptance of the concept of adaptive trial design.
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Affiliation(s)
- John Mandrola
- Baptist Health Louisville, Louisville, Kentucky, USA.
| | - Andrew D Althouse
- Center for Clinical Trials and Data Coordination, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Andrew Foy
- Penn State Heart and Vascular Institute, Penn State College of Medicine, Hershey, Pennsylvania, USA; Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Deepak L Bhatt
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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33
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Zhao S, Dai Y, Ning X, Tang M, Zhao Y, Li Z, Zhang S. Vagus Nerve Stimulation in Early Stage of Acute Myocardial Infarction Prevent Ventricular Arrhythmias and Cardiac Remodeling. Front Cardiovasc Med 2021; 8:648910. [PMID: 33981734 PMCID: PMC8107219 DOI: 10.3389/fcvm.2021.648910] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/30/2021] [Indexed: 11/17/2022] Open
Abstract
Aims: To evaluate whether low level left vagus nerve stimulation (LLVNS) in early stage of myocardial infarction (MI) could effectively prevent ventricular arrhythmias (VAs) and protect cardiac function, and explore the underlying mechanisms. Methods and Results: After undergoing implantable cardioverter defibrillators (ICD) and left cervical vagal stimulators implantation and MI creation, 16 dogs were randomly divided into three groups: the MI (n = 6), MI+LLVNS (n = 5), and sham operation (n = 5) groups. LLVNS was performed for 3 weeks. VAs, the left ventricular function, the density of the nerve fibers in the infarction area and gene expression profiles were analyzed. Compared with the MI group, dogs in the MI+LLVNS group had a lower VAs incidence (p < 0.05) and better left ventricular function. LLVNS significantly inhibited excessive sympathetic nerve sprouting with the evidences of decreased density of TH, GAP43 and NF positive nerves (p < 0.05). The gene expression profiling found a total of 206 genes differentially expressed between MI+LLVNS and MI dogs, mainly involved in cardiac tissue remodeling, cardiac neural remodeling, immune response and apoptosis. These genes, including 55 up-regulated genes and 151 down-regulated genes, showed more protective expressions under LLVNS. Conclusions: This study suggests that LLVNS was delivered without altering heart rate, contributing to reduced incidences of VAs and improved left ventricular function. The potential mechanisms included suppressing cardiac neuronal sprouting, inhibiting excessive sympathetic nerve sprouting and subduing pro-inflammatory responses by regulating gene expressions from a canine experimental study.
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Affiliation(s)
- Shuang Zhao
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Dai
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaohui Ning
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Min Tang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yunzi Zhao
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zeyi Li
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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34
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Libbus I, Stubbs SR, Mazar ST, Mindrebo S, KenKnight BH, DiCarlo LA. Effect of defibrillation on the performance of an implantable vagus nerve stimulation system. Bioelectron Med 2021; 7:3. [PMID: 33722304 PMCID: PMC7962382 DOI: 10.1186/s42234-021-00064-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 02/09/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Vagus Nerve Stimulation (VNS) delivers Autonomic Regulation Therapy (ART) for heart failure (HF), and has been associated with improvement in cardiac function and heart failure symptoms. VNS is delivered using an implantable pulse generator (IPG) and lead with electrodes placed around the cervical vagus nerve. Because HF patients may receive concomitant cardiac defibrillation therapy, testing was conducted to determine the effect of defibrillation (DF) on the VNS system. METHODS DF testing was conducted on three ART IPGs (LivaNova USA, Inc.) according to international standard ISO14708-1, which evaluated whether DF had any permanent effects on the system. Each IPG was connected to a defibrillation pulse generator and subjected to a series of high-energy pulses. RESULTS The specified series of pulses were successfully delivered to each of the three devices. All three IPGs passed factory electrical tests, and interrogation confirmed that software and data were unchanged from the pre-programmed values. No shifts in parameters or failures were observed. CONCLUSIONS Implantable VNS systems were tested for immunity to defibrillation, and were found to be unaffected by a series of high-energy defibrillation pulses. These results suggest that this VNS system can be used safely and continue to function after patients have been defibrillated.
