Mechanical and pharmacological combination therapy provides sustained reversal of severe heart failure

A regimen of mechanical and pharmacological therapy can enhance the frequency and durability of myocardial recovery in patients with severe heart failure, a N Engl J Med study has shown.Prolonged, near-complete unloading of the left ventricle through the use of a mechanical pump has been associated with structural reverse modelling in the myocardium that is occasionally accompanied by functional improvement. Birks et al. conducted a prospective study of a form of combination therapy consisting of a HeartMate left ventricular assist device and drugs known to enhance reverse remodelling, followed by the use of the beta2-adrenergic-receptor agonist clenbuterol.Fifteen patients with severe heart failure who received a HeartMate left ventricular assist device for non-ischaemic cardiomyopathy, in the absence of histologic evidence of active myocarditis, and who became clinically stable 4 or more weeks after insertion of the device were enrolled into the study. All patients were receiving inotropic support, and had low cardiac output. Patients were treated with lisinopril, carvedilol, spironolactone, and losartan to enhance reverse modelling. In order to prevent myocardial atrophy, clenbuterol was administered once a constant left ventricular size had been maintained for at least 2 weeks.At a mean of 320 days after implantation of the left ventricular assist device, 73% of patients demonstrated sufficient myocardial recovery to undergo explantation, and four underwent transplantation. None of the patients died during the course of combination therapy. The cumulative rate of freedom from recurrence of heart failure 1 and 4 years after explantation was 100% and 88.9%, respectively.Quality of life among the patients who underwent successful explantation compared favourably with that of patients with long-term implantation of ventricular assist devices, as assessed by the Minnesota Living with Heart Failure Questionnaire."The rate and duration of recovery in our series were significantly higher than previously reported after implantation of left ventricular assist devices," they stated.Despite the small number of patients used and lack of a control group the authors concluded that sustained reversal of severe heart failure secondary to non-ischaemic cardiomyopathy was achievable in certain patients.Reference...