Exercise-Induced Left Atrial Hypertension in Heart Failure With Preserved Ejection Fraction.

Many patients with heart failure and preserved ejection fraction have no overt volume overload and normal resting left atrial (LA) pressure. This study sought to characterize patients with normal resting LA pressure (pulmonary capillary wedge pressure [PCWP] <15 mm Hg) but exercise-induced left atrial hypertension (EILAH). The REDUCE LAP-HF II (A Study to Evaluate the Corvia Medical, Inc. IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure) trial randomized 626 patients with ejection fraction ≥40% and exercise PCWP ≥25 mm Hg to atrial shunt or sham procedure. The primary trial outcome, a hierarchical composite of death, heart failure hospitalization, intensification of diuretics, and change in health status was compared between patients with EILAH and those with heart failure and resting left atrial hypertension (RELAH). Patients with EILAH (29%) had similar symptom severity, but lower natriuretic peptide levels, higher 6-minute walk distance, less atrial fibrillation, lower left ventricular mass, smaller LA volumes, lower E/e', and better LA strain. PCWP was lower at rest, but had a larger increase with exercise in EILAH. Neither group as a whole had a significant effect from shunt therapy vs sham. Patients with EILAH were more likely to have characteristics associated with atrial shunt responsiveness (peak exercise pulmonary vascular resistance <1.74 WU) and no pacemaker (63% vs 46%; P < 0.001). The win ratio for the primary outcome was 1.56 (P = 0.08) in patients with EILAH and 1.51 (P = 0.04) in those with RELAH when responder characteristics were present. Patients with EILAH had similar symptom severity but less advanced myocardial and pulmonary vascular disease. This important subgroup may be difficult to diagnose without invasive exercise hemodynamics, but it has characteristics associated with favorable response to atrial shunt therapy. (A Study to Evaluate the Corvia Medical, Inc. IASD System II to Reduce Elevated Left Atrial Pressure in Patients With Heart Failure [REDUCE LAP-HF TRIAL II]; NCT03088033).

Litwin SE ，Komtebedde J ，Hu M ，Burkhoff D ，Hasenfuß G ，Borlaug BA ，Solomon SD ，Zile MR ，Mohan RC ，Khawash R ，Sverdlov AL ，Fail P ，Chung ES ，Kaye DM ，Blair J ，Eicher JC ，Hummel SL ，Zirlik A ，Westenfeld R ，Hayward C ，Gorter TM ，Demers C ，Shetty R ，Lewis G ，Starling RC ，Patel S ，Gupta DK ，Morsli H ，Penicka M ，Cikes M ，Gustafsson F ，Silvestry FE ，Rowin EJ ，Cutlip DE ，Leon MB ，Kitzman DW ，Kleber FX ，Shah SJ ，REDUCE LAP-HF Investigators and Research Staff ... -  《-》

Transcatheter Interatrial Shunt Device for the Treatment of Heart Failure With Preserved Ejection Fraction (REDUCE LAP-HF I [Reduce Elevated Left Atrial Pressure in Patients With Heart Failure]): A Phase 2, Randomized, Sham-Controlled Trial.

In nonrandomized, open-label studies, a transcatheter interatrial shunt device (IASD, Corvia Medical) was associated with lower pulmonary capillary wedge pressure (PCWP), fewer symptoms, and greater quality of life and exercise capacity in patients with heart failure (HF) and midrange or preserved ejection fraction (EF ≥40%). We conducted the first randomized sham-controlled trial to evaluate the IASD in HF with EF ≥40%. REDUCE LAP-HF I (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure) was a phase 2, randomized, parallel-group, blinded multicenter trial in patients with New York Heart Association class III or ambulatory class IV HF, EF ≥40%, exercise PCWP ≥25 mm Hg, and PCWP-right atrial pressure gradient ≥5 mm Hg. Participants were randomized (1:1) to the IASD versus a sham procedure (femoral venous access with intracardiac echocardiography but no IASD placement). The participants and investigators assessing the participants during follow-up were blinded to treatment assignment. The primary effectiveness end point was exercise PCWP at 1 month. The primary safety end point was major adverse cardiac, cerebrovascular, and renal events at 1 month. PCWP during exercise was compared between treatment groups using a mixed-effects repeated measures model analysis of covariance that included data from all available stages of exercise. A total of 94 patients were enrolled, of whom 44 met inclusion/exclusion criteria and were randomized to the IASD (n=22) and control (n=22) groups. Mean age was 70±9 years, and 50% were female. At 1 month, the IASD resulted in a greater reduction in PCWP compared with sham control (P=0.028 accounting for all stages of exercise). Peak PCWP decreased by 3.5±6.4 mm Hg in the treatment group versus 0.5±5.0 mm Hg in the control group (P=0.14). There were no peri-procedural or 1-month major adverse cardiac, cerebrovascular, and renal events in the IASD group and 1 event (worsening renal function) in the control group (P=1.0). In patients with HF and EF ≥40%, IASD treatment reduces PCWP during exercise. Whether this mechanistic effect will translate into sustained improvements in symptoms and outcomes requires further evaluation. URL: https://clinicaltrials.gov. Unique identifier: NCT02600234.