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Affiliation(s)
- Imad Libbus
- LivaNova USA, Inc, 100 Cyberonics Blvd., TX, 77058, Houston, USA.
| | - Scott R Stubbs
- LivaNova USA, Inc, 100 Cyberonics Blvd., TX, 77058, Houston, USA
| | - Scott T Mazar
- LivaNova USA, Inc, 100 Cyberonics Blvd., TX, 77058, Houston, USA
| | - Scott Mindrebo
- LivaNova USA, Inc, 100 Cyberonics Blvd., TX, 77058, Houston, USA
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Konstam MA. The Battle for Enrollment: Preventing Collateral Damage on Clinical Trial Outcomes. JACC-HEART FAILURE 2021; 9:212-214. [PMID: 33549558 DOI: 10.1016/j.jchf.2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Marvin A Konstam
- CardioVascular Center at Tufts Medical Center, Boston, Massachusetts, USA.
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Hadaya J, Ardell JL. Autonomic Modulation for Cardiovascular Disease. Front Physiol 2020; 11:617459. [PMID: 33414727 PMCID: PMC7783451 DOI: 10.3389/fphys.2020.617459] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 11/25/2020] [Indexed: 12/11/2022] Open
Abstract
Dysfunction of the autonomic nervous system has been implicated in the pathogenesis of cardiovascular disease, including congestive heart failure and cardiac arrhythmias. Despite advances in the medical and surgical management of these entities, progression of disease persists as does the risk for sudden cardiac death. With improved knowledge of the dynamic relationships between the nervous system and heart, neuromodulatory techniques such as cardiac sympathetic denervation and vagal nerve stimulation (VNS) have emerged as possible therapeutic approaches for the management of these disorders. In this review, we present the structure and function of the cardiac nervous system and the remodeling that occurs in disease states, emphasizing the concept of increased sympathoexcitation and reduced parasympathetic tone. We review preclinical evidence for vagal nerve stimulation, and early results of clinical trials in the setting of congestive heart failure. Vagal nerve stimulation, and other neuromodulatory techniques, may improve the management of cardiovascular disorders, and warrant further study.
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Affiliation(s)
- Joseph Hadaya
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, CA, United States.,UCLA Neurocardiology Research Program of Excellence, UCLA, Los Angeles, CA, United States.,Molecular, Cellular, and Integrative Physiology Program, UCLA, Los Angeles, CA, United States
| | - Jeffrey L Ardell
- University of California, Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, Los Angeles, CA, United States.,UCLA Neurocardiology Research Program of Excellence, UCLA, Los Angeles, CA, United States
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Nearing BD, Anand IS, Libbus I, Dicarlo LA, Kenknight BH, Verrier RL. Vagus Nerve Stimulation Provides Multiyear Improvements in Autonomic Function and Cardiac Electrical Stability in the ANTHEM-HF Study. J Card Fail 2020; 27:208-216. [PMID: 33049374 DOI: 10.1016/j.cardfail.2020.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with heart failure with reduced left ventricular ejection fraction (LVEF) (HFrEF) experience long-term deterioration of autonomic function and cardiac electrical stability linked to increased mortality risk. The Autonomic Neural Regulation Therapy to Enhance Myocardial Function in Heart Failure (ANTHEM-HF) trial reported improved heart rate variability (HRV) and heart rate turbulence (HRT) and reduced T-wave alternans (TWA) after 12 months of vagus nerve stimulation (VNS). We investigated whether the benefits of chronic VNS persist in the long term. METHODS AND RESULTS Effects of chronic VNS on heart rate, HRV, HRT, TWA, R-wave and T-wave heterogeneity (RWH, TWH), and nonsustained ventricular tachycardia (NSVT) incidence were evaluated in all ANTHEM-HF patients with ambulatory ECG data at 24 and 36 months (n = 25). Autonomic markers improved significantly at 24 and 36 months compared to baseline [heart rate, square root of the mean squared differences of successive normal-to-normal intervals (rMSSD), standard deviation of the normal-to-normal intervals (SDNN), HF-HRV, HRT slope, P < 0.05]. Peak TWA levels remained reduced at 24 and 36 months (P < 0.0001). Reductions in RWH and TWH at 6 and 12 months persisted at 24 and 36 months (P < 0.01). NSVT decreased at 12, 24, and 36 months (P < 0.025). No sudden cardiac deaths, ventricular fibrillation, or sustained ventricular tachycardia occurred. CONCLUSION In symptomatic patients with HFrEF, chronic VNS appears to confer wide-ranging, persistent improvements in autonomic tone (HRV), baroreceptor sensitivity (HRT), and cardiac electrical stability (TWA, RWH, TWH).
