Non-Mask-based Therapies for Central Sleep Apnea in Patients with Heart Failure

Phrenic Nerve Stimulation for the Treatment of Central Sleep Apnea: A Pooled Cohort Analysis

STUDY OBJECTIVES

Early evidence with transvenous phrenic nerve stimulation (PNS) demonstrates improved disease severity and quality of life (QOL) in patients with central sleep apnea (CSA). The goal of this analysis is to evaluate the complete prospective experience with PNS in order to better characterize its efficacy and safety, including in patients with concomitant heart failure (HF).

METHODS

Using pooled individual data from the pilot (n = 57) and pivotal (n = 151) studies of the remedē System in patients with predominant moderate to severe CSA, we evaluated 12-month safety and 6- and 12-month effectiveness based on polysomnography data, QOL, and cardiac function.

RESULTS

Among 208 combined patients (June 2010 to May 2015), a remedē device implant was successful in 197 patients (95%), 50/57 pilot study patients (88%) and 147/151 pivotal trial patients (97%). The pooled cohort included patients with CSA of various etiologies, and 141 (68%) had concomitant HF. PNS reduced apnea-hypopnea index (AHI) at 6 months by a median of -22.6 episodes/h (25th and 75th percentile; -38.6 and -8.4, respectively) (median 58% reduction from baseline, P < .001). Improvement in sleep variables was maintained through 12 months of follow-up. In patients with HF and ejection fraction ≤ 45%, PNS was associated with improvement in systolic function from 27.0% (23.3, 36.0) to 31.1% (24.0, 41.5) at 12 months (P = .003). In the entire cohort, improvement in QOL was concordant with amelioration of sleep measures.

CONCLUSIONS

Transvenous PNS significantly improves CSA severity, sleep quality, ventricular function, and QOL regardless of HF status. Improvements, which are independent of patient compliance, are sustained at 1 year and are associated with acceptable safety.

Sleep Apnea in Heart Failure

PURPOSE OF REVIEW

In this review, we discuss the current treatment options for sleep-disordered breathing (SDB) in patients with heart failure (HF). We address the role of positive airway pressure (PAP) devices and other emerging therapies. The review includes discussion of recent trials that reported negative consequences for the PAP devices in patients with heart failure.

RECENT FINDINGS

Optimal guideline-directed medical therapies of HF and PAP devices have been the mainstay treatments for HF patients with SDB. Recently, randomized controlled trials (RCTs) evaluated the effect of PAP on clinical outcomes in patients with cardiovascular (CV) disease and heart failure and found no benefit in decreasing fatal and non-fatal CV events. The Sleep Apnea Cardiovascular Endpoints (SAVE) trial evaluated continuous positive airway pressure (CPAP) ventilation in patients with CV disease and obstructive sleep apnea (OSA) and did not observe any improvement in CV effect. In patients with HF and central sleep apnea (CSA), adaptive servo-ventilation (ASV) was hypothesized to help HF outcomes, but the Adaptive Servo-Ventilation for Central Sleep Apnea in Systolic Heart Failure (SERVE-HF) trial did not show any mortality benefit. Instead, the trial suggested an increase in all-cause and CV mortality in the treatment arm. currently, studies have not shown the use of PAP therapy to improve any risks of CV outcomes or death in HF patients with sleep apnea, but some associations with improvements in symptoms from OSA have been observed.