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The twenty-first century has revolutionized the management of congestive heart failure with the widespread use of left ventricular assist devices and other treatment modalities that improve morbidity and mortality after the failure of medical management. These novel devices come with significant side effects. One of the most common side effects of left ventricular assist devices is the increased frequency of lower gastrointestinal bleeding compared to heart failure patients without left ventricular assist devices. Multiple etiologies of recurrent gastrointestinal bleeding in such patients have been studied. The decreased amount of von Willebrand factor polymers is now recognized as one of the most common causes of increased incidence of gastrointestinal bleeding in patients with left ventricular assist devices alongside increased arteriovenous malformations. Multiple treatment modalities have been identified to prevent and treat gastrointestinal bleeding in these patients. Since the use of left ventricular assist devices is becoming more prevalent in patients with advanced heart failure, we decided to conduct this systematic review. The article summarizes the incidence, pathophysiology, and management of lower gastrointestinal bleeding in patients with left ventricular assist devices.

Heart failure is a progressive disease. A considerable number of patients eventually reach an advanced or terminal phase, in spite of developments in diagnostic procedure, alternative treatments that can slow progression, management, and follow-up. In addition to palliative care of patients in the terminal phase, accurate recognition of advanced disease is vital in the determination of therapeutic options. Overall management of patients with heart failure requires the collaboration of professionals from multiple disciplines. Still, patients with advanced heart failure should be managed by a 'heart team,' as indicated by guidelines; communication and collaboration among cardiologists, cardiovascular surgeons, and other medical staff responsible for patient care is necessary. While our country has physicians experienced in the management of patients with advanced heart failure, these professionals are not distributed evenly across the country, and equitable access to therapeutic options is not provided. Hence, progress has yet to be made regarding appropriate referrals and patient circulation. The aims of the present consensus report are to strengthen the connection between certified, experienced centers and those that care for patients irrespective of disease phase and healthcare staff, as well as to raise awareness and provide information regarding conditions in Turkey.

In advanced heart failure (AHF) clinical evaluation fails to detect subclinical HF deterioration in outpatient settings. The aim of the study was to determine whether the strategy of intensive outpatient echocardiographic monitoring, followed by treatment modification, reduces mortality and re-hospitalizations at 12 months. Methods: 214 patients with ejection fraction < 30% and >1 hospitalization during the last year underwent clinical evaluation and echocardiography at discharge and were divided into intensive (IMG; N = 143) or standard monitoring group (SMG; N = 71). In IMG, volemic status and left ventricular filling pressure were assessed 14, 30, 90, 180 and 365 days after discharge. HF treatment, particularly diuretic therapy, was temporarily intensified when HF deterioration signs and E/e’ > 15 were detected. In SMG, standard outpatient monitoring without obligatory echocardiography at outpatient visits was performed. Results: We observed lower hospitalization (absolute risk reduction [ARR]-0.343, CI-95%: 0.287–0.434, p < 0.05; number needed to treat [NNT]-2.91) and mortality (ARR-0.159, CI 95%: 0.127–0.224, p < 0.05; NNT-6.29) in IMG at 12 months. One-year survival was 88.8% in IMG and 71.8% in SMG (p < 0.05). Conclusion: In AHF, outpatient monitoring of volemic status and intracardiac filling pressures to individualize treatment may potentially reduce hospitalizations and mortality at 12 months follow-up. Echocardiography-guided outpatient therapy is feasible and clinically beneficial, providing evidence for the larger application of this approach.

Aims We sought to evaluate the effectiveness of cardiac resynchronization therapy (CRT) in far‐advanced heart failure (FA‐HF) patients with New York Heart Association (NYHA) class‐IV status and dependency on intravenous drugs (IVDs) and/or invasive supportive treatments (ISTs). Methods and results Among 305 patients who underwent CRT implantation between October 2005 to December 2019, we identified 17 FA‐HF patients with NYHA class‐IV status and dependency on IVDs (inotropes, diuretics, vasopressors, or vasodilators) and/or ISTs (extracorporeal membranous oxygenator or continuous renal replacement therapy). All patients (median age = 68.7 years, non‐ischaemic cardiomyopathy = 15) remained dependent on several IVDs (2.2 ± 1.3 per patient) and/or ISTs for 11.3 ± 7.8 days due to multiple tapering failure (4.3 ± 3.2 per patient) before CRT implantation. However, 14 (82%) patients were successfully weaned from IVDs/ISTs within 5.2 ± 5.3 days following CRT, and 12 (71%) stayed alive for more than 1 year free of ventricular assist device or heart transplantation with symptom improvement (≥1 NYHA class) and a reduced annual HF hospitalization rate (P = 0.002). Considerable improvements in ventricular systolic function (P = 0.004) and volumetric reverse remodelling (P = 0.007) were noticed during the long‐term follow‐up period (35 ± 15 months post‐CRT). The ventricular assist device/heart transplantation/death‐free survival rate post‐CRT was 71% and 65% at 1 and 3 years, respectively. Conclusions Cardiac resynchronization therapy implantation may be a feasible treatment that can offer short‐term and long‐term clinical benefits for NYHA class‐IV FA‐HF patients who are dependent on IVDs/ISTs. When considering treatment options, CRT should not be prematurely excluded solely based on a patient's dependency on IVDs/ISTs without first attempting to identify favourable CRT response factors.