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Affiliation(s)
- Bruce D Nearing
- Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | - Richard L Verrier
- Beth Israel Deaconess Medical Center, Division of Cardiovascular Medicine, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
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Sharma K, Premchand RK, Mittal S, Monteiro R, Libbus I, DiCarlo LA, Ardell JL, Amurthur B, KenKnight BH, Anand IS. Long-term Follow-Up of Patients with Heart Failure and Reduced Ejection Fraction Receiving Autonomic Regulation Therapy in the ANTHEM-HF Pilot Study. Int J Cardiol 2020; 323:175-178. [PMID: 33038408 DOI: 10.1016/j.ijcard.2020.09.072] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/14/2020] [Accepted: 09/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The ANTHEM-HF pilot study was an open-label study that evaluated the safety and feasibility of autonomic regulation therapy (ART) utilizing cervical vagus nerve stimulation (VNS) for patients with chronic HF with reduced EF (HFrEF). Patients in NYHA class II-III with EF ≤40% (n = 60) received ART for 6 months post-titration. ART was associated with sustained improvement in left ventricular (LV) function and HF symptoms at 6 and 12 months. METHODS Continuously cyclic VNS was maintained to determine longer-term safety and chronic effects of ART. Echocardiographic parameters and HF symptoms were assessed throughout a follow-up period of at least 42 months. RESULTS Between 12 and 42 months after initial titration, there were no device-related SAEs or malfunctions. There were 10 SAEs adjudicated to be unrelated to VNS, including 5 deaths. There were 6 non-serious adverse events that were adjudicated to be device-related (2 oropharyngeal pain, 1 implant site pain, 2 voice alteration, and 1 hoarseness). At 42 months, there was significant improvement from baseline in LVEF, NYHA class, 6-min walk distance, and MLHFQ score. However, these improvements at 42 months were not significantly different from mean values at 6 and 12 months. CONCLUSIONS In a 42-month follow-up, ART was durable, safe, and was associated with beneficial effects on LVEF and 6-min walk distance. Long term, chronic, open-loop ART continued to be well-tolerated in patients with HFrEF. The open label, randomized, controlled, ANTHEM-HFrEF Pivotal Study is currently underway to further evaluate ART in patients with advanced HF.
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Affiliation(s)
- Kamal Sharma
- Sanjivani Super Specialty Hospitals, Ahmedabad, India
| | | | | | | | - Imad Libbus
- LivaNova PLC, Inc., Houston, TX, United States of America
| | | | - Jeffrey L Ardell
- University of California at Los Angeles, Los Angeles, CA, United States of America
| | - Badri Amurthur
- LivaNova PLC, Inc., Houston, TX, United States of America
| | | | - Inder S Anand
- University of Minnesota, Minneapolis, MN, United States of America.
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Machhada A, Hosford PS, Dyson A, Ackland GL, Mastitskaya S, Gourine AV. Optogenetic Stimulation of Vagal Efferent Activity Preserves Left Ventricular Function in Experimental Heart Failure. JACC Basic Transl Sci 2020; 5:799-810. [PMID: 32875170 PMCID: PMC7452237 DOI: 10.1016/j.jacbts.2020.06.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 06/05/2020] [Accepted: 06/06/2020] [Indexed: 12/21/2022]
Abstract
This study was designed to determine the effect of selective optogenetic simulation of vagal efferent activity on left ventricular function in an animal (rat) model of MI-induced heart failure. Optogenetic stimulation of dorsal brainstem vagal pre-ganglionic neurons transduced to express light-sensitive channels preserved LV function and exercise capacity in animals with MI. The data suggest that activation of vagal efferents is critically important to deliver the therapeutic benefit of VNS in chronic heart failure.