Feldman T ，Mauri L ，Kahwash R ，Litwin S ，Ricciardi MJ ，van der Harst P ，Penicka M ，Fail PS ，Kaye DM ，Petrie MC ，Basuray A ，Hummel SL ，Forde-McLean R ，Nielsen CD ，Lilly S ，Massaro JM ，Burkhoff D ，Shah SJ ，REDUCE LAP-HF I Investigators and Study Coordinators ... -  《-》

Latent Pulmonary Vascular Disease May Alter the Response to Therapeutic Atrial Shunt Device in Heart Failure.

Borlaug BA ，Blair J ，Bergmann MW ，Bugger H ，Burkhoff D ，Bruch L ，Celermajer DS ，Claggett B ，Cleland JGF ，Cutlip DE ，Dauber I ，Eicher JC ，Gao Q ，Gorter TM ，Gustafsson F ，Hayward C ，van der Heyden J ，Hasenfuß G ，Hummel SL ，Kaye DM ，Komtebedde J ，Massaro JM ，Mazurek JA ，McKenzie S ，Mehta SR ，Petrie MC ，Post MC ，Nair A ，Rieth A ，Silvestry FE ，Solomon SD ，Trochu JN ，Van Veldhuisen DJ ，Westenfeld R ，Leon MB ，Shah SJ ，REDUCE LAP-HF-II Investigators ... -  《-》

Atrial Shunt Device Effects on Cardiac Structure and Function in Heart Failure With Preserved Ejection Fraction: The REDUCE LAP-HF II Randomized Clinical Trial.

Patel RB ，Silvestry FE ，Komtebedde J ，Solomon SD ，Hasenfuß G ，Litwin SE ，Borlaug BA ，Price MJ ，Kawash R ，Hummel SL ，Cutlip DE ，Leon MB ，van Veldhuisen DJ ，Rieth AJ ，McKenzie S ，Bugger H ，Mazurek JA ，Kapadia SR ，Vanderheyden M ，Ky B ，Shah SJ ... -  《-》

2-Year Outcomes of an Atrial Shunt Device in HFpEF/HFmrEF: Results From REDUCE LAP-HF II.

The REDUCE LAP-HF II (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure II) trial found that, compared with a sham procedure, the Corvia Atrial Shunt did not improve outcomes in heart failure with preserved or mildly reduced ejection fraction. However, after 12-month follow-up, "responders" (peak-exercise pulmonary vascular resistance <1.74 WU and absence of a cardiac rhythm management device) were identified. This study sought to determine: 1) the overall efficacy and safety of the atrial shunt vs sham control after 2 years of follow-up; and 2) whether the benefits of atrial shunting are sustained in responders during longer-term follow-up or are offset by adverse effects of the shunt. The study analyzed 2-year outcomes in the overall REDUCE LAP-HF II trial, as well as in responder and nonresponder subgroups. The primary endpoint was a hierarchical composite of cardiovascular death or nonfatal ischemic/embolic stroke, total heart failure events, and change in health status. In 621 randomized patients, there was no difference between the shunt (n = 309) and sham (n = 312) groups in the primary endpoint (win ratio: 1.01 [95% CI: 0.82-1.24]) or its individual components at 2 years. Shunt patency at 24 months was 98% in shunt-treated patients. Cardiovascular mortality and nonfatal ischemic stroke were not different between the groups; however, major adverse cardiac events were more common in those patients assigned to the shunt compared with sham (6.9% vs 2.7%; P = 0.018). More patients randomized to the shunt had an increase in right ventricular volume of ≥30% compared with the sham control (39% vs 28%, respectively; P < 0.001), but right ventricular dysfunction was uncommon and not different between the treatment groups. In responders (n = 313), the shunt was superior to sham (win ratio: 1.36 [95% CI: 1.02-1.83]; P = 0.037, with 51% fewer HF events [incidence rate ratio: 0.49 [95% CI: 0.25-0.95]; P = 0.034]). In nonresponders (n = 265), atrial shunting was inferior to sham (win ratio: 0.73 [95% CI: 0.54-0.98]). At 2 years of follow-up in REDUCE LAP-HF II, there was no difference in efficacy between the atrial shunt and sham groups in the overall trial group. The potential clinical benefit identified in the responder group after 1 and 2 years of follow-up is currently being evaluated in the RESPONDER-HF (Re-Evaluation of the Corvia Atrial Shunt Device in a Precision Medicine Trial to Determine Efficacy in Mildly Reduced or Preserved Ejection Fraction Heart Failure) trial. (Reduce Elevated Left Atrial Pressure in Patients With Heart Failure II [REDUCE LAP-HF II]; NCT03088033).

Gustafsson F ，Petrie MC ，Komtebedde J ，Swarup V ，Winkler S ，Hasenfuß G ，Borlaug BA ，Mohan RC ，Flaherty JD ，Sverdlov AL ，Fail PS ，Chung ES ，Lurz P ，Lilly S ，Kaye DM ，Cleland JGF ，Cikes M ，Leon MB ，Cutlip DE ，van Veldhuisen DJ ，Solomon SD ，Shah SJ ... -  《-》