Temporary mechanical cardiac support (TMCS) devices intend to restore systemic perfusion and prevent further end-organ damage in patients with refractory cardiogenic shock until the insult is addressed. TMCS has been associated with reductions in hospital costs and in-hospital mortality. We review the four primary TMCS modalities available: intra-aortic balloon pump, TandemHeart, veno-arterial extracorporeal membrane oxygenation, and Impella pump. All have their own implantation technique and hemodynamic profile, and their use may therefore be tailored to the specific patient's needs. The appropriate TMCS may thus help stabilize the patient, enabling the care team to make decisions about durable support or transplantation.

Background Quality of life (QOL) and functional status are two key outcomes for patients with advanced heart failure (HF). We examined the association of eleven symptoms with QOL and functional status impairment in patients with advanced HF. Methods and results This was a retrospective analysis of baseline data from a multi-center, cluster-randomized controlled trial (NCT01459744) which enrolled patients with an implanted cardioverter-defibrillator and advanced HF at high-risk for mortality. Study instruments included the Condensed Memorial Symptom Assessment Scale, the Kansas City Cardiomyopathy Questionnaire QOL subscale, and the number of activities of daily living (ADL) patients had difficulties with. The study included 413 subjects. In generalized linear models which were adjusted for baseline characteristics, the total number of symptoms was significantly associated with worse QOL, as was the presence of each individual symptom, except constipation. Lack of energy demonstrated the strongest negative association with QOL. Similarly, the total number of symptoms was associated with a higher number of ADL difficulties (i.e., worse functional status). The presence of pain, lack of energy and drowsiness was individually associated with more ADL difficulties. Conclusion Among patients with advanced HF, a higher number of symptoms and specific individual symptoms were associated with worse QOL and functional status. Lay summary People living with advanced heart failure typically experience shortness of breath and leg swelling. We found that many of them also experience additional unpleasant symptoms e.g., lack of energy, difficulty sleeping and dry mouth. The more symptoms patients with heart failure experience, the worse is their quality of life and the more help they need with their daily activities (e.g. bathing, dressing, toileting). Some symptoms seem to be more harmful than others. The symptoms which had a negative effect on both quality of life and daily activities were lack of energy, pain and drowsiness.

•AHFTC positions rose 10%, but applicants dropped 24% (2020–2025).•The number of unfilled AHFTC spots increased from 30% to 52% over 5 years.•First-choice match rate improved from 67% to 83% (2020–2025).•Growing gap between training spots and applicant interest in AHFTC.•Efforts are urgently needed to stimulate interest in AHFTC training. Advanced Heart Failure and Transplant Cardiology (AHFTC) is a vital subspecialty addressing the growing burden of heart failure and the increasing need for advanced therapies such as mechanical circulatory support and heart transplantation. Despite rising clinical demand, interest in AHFTC fellowship training appears to be declining. This study evaluated trends in applicants, training positions, match rates, and unfilled positions in the AHFTC match from 2020 to 2025. We performed a national, cross-sectional analysis of all AHFTC fellowship applicants during this period. Primary outcomes included the annual number of applicants and training positions, match rates, and the percentage of unfilled positions. Temporal trends were analyzed using linear regression. Between 2020 and 2025, 470 applicants competed for 737 training positions, resulting in an overall fill rate of 58%. Matched fellows included 52% US allopathic and 48% non-US allopathic graduates. The number of training positions per year increased by 10% (115 to 127) while the number of applicants per year decreased by 24% (84 to 64). The applicant-to-position ratio decreased significantly from 0.7 to 0.5 (p < 0.001), and unfilled positions rose from 30% to 52% (p < 0.001). The proportion of applicants matching at their first-choice program increased from 67% to 83% (p < 0.001). These findings highlight a growing mismatch between AHFTC training capacity and applicant interest. To preserve the future workforce needed to address the rising burden of heart failure, efforts are needed to stimulate interest in AHFTC training.

