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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EUntil the recent Rythmol Atrial Fibrillation [RAFT] Trial, it was unclear whether cardiac resynchronization therapy was beneficial in patients with mild to moderate congestive heart failure (HF). The cumulative evidence to date indicates that the addition of CRT to optimal medical or defibrillator therapy significantly reduces mortality among patients with HF [Wells G et al. \u003Cem\u003ECMAJ\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EUntil the recent Rythmol Atrial Fibrillation (RAFT) Trial, it was unclear whether cardiac resynchronization therapy (CRT) was beneficial in patients with mild to moderate congestive heart failure (HF). The cumulative evidence to date indicates that the addition of CRT to optimal medical or defibrillator therapy significantly reduces mortality among patients with HF [Wells G et al. \u003Cem\u003ECMAJ\u003C\/em\u003E 2011]. John Cleland, MD, University of Hull, Kingston-upon-Hull, UK, discussed the role and guidelines for CRT therapy in HF patients.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003ECurrent guidelines state that patients who receive these devices should have a left ventricular ejection fraction (LVEF) \u226435%, a QRS duration \u22650.12 seconds, and sinus rhythm; be NYHA functional Class III; and already be receiving optimal medical therapy. According to Prof. Cleland, patients with HF who require an implantable defibrillator should have CRT routinely [Cleland JG et al. \u003Cem\u003EHeart\u003C\/em\u003E 2008]. CRT is useful because it can sense and pace the right atrium, shorten the atrioventricular interval, pace the right ventricle (RV) and the left ventricle (LV), alter the timing of RV and LV free-wall contraction and relaxation, raise systolic blood pressure, and improve hemodynamics.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EDespite major advances in cardiac treatment, HF remains a progressive and fatal disease. Mark S. Slaughter, MD, University of Louisville, Kentucky, USA, described the implantable ventricular assist devices that are available as a bridge to heart transplantation for patients with advanced HF.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003ESurvival rates \u0026gt;90% out to 1 year and improvements in functional status, quality of life, and 6-minute walk test have been achieved with continuous flow left ventricular assist devices (LVADs) in patients who are awaiting transplantation (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). These improvements are equal to, if not better than, those that are achieved with heart transplantation at 1 year for patients in the most critical categories. Adverse events have also been significantly reduced. With increased wait times for transplants, it is unlikely that patients would survive to transplant without the use of these devices. Based on the significant advances in the last several years, Dr. Slaughter believes continuous flow LVADs should be used earlier in patients with advanced HF for both bridge to transplantation or for permanent use (ie, destination therapy).\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/28\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Improving Survival in LVAD Trials.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1700487284\u0022 data-figure-caption=\u0022Improving Survival in LVAD Trials.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/28\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/28\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/28\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12265\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003EImproving Survival in LVAD Trials.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from M. Slaughter, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-7\u0022\u003EAndreas M. Zeiher, MD, University of Frankfurt, Frankfurt, Germany, believes that there is now evidence that the heart is a regenerating organ. The capacity to generate cardiomyocytes in healthy and injured hearts suggests that it may be rational to work toward the development of therapeutic strategies that are aimed at stimulating this process in cardiac pathologies [Bergmann O et al. \u003Cem\u003EScience\u003C\/em\u003E 2009]. Beyond conventional therapy, evidence suggests that adult bone marrow-derived cell transplantation is associated with modest improvements in physiological and anatomical parameters in patients with both acute myocardial infarction (AMI) and chronic ischemic heart disease [Abdel-Latif A et al. \u003Cem\u003EArch Intern Med\u003C\/em\u003E 2007]. The mechanism of action includes effects on vasculogenesis, paracrine effects, and cardiomyogenesis. Although the effects are modest, enhanced strategies, such as shockwave-facilitated cell therapy, may improve efficacy, at least for AMI. There is a lack of data to recommend this treatment for chronic postinfarction HF.\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003E\u201cThe management of volume overload in advanced heart failure is one of the most difficult areas for physicians,\u201d said Barry M. Massie, MD, University of California, San Francisco, California, USA. Although loop diuretics are at the core of pharmacological management of volume overload in chronic HF, current treatments have issues. Furosemide has a highly variable oral bioavailability (20% to 60%) and is short-acting. Bumetanide is relatively short-acting but is safe in patients with a sulfa allergy. Torsemide has a high oral bioavailability (60% to 80%) and a long duration of action.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003ERecent evidence with furosemide therapy in patients with acute decompensated heart failure (ADHF) demonstrated no significant difference in patients\u0027 global assessment of symptoms with a high-dose strategy of loop diuretic within the first 3 days of ADHF compared to a more conservative low-dose strategy. The Diuretic Optimization Strategies Evaluation (DOSE) trial [Felker GM et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011] compared various diuretic strategies for patients with ADHF. Patients were randomly assigned, in a 1:1:1:1 ratio, to either a low-dose strategy (total intravenous furosemide dose equal to their total daily oral loop diuretic dose in furosemide equivalents) or a high-dose strategy (total daily intravenous furosemide dose 2.5 times their total daily oral loop diuretic dose in furosemide equivalents) and to administration of furosemide either by intravenous bolus every 12 hours or by continuous intravenous infusion. In comparison of bolus with continuous infusion, there were no significant differences in the co-primary endpoints of patients\u0027 global assessment of symptoms (mean AUC, 4236\u00b11440 and 4373\u00b11404, respectively; p=0.47) or in the mean change in the creatinine level (0.05\u00b10.3 mg\/dL [4.4\u00b126.5 \u03bcmol\/L] and 0.07\u00b10.3 mg\/dL [6.2\u00b126.5 \u03bcmol\/L], respectively; p=0.45). In the comparison of the high-dose strategy with the low-dose strategy, there was a nonsignificant trend toward greater improvement in patients\u0027 global assessment of symptoms in the high-dose group (mean AUC, 4430\u00b11401 vs. 4171\u00b11436; p=0.06). There was no significant difference between these groups in the mean change in the creatinine level (0.08\u00b10.3 mg\/dL [7.1\u00b126.5 \u03bcmol\/L] with the high-dose strategy and 0.04\u00b10.3 mg\/dL [3.5\u00b126.5 \u03bcmol\/L] with the low-dose strategy, p=0.21). Although there was no clear benefit from a high-dose strategy on the prespecified primary endpoints, a high-dose strategy was associated with greater diuresis and more favorable outcomes in some secondary measures, but also with transient worsening of renal function.\u003C\/p\u003E\u003Cp id=\u0022p-10\u0022\u003EIntravenous loop diuretics are the mainstay therapy for patients with ADHF. However, because of complications, such as diuretic resistance and worsening renal function, other treatments, especially adjunctive use of aldosterone blockers (spironolactone, eplerenone), are often useful, both in the short- and long-term. The combination of loop and thiazide diuretics can be very effective, but the magnitude of diuresis is unpredictable and may be excessive. This combination should be initiated in inpatients and only maintained postdischarge after the effect in individual patients has been characterized. Dr. Massie recommended that it is best used every other day or less as needed because of the potential for excessive diuresis and electrolyte abnormalities. Addition of an adenosine antagonist (aminolphylline is one such drug) has been used in this setting and has the potential to overcome diuretic resistance, but recent trials have not shown the expected benefit.\u003C\/p\u003E\u003Cp id=\u0022p-11\u0022\u003EAnother approach is ultrafiltration, which can remove fluid from the blood at the same rate that fluid can be naturally recruited from the tissue. The transient removal of blood elicits a compensatory mechanism, called plasma or intravascular refill (PR). In decompensated HF, ultrafiltration safely produces greater weight and fluid loss than intravenous diuretics, reduces 90-day resource utilization for HF, and is an effective alternative therapy (Ultrafiltration vs IV Diuretics for Patients Hospitalized for Acute Decompensated CHF [\u003Cem\u003EUNLOAD;\u003C\/em\u003E \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00124137\u0026amp;atom=%2Fspmdc%2F11%2F3%2F28.atom\u0022\u003ENCT00124137\u003C\/a\u003E]) (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E) [Costanzo MR et al. \u003Cem\u003EJ Am Col Cardiol\u003C\/em\u003E 2007]. The Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS; \u003Ca class=\u0022external-ref external-ref-type-clintrialgov\u0022 href=\u0022\/lookup\/external-ref?link_type=CLINTRIALGOV\u0026amp;access_num=NCT00608491\u0026amp;atom=%2Fspmdc%2F11%2F3%2F28.atom\u0022\u003ENCT00608491\u003C\/a\u003E) study of ultrafiltration versus diuretics in patients with ADHF is in the process of confirming these findings.\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/28\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Freedom from Rehospitalization for HF.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1700487284\u0022 data-figure-caption=\u0022Freedom from Rehospitalization for HF.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/28\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/28\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/3\/28\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12266\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-12\u0022 class=\u0022first-child\u0022\u003EFreedom from Rehospitalization for HF.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReprinted from \u003Cem\u003EJ Am Col Cardiol.\u003C\/em\u003E Constanza MR et al. Feb 13, 2007;49(6):675\u2013683. With permission from Elsevier.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/3\/28.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzn3g1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzn3g1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}