Large clinical trials designed to test the efficacy of vagus nerve stimulation (VNS) in patients with heart failure did not demonstrate benefits with respect to the primary endpoints. The nonselective nature of VNS may account for the failure to translate promising results of preclinical and earlier clinical studies. This study showed that optogenetic stimulation of vagal pre-ganglionic neurons transduced to express light-sensitive channels preserved left ventricular function and exercise capacity in a rat model of myocardial infarction−induced heart failure. These data suggested that stimulation of vagal efferent activity is critically important to deliver the therapeutic benefit of VNS in heart failure.
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Key Words
- ABP, arterial blood pressure
- DVMN, dorsal motor nucleus of the vagus nerve
- GRK2, G-protein−coupled receptor kinase 2
- LAD, left anterior descending coronary artery
- LV dP/dtMAX, maximum rate of rise of left ventricular pressure
- LV, left ventricle
- LVEDP, left ventricular end-diastolic pressure
- LVESP, left ventricular end-systolic pressure
- LVP, left ventricular pressure
- LVV, lentiviral vector
- MI, myocardial infarction
- VNS, vagus nerve stimulation
- autonomic nervous system
- eGFP, enhanced green fluorescent protein
- heart failure
- myocardial infarction
- neuromodulation
- vagus nerve stimulation
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Affiliation(s)
- Asif Machhada
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Patrick S Hosford
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom.,Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Alex Dyson
- Clinical Physiology, Division of Medicine, University College London, London, United Kingdom
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Svetlana Mastitskaya
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
| | - Alexander V Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Department of Neuroscience, Physiology and Pharmacology, University College London, London, United Kingdom
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Anand I, Ardell JL, Gregory D, Libbus I, DiCarlo L, Premchand RK, Sharma K, Mittal S, Monteiro R. Baseline NT-proBNP and responsiveness to autonomic regulation therapy in patients with heart failure and reduced ejection fraction. IJC HEART & VASCULATURE 2020; 29:100520. [PMID: 32509959 PMCID: PMC7264752 DOI: 10.1016/j.ijcha.2020.100520] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 04/15/2020] [Indexed: 11/26/2022]
Abstract
Background Recent heart failure studies have associated lower baseline natriuretic peptide levels with improved morbidity/mortality outcomes during pharmaceutical treatment, and better clinical outcomes during neuromodulation (NM) with carotid nerve plexus stimulation for HFrEF when NT-proBNP < 1600 pg/ml. Whether baseline NT-proBNP is associated with HFrEF responsiveness to NM using vagus nerve stimulation (VNS) has not been examined. Hence, we evaluated the interaction of baseline NT-proBNP with changes in symptoms and function that occurred during chronic VNS in the ANTHEM-HF study. Methods A repeated measures, generalized-estimating, equations model evaluated the relationship of baseline NT-proBNP values above and below 1600 pg/ml to symptomatic and functional responses in ANTHEM-HF. Results Median (interquartile range; maximum) NT-proBNP was 868 (322, 1875; 14,656) pg/ml (N = 58). Heart rate (HR), HR variability (SDNN), 6-minute walk distance, MLWHF mean score, and NYHA improved significantly, independent of baseline NT-proBNP. While there was a statistical interaction between baseline NT-proBNP and better LVEF improvement during VNS, LVEF improved overall in the study cohort (N = 60; 32 ± 7 to 37 ± 10%; p = 0.0042), and in those patients whose baseline NT-proBNP was below the median baseline NT-proBNP value (n = 29; 36 ± 6 to 42 ± 10%; p < 0.0025)] or above this value (n = 29; 29 ± 7 to 32 ± 9%; p < 0.05). Conclusions In ANTHEM-HF, overall symptomatic and functional improvement during chronic VNS was independent of baseline NTproBNP. These are preliminary and hypothesis-generating findings, and the reason for a differing interaction between baseline NT-proBNP and response to CNPS and VNS remains unclear. It is anticipated that the ongoing ANTHEM-HFrEF Pivotal Study of VNS will provide additional insight.
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Affiliation(s)
- Inder Anand
- University of Minnesota (Emeritus), Minneapolis, MN, USA
| | | | - Doug Gregory
- Clinical Cardiovascular Science Foundation, Boston, MA, USA
| | | | | | | | - Kamal Sharma
- Sanjivani Super Specialty Hospitals, Ahmedabad, India
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Park JH, Gorky J, Ogunnaike B, Vadigepalli R, Schwaber JS. Investigating the Effects of Brainstem Neuronal Adaptation on Cardiovascular Homeostasis. Front Neurosci 2020; 14:470. [PMID: 32508573 PMCID: PMC7251082 DOI: 10.3389/fnins.2020.00470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 04/16/2020] [Indexed: 01/01/2023] Open
Abstract
Central coordination of cardiovascular function is accomplished, in part, by the baroreceptor reflex, a multi-input multi-output physiological control system that regulates the activity of the parasympathetic and sympathetic nervous systems via interactions among multiple brainstem nuclei. Recent single-cell analyses within the brain revealed that individual neurons within and across brain nuclei exhibit distinct transcriptional states contributing to neuronal function. Such transcriptional heterogeneity complicates the task of understanding how neurons within and across brain nuclei organize and function to process multiple inputs and coordinate cardiovascular functions within the larger context of the baroreceptor reflex. However, prior analysis of brainstem neurons revealed that single-neuron transcriptional heterogeneity reflects an adaptive response to synaptic inputs and that neurons organize into distinct subtypes with respect to synaptic inputs received. Based on these results, we hypothesize that adaptation of neuronal subtypes support robust biological function through graded cellular responses. We test this hypothesis by examining the functional impact of neuronal adaptation on parasympathetic activity within the context of short-term baroreceptor reflex regulation. In this work, we extend existing quantitative closed-loop models of the baroreceptor reflex by incorporating into the model distinct input-driven neuronal subtypes and neuroanatomical groups that modulate parasympathetic activity. We then use this extended model to investigate, via simulation, the functional role of neuronal adaptation under conditions of health and systolic heart failure. Simulation results suggest that parasympathetic activity can be modulated appropriately by the coordination of distinct neuronal subtypes to maintain normal cardiovascular functions under systolic heart failure conditions. Moreover, differing degrees of adaptation of these neuronal subtypes contribute to cardiovascular behaviors corresponding to distinct clinical phenotypes of heart failure, such as exercise intolerance. Further, our results suggest that an imbalance between sympathetic and parasympathetic activity regulating ventricular contractility contributes to exercise intolerance in systolic heart failure patients, and restoring this balance can improve the short-term cardiovascular performance of these patients.
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Affiliation(s)
- James H Park
- Department of Pathology, Anatomy and Cell Biology, Jefferson Medical College, Daniel Baugh Institute for Functional Genomics and Computational Biology, Thomas Jefferson University, Philadelphia, PA, United States.,Department of Chemical and Biochemical Engineering, University of Delaware, Newark, DE, United States.,Institute for Systems Biology, Seattle, WA, United States
| | - Jonathan Gorky
- Department of Pathology, Anatomy and Cell Biology, Jefferson Medical College, Daniel Baugh Institute for Functional Genomics and Computational Biology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Babatunde Ogunnaike
- Department of Chemical and Biochemical Engineering, University of Delaware, Newark, DE, United States
| | - Rajanikanth Vadigepalli
- Department of Pathology, Anatomy and Cell Biology, Jefferson Medical College, Daniel Baugh Institute for Functional Genomics and Computational Biology, Thomas Jefferson University, Philadelphia, PA, United States
| | - James S Schwaber
- Department of Pathology, Anatomy and Cell Biology, Jefferson Medical College, Daniel Baugh Institute for Functional Genomics and Computational Biology, Thomas Jefferson University, Philadelphia, PA, United States
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Anand IS, Konstam MA, Klein HU, Mann DL, Ardell JL, Gregory DD, Massaro JM, Libbus I, DiCarlo LA, Udelson JJE, Butler J, Parker JD, Teerlink JR. Comparison of symptomatic and functional responses to vagus nerve stimulation in ANTHEM-HF, INOVATE-HF, and NECTAR-HF. ESC Heart Fail 2020; 7:75-83. [PMID: 31984682 PMCID: PMC7083506 DOI: 10.1002/ehf2.12592] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 11/11/2019] [Accepted: 11/25/2019] [Indexed: 12/19/2022] Open
Abstract
AIMS Clinical studies of vagal nerve stimulation (VNS) for heart failure with reduced ejection fraction have had mixed results to date. We sought to compare VNS delivery and associated changes in symptoms and function in autonomic regulation therapy via left or right cervical vagus nerve stimulation in patients with chronic heart failure (ANTHEM-HF), increase of vagal tone in heart failure (INOVATE-HF), and neural cardiac therapy for heart failure (NECTAR-HF) for hypothesis generation. METHODS AND RESULTS Descriptive statistics were used to analyse data from the public domain for differences in proportions using Pearson's chi-square test, differences in mean values using Student's unpaired t-test, and differences in changes of mean values using two-sample t-tests. Guideline-directed medical therapy recommendations were similar across studies. Fewer patients were in New York Heart Association 3, and baseline heart rate (HR) was higher in ANTHEM-HF. In INOVATE-HF, VNS was aimed at peripheral neural targets, using closed-loop delivery that required synchronization of VNS to R-wave sensing by an intracardiac lead. Pulse frequency was low (1-2 Hz) because of a timing schedule allowing ≤3 pulses of VNS following at most 25% of detected R waves. NECTAR-HF and ANTHEM-HF used open-loop VNS delivery (i.e. independent of any external signal) aimed at both central and peripheral targets. In NECTAR-HF, VNS delivery at 20 Hz caused off-target effects that limited VNS up-titration in a majority of patients. In ANTHEM-HF, VNS delivery at 10 Hz allowed up-titration until changes in HR dynamics were confirmed. Six months after VNS titration, significant improvements in both HR and HR variability occurred only in ANTHEM-HF. When ANTHEM-HF and NECTAR-HF were compared, greater improvements from baseline were observed in ANTHEM-HF in standard deviation in normal-to-normal R-R intervals (94 ± 26 to 111 ± 50 vs. 146 ± 48 to 130 ± 52 ms; P < 0.001), left ventricular ejection fraction (32 ± 7 to 37 ± 0.4 vs. 31 ± 6 to 33 ± 6; P < 0.05), and Minnesota Living with Heart Failure mean score (40 ± 14 to 21 ± 10 vs. 44 ± 22 to 36 ± 21; P < 0.002). When compared with INOVATE-HF, greater improvement in 6-min walk distance was observed in ANTHEM-HF (287 ± 66 to 346 ± 78 vs. 304 ± 111 to 334 ± 111 m; P < 0.04). CONCLUSIONS In this post-hoc analysis, differences in patient demographics were seen and may have caused the differential responses in symptoms and function observed in association with VNS. Major differences in technology platforms, neural targets, VNS delivery, and HR and HR variability responses could have also potentially played a very important role. Further study is underway in a randomized controlled trial with these considerations in mind.
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Affiliation(s)
- Inder S. Anand
- Division of CardiologyUniversity of MinnesotaMinneapolisMNUSA
| | | | - Helmut U. Klein
- Division of CardiologyUniversity of Rochester Medical CenterRochesterNYUSA
| | - Douglas L. Mann
- Center for Cardiovascular ResearchWashington University School of MedicineSaint LouisMOUSA
| | - Jeffrey L. Ardell
- UCLA Neurocardiology Program of ExcellenceUniversity of CaliforniaLos AngelesCAUSA
| | | | - Joseph M. Massaro
- Department of Biostatistics, School of Public HealthBoston UniversityBostonMAUSA
| | | | | | | | - Javed Butler
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - John D. Parker
- University of TorontoUniversity Health NetworkTorontoOntarioCanada
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of MedicineUniversity of CaliforniaSan FranciscoCAUSA
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