Our aim was to assess the distribution of primary (with no trigger) and secondary (with a decompensation trigger) heart failure events in a severe heart failure population and their association with 2-year all-cause mortality in the Mitra.Fr study. We included 304 patients with symptomatic heart failure, and severe mitral regurgitation and guideline directed medical therapy randomized to medical therapy alone or medical therapy with percutaneous mitral valve repair. According to the follow-up, we defined 3 categories of events: follow-up without any heart failure event, at least 1 decompensation starting with a primary heart failure decompensation or starting with a precipitated secondary heart failure event. The primary outcome was 2-years all-cause mortality. A total of 179 patients (59 %) had at least 1 heart failure decompensation within 24-months of follow-up. 129 heart failure decompensations (72%) were a first primary heart failure and 50 (28%) were a first secondary decompensation. Finally, 30 patients had both types of decompensations but these were not taken into account for the comparison of primary and secondary decompensations. Primary decompensations were 3-times more frequent than secondary decompensations, but the mean number of heart failure decompensations was similar in the “Primary heart failure group” compared to the “Secondary heart failure group”: (1.94 ± 1.39 vs 1.80 ± 1.07 respectively; P = .480). Compared to patients without heart failure decompensation, patients with “Only primary decompensation” or with “Only secondary decompensation” had a significantly increased risk of death (HR = 4.87, 95% CI [2.86, 8.32] and 2.68 95%CI [1.64, 4.37] respectively). All-cause mortality, was not significantly different between these 2 type of decompensations (HR = 1.82, 95% CI [0.93, 3.58]; P = .082), but each additional heart failure recurrence was associated with a significant increase in mortality risk (HR = 1.27, 95% CI [1.08; 1.50]; P = .005). In heart failure with reduced ejection fraction and severe secondary mitral regurgitation patients, primary heart failure decompensations were 3-times more frequent compared to precipitated decompensations with a nonsignificant trend in increased risk of all-cause mortality. Our results fail to support the differentiation between primary and secondary decompensations as they seem to portend the same outcome impact. [Display omitted]

Heart failure (HF) is a major cause of mortality, hospitalizations, and reduced quality of life and a major burden for the healthcare system. The number of patients that progress to an advanced stage of HF is growing. Only a limited proportion of these patients can undergo heart transplantation or mechanical circulatory support. The purpose of this review is to summarize medical management of patients with advanced HF. First, evidence‐based oral treatment must be implemented although it is often not tolerated. New therapeutic options may soon become possible for these patients. The second goal is to lessen the symptomatic burden through both decongestion and haemodynamic improvement. Some new treatments acting on cardiac function may fulfil both these needs. Inotropic agents acting through an increase in intracellular calcium have often increased risk of death. However, in the recent Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial, omecamtiv mecarbil was safe and effective in the reduction of the primary outcome of cardiovascular death or HF event compared with placebo (hazard ratio, 0.92; 95% confidence interval, 0.86–0.99; P = 0.03) and its effects were larger in those patients with more severe left ventricular dysfunction. Patients with severe HF who received omecamtiv mecarbil experienced a significant treatment benefit, whereas patients without severe HF did not (P = 0.005 for interaction). Lastly, clinicians should take care of the end of life with an appropriate multidisciplinary approach. Medical treatment of advanced HF therefore remains a major challenge and a wide open area for further research.

Levosimendan, a calcium sensitizer and potassium channel-opener, is widely appreciated by many specialist heart failure practitioners for its effects on systemic and pulmonary hemodynamics and for the relief of symptoms of acute heart failure. The drug’s impact on mortality in large randomized controlled trials has been inconsistent or inconclusive but, in contrast to conventional inotropes, there have been no indications of worsened survival and some signals of improved heart failure-related quality of life. For this reason, levosimendan has been proposed as a safer inodilator option than traditional agents in settings, such as advanced heart failure. Positive effects of levosimendan on renal function have also been described. At the HEART FAILURE 2018 congress of the Heart Failure Association of the European Society of Cardiology, safe and effective use levosimendan in acute and advanced heart failure was examined in a series of expert tutorials. The proceedings of those tutorials are summarized in this review, with special reference to advanced heart failure and heart failure with concomitant renal dysfunction. Meta-analysis of clinical trials data is supportive of a renal-protective effect of levosimendan, while physiological observations suggest that this effect is exerted at least in part via organ-specific effects that may include selective vasodilation of glomerular afferent arterioles and increased renal blood flow, with no compromise of renal oxygenation. These lines of evidence require further investigation and their clinical significance needs to be evaluated in specifically designed prospective